Introduction

Medications will be administered to patients by qualified personnel in compliance with federal

and provincial laws and regulatory standards of practice. Medications will be stored, handled and
accounted for in a safe manner complying with federal and provincial laws and regulatory
standards of practice.

PURPOSE

To define safe and effective practice guidelines for the medication use process at Windsor
Regional Hospital. This includes:

 medication prescribing,
 dispensing/preparation,
 storage,
 administration/documentation;
 monitoring
 Where processes are not specifically defined, refer to regulatory body standards of
practice.

PROCEDURES

1. PRESCRIBING

1.1 General Guidelines:

 All medications administered to a patient will be: Ordered using the standard prescription.

 A licensed professional authorized to prescribe medications include the prescriber.

 The prescriber will review the patient’s current home medication regimen and reconcile the
home medication list with the medications ordered on admission.

 Only medications required to treat the patient’s condition(s) should be ordered. All medications
ordered should have an indication for use documented in the patient’s medical record.

 The prescriber should interview the patient and document the patient’s allergy information on
all admission medication orders.

 The prescriber will correctly identify the patient using two separate patient identifiers:

 Medication orders/Prescriptions should be complete and include the following:

 Patient name/identifier
 Date and time the order is written
 Name of the medication completely written out – generic name is preferred.
  Dose
 Route
 Frequency

 Abbreviations for medication names and clinical symbols are not acceptable.

 All medication orders should be written using metric units (e.g. mL, L, mcg, mg, gram).

 All medication orders must be signed by the ordering prescriber.

 Medication orders must include the name of the medication. General orders such as “continue
previous medications”, “continue/resume pre-op medications”, “meds as at home”, “continue all
meds”, “discontinue pre-op meds”, etc. are subject to misinterpretation and are not acceptable.

 If these are written, the nurse will contact the practitioner and a clarification order will be
written.

 Only current, active orders may be reordered using the drug name only.

 Orders for medications that have been stopped are considered new orders and must be
completely rewritten including the drug name, dose, frequency, route, etc. An order that changes
in any way, i.e. dose, route, frequency, is considered a new order and must be completely
rewritten.

 Where there is any doubt about the accuracy, clarity, safety or validity of any medication order,
the medication will be held until clarification is obtained from the practitioner. If the practitioner
is not available / does not respond to a page, another practitioner will be contacted.

1.2 Special Considerations:

 Clarifications: Signed orders must never be altered. Once an order/preprinted order has been
signed any changes/additions to those orders MUST be written as a new order. This applies to all
handwritten orders, order sets and Admission Medication order forms.

 Pediatric / Neonatal orders: Weight, in kilograms, must be included on all orders. Medication
orders for pediatric / neonatal patients weighing 50kg or less MUST be written using weight-
based dosing. (e.g. mg/kg) along with the patient-specific dose for drugs that have a published
pediatric/neonatal mg/kg (or other appropriate unit of measure) dosing guideline. The dose
should not exceed the maximum dose. Example: Ceftriaxone 250mg (50mg/kg, pt weighs 5kg)
IV every 24 hours

 Chemotherapy orders: All parenteral chemotherapy orders must be written or entered into
OPIS by the physician. Medication orders for chemotherapy drugs will include the patient-
specific dose and the mg/kg, mg/m2 , units/m2 , area under the curve, or other dosing method
used to calculate the patient-specific dose.

 Hypoglycemic medications: All glycemic control orders (i.e. insulin, oral hypoglycemic,
glucose, capillary blood glucose monitoring) will be placed on the buff-coloured “glycemic
control treatment records” or applicable preprinted order set. If glycemic control medication
orders are written on the incorrect treatment record, one nurse must transcribe the orders to the
appropriate glycemic control treatment record/order set AND a second nurse must perform an
independent double check. Both nurses must sign to validate that correct transcription has
occurred When new insulin orders are written, “see new orders” will be documented in red pen
on the previous insulin order.

 Automatic Stop Order: is a date or time that is predetermined and approved by the Pharmacy &
Therapeutics Committee and Medical Advisory Committee to discontinue a medication.

1.2.1.1: All medication orders will remain active until discontinued by the prescriber or a hard
stop date is reached as defined in this policy.

1.2.1.2: Unless otherwise ordered, anti-infective medications will follow a 7-day automatic stop.

1.2.1.3: An order written for a specific number of doses will override the automatic stop.

1.2.1.4: A report will be generated 24-48 hours prior to the medication expiration date and will
be placed in the physician’s order section of the chart for review by the prescriber.

1.2.1.5: The prescriber will review each medication listed on the automatic stop order, indicate
any medications to be reordered, and sign the order. The prescriber may also reorder the
medication by rewriting it in full on a ‘physician’s order form’. All reorders are to be faxed to
the pharmacy department for processing..

 Range Order is a medication order in which the dose, frequency or route varies over a
prescribed range or interval.

1.2.2.1 Dose ranges will be interpreted as follows: o The lowest dosage in the range will be used
to initiate therapy. o If the response to initial therapy is inadequate, the dose will be escalated
within the range, based on the clinical judgment of the qualified personnel, to achieve the desired
end point. o If in the clinical judgment of the qualified personnel, the lowest dose in the range
will be inadequate to achieve the desired end point, the rationale and supporting information for
the dose selected will be documented in the medical record. o The rationale and supporting
information (e.g. pain score, previous response, symptoms, etc.) for all dosage adjustments will
be documented in the patient’s medical record.
1.2.2.2: Frequency ranges are not acceptable. Orders written with frequency ranges will be
interpreted as the shortest time interval within the range prescribed (e.g. an order written as every
4 to 6 hours will be interpreted as every 4 hours)

1.2.2.3: Route ranges will be interpreted as follows: A route range should be interpreted as the
least invasive route being the route of first choice. Routes of administration from least to most
invasive: PO (oral) / NG (nasogastric) / PR (per rectum) / SC (subcutaneous) / IM
(intramuscular) / IV (Intravenous) (e.g. PO or IV … PO should be interpreted as the preferred
route. The parenteral route should be the alternative used if the patient is unable to take the
medication by mouth.) **Prescribers should recognize that doses may NOT be of equal potency
as the route of administration changes and dose adjustments should be written accordingly.

 Titrating Order is an order in which the dose is either progressively increased or decreased in
response to the patient’s parameter as specified within the initial order. The order must clearly
indicate a starting dose with specific parameters for titration and include a lower and upper dose
limit. (e.g. ‘start dopamine infusion at 5 mcg/kg/min and titrate from 0-20 mcg/kg/min to
maintain SBP greater than 90mmHg)

 Taper Order is an order in which the dose is decreased by a specific amount within each dosing
interval. The order must clearly indicate specific dosage increments with timing intervals. (e.g.
prednisone 40mg daily for 2 days, then 30mg daily for 2 days, 20mg daily for 2 days, 10mg daily
for 2 days, then stop)

 As Needed (PRN) Order is an order acted upon based on the occurrence of a specific indication
or symptom. All PRN orders must include the indication for use. Orders without an indication
for use will be clarified as per the “Patient Order Processing Policy

 Hold Orders:

1.2.3.1: When the prescriber writes an order to “hold” a medication, the order should include
specific clinical parameters or the length of time the medication is to be held (e.g. “hold for SBP
less than 100mmHg”, or “hold for 24hrs then reassess”).

1.2.3.2: Hold orders without clinical parameters or limited time/number of doses will be placed
on hold in the pharmacy patient profile system. When the next CMAR is printed, administration
times will not appear next to the held medication, instead, the notation “ON HOLD” will appear.

1.2.3.3: The prescriber is responsible to reassess hold orders.

 NPO Orders: No medications will be administered when a patient is NPO. If medications are
required while the patient is NPO, an order must be written to specify the medication to be
continued. (i.e. “NPO except meds”, “NPO except ramipril and metoprolol”)
 Medication Samples: Prescribers shall not bring in medication samples for hospitalized
patients. Any exceptions to this policy must be approved by a Windsor Regional Pharmacist and
will be made on an individual patient basis where it is deemed that there is significant risk that
the patient will not receive their essential medication (e.g. disadvantaged population) unless it is
facilitated by the pharmacy department. If sample use is required, the medication sample will be
reviewed, identified and appropriately labeled by a pharmacist/other qualified healthcare
professional.

 Medications from Home

1.2.4.1 Medications brought from home by the patient should be sent home with the visiting
family or caregiver. If they cannot be sent home, they must be secured on the nursing unit and
sent home with the patient on discharge. All medications must be placed in Ziploc bag or
envelope and seal with tamper proof tape or staple to prevent tampering. Store all patient home
medication in designated lock cupboard and return key to Pyxis. Notation to be made on the
discharge form as to whether the medications were returned to the patient or destroyed.

1.2.4.2 Non-narcotic medications brought from home may only be used for administration during
the inpatient admission if:

1.2.4.2-1 The prescriber has ordered the non-formulary medication for use during the admission,
AND

1.2.4.2-2 A pharmacist or other qualified healthcare professional, when a pharmacist is

unavailable, has reviewed and identified the medication in the bottle/vial to match the
prescriber’s order. The pharmacist/other qualified healthcare professional will affix a verification
label on the patient’s own medication vial to signify that the medication has been verified and is
ready for use.

1.2.4.2-3 For patient’s narcotic non-formulary medications, the nurse and nurse witness fill out
the Home Medication form and must include: -patient demographics -narcotic name, strength,
and quantity -nurse name and signature -witness name and signature All medications must be
placed in Ziploc bag or envelope and seal with tamper proof tape or staple to prevent tapering.
Store all patient home medication in designated lock cupboard and return key to Pyxis. At
discharge, the nurse will return the medications to the patient and document this in the progress
notes

1.2.4.2-4 In the event that a patient’s medication brought from home is an insufficient quantity
for the duration of the admission, an additional supply will need to be requested by the nurse to
the family/caregiver. In the event that there is no family/caregiver, the nurse will need to contact
the pharmacist for any additional supplies to ensure a new review and identification occurs prior
to the medication being administered.
 Changes in Level of Care: A change in the intensity of services required as a result of changes
in the patient’s health status. Patients moved between the acute care hospital and outpatient
departments or rehabilitation units or complex continuing care units or mental health units are
discharged from the sending unit and admitted to the receiving unit. Refer to Medication
Reconciliation policy/guidelines

1.2.5.1 New medication orders must be written / prior med orders must be authorized for the
following changes in level of care:

 A patient that has undergone any surgical or other procedure requiring higher level anaesthesia
(excludes mild to moderate sedation)

 A patient that is transferred from: o the Critical Care Program (CCP) to a non-CCP bed o a
general care unit to the CCP unit

 A patient is admitted from the following areas: o Same day surgery to a patient care unit

 A patient is discharged from: o A general patient care unit and admitted to a rehabilitation unit
(and vice versa) o A general patient care unit and admitted to a complex continuing care unit
(and vice versa) o A general patient care unit and admitted to a mental health unit (and vice
versa)

1.2.5.2 To facilitate the transfer process, the transferring physician may generate a “Transfer
Medication Orders” form from the pharmacy patient profile system. See Appendix B for
Guidelines for Use of the “Transfer Medication Orders” form

1.2.5.3 When the “Transfer Medication Orders” form is not available:

 All medication orders must be re-written.

 Internal transfer orders will be re-written by the prescriber transferring from the higher acuity
unit. (i.e. written by the prescriber in ICU when going from ICU/CCU to unit, or from the unit to
the ICU/CCU)  External transfer orders will be written/authorized by the accepting MRP

 The prescriber will reconcile each medication against the current medication administration
record and the admission medication history, and decide which medications to continue or
discontinue.

1.2.5.4 Blanket orders are not acceptable (e.g. “resume previous orders”, “resume pre-op orders”,
“resume home medications”). If these orders are written, the prescriber will be contacted for
complete medication orders.

 Discharge Medication Orders:

1.2.6.1 Prior to discharge, the prescriber should review the list of medications that patient was on
at home (located on the Admission Medication Orders) and the current medication
administration record.

1.2.6.2 The prescriber may generate the “Discharge Prescription” form from Horizon Meds
Manager/WORX and will indicate which medications to continue or discontinue, and order any
additional new medications. See Appendix C for Guidelines for Use of the “Discharge
Prescription” form.

1.2.6.3 The prescriber must review and reconcile all medications before the patient is discharged.

1.2.6.4 On discharge, the nurse will review the list with the patient and provide a copy of the
Horizon Meds Manager/WORX/manually generated “Medication Card”. 1.2.6.5 Prescription
medications that have been prescribed, dispensed, and administered in the hospital may not be
sent home with the patient. (i.e. creams, inhalers, eye drops supplied by WRH inpatient
pharmacy are to be disposed of at discharge).

1.2.6.6 Blanket discharge orders are not acceptable (i.e. “discharge on same home meds”). If
these orders are written, the prescriber will be contacted for complete discharge medication
orders.

2. DISPENSING / PREPARATION

2.1 Pharmacist/Nurse Review of Orders

2.1.1 All medications administered must be ordered/documented. Over-the-counter medications

require an order in the chart.

2.1.2 The pharmacist will review all medication orders against the patient’s medication profile
for validity, safety and appropriateness prior to dispensation and administration.

2.1.3 For orders written outside of pharmacy operational hours:

2.1.2.1: Administration of the new medications ordered during non-pharmacy covered hours
should be postponed until the pharmacy opens, whenever possible.

2.1.2.2: When clinical care of the patient would be compromised by postponing implementation
of the new order, the nurse may access the medication using the override function in the
automated dispensing device (i.e. pyxis) or from the night cabinet. The amount of medication
removed should be sufficient to meet the ordered dose and should not exceed the amount
required to last until a pharmacist is available to review the order.

2.1.2.3: The nurse removing medications via override will review the orders for safety, efficacy,
and appropriateness. See 2.1.4 for parameters which require review. Any concerns, issues or
questions that arise are to be clarified with the prescriber before retrieving and administering the
medication.

2.1.2.4: The on-call pharmacist can be contacted for additional clarification or information on
orders.

2.1.2.5: A retrospective review of the orders will occur by the pharmacist as soon as possible the
following morning when the pharmacy department opens.

2.1.4 The pharmacist review of the medication order prior to dispensing and administration is not
necessary when:

 A licensed independent practitioner controls the ordering, preparation and administration of the
medication. This includes but is not limited to the following clinical areas: Operating Rooms,
Radiology, Emergency Room, and Endoscopy procedure area.

 In urgent situations when such a review would cause a medically unacceptable delay, such as
when the patient experiences a sudden change in clinical status. The pharmacist will review the
order as soon as possible after the administration of the dose and should review any orders prior
to the administration of subsequent doses if an order is written to continue therapy.

2.1.5 The pharmacist review (and nurse review if initiating medication orders outside of a
pharmacist review) of the order will include the following:

2.1.5.1: Identification of the patient using two separate patient identifiers.

2.1.5.2: The patient’s real or potential allergies, sensitivities, or adverse drug reactions:

 If allergies are not documented on the patient admission records, then the pharmacist (or nurse)
is responsible for contacting the prescriber / nursing unit to determine the allergy status prior to
dispensing.

 If a prescribed medication is listed as an allergy, the pharmacist (or nurse) should contact the
physician to recommend therapeutic alternatives. This should be documented in the patient’s
profile in the pharmacy information system.

 If a discrepancy is found between the allergy information documented in the medical record
and electronic information system, the pharmacist (or nurse) will reconcile the allergy/adverse
drug reaction information with the patient and contact the prescriber to clarify the allergy or if
indicated, recommend a therapeutic alternative.

 If allergy information is not readily available due to the patient’s status or when obtaining such
information would cause a medically unacceptable delay, the pharmacist (or nurse) may use
professional judgment in dispensing the medication prior to the review of allergy information
2.1.5.3: Therapeutic duplication

2.1.5.4: Appropriateness of medication, dose, route or frequency.

2.1.5.5: Any drug-drug interactions

2.1.5.6: Any pertinent laboratory values (e.g. serum creatinine for renally eliminated drugs, INR
for warfarin orders, etc.)

2.1.5.7: Contraindications

2.1.5.8: Variation from criteria for use

2.1.5.9: Other relevant medication related issues or concerns

2.1.6 The pharmacist and/or nurse will contact the prescriber in the event that a clarification is
needed for any of the above stated elements.

2.2 Medication Preparation

2.2.1 All sterile medication, intravenous admixtures, or other drugs that require compounding,
mixing, manipulation or admixing should be prepared according to standardized concentrations
(refer to the Windsor Regional Hospital IV manual of formulary drugs), labeled, and dispensed
by the pharmacy except:

 In emergency situations when the pharmacy preparation would cause medically unacceptable
delay. (e.g. after pharmacy hours, life-threatening situations)

 When drug product stability is short.

2.2.2 Medications that are not commercially available are prepared in pharmacy in accordance
with provincial and federal regulations.

2.2.3 Any medication prepared outside the pharmacy should be initiated in the area where it was
prepared.

2.2.4 Any medication prepared outside the pharmacy and not initiated should NOT be transferred
with the patient. The receiving unit nurse should prepare the medication new.

2.2.5 In ambulatory or other areas in which pharmacy may not be preparing the medications,
processes related to preparation, dispensing, safety, storage, and infection control should be
utilized. (e.g. aseptic technique preparation). The stopper on all medication vials should be
disinfected prior to insertion of a sterile needle to aspirate contents.

2.2.6 It is recommended that a filter needle/filter straw be used in the preparation of any
medication aspirated from a glass ampoule to prevent infusion of glass microparticles that may
occur during breaking/opening of the ampoule. Solutions in plastic ampoules do not require
filtering prior to administration unless specifically indicated by the manufacturer.

2.2.7 Medications in care areas are to be maintained in the most ready to administer forms
available from the manufacturer. Where feasible, and not available in ready the administer forms
from the manufacturer, unit doses will be repackaged by the pharmacy department or a licensed
repackager.

2.2.8 During hours of operation, Pharmacy will receive and order from the nursing unit and will
process according to the following turn around times:

 STAT CRITICAL orders immediately after receiving phone call

 STAT orders 15-30 minutes from the time the order was received

 Antibiotic orders 30-60 minutes from the time the order was received

 Routine orders 60-90 minutes from the time the order was received 2.2.9 Refer to the WRH
Automated Dispensing Device (Pyxis) policy for medications removed from the automated
dispensing cabinet.

2.3Medication Labeling

2.3.1 All medications, medication containers, or other solutions on and off a sterile field must be
labeled. These would include, but are not limited to, syringes, medicine cups, and basins.

2.3.2 Medications and solutions both on and off the sterile field are to be labeled even if there is
only one medication being used.

2.3.3 Labeling occurs when any medication or solution is transferred from the original packaging
to another container.

2.3.4 All medication or solution labels are verified both verbally and visually by two qualified
individuals whenever the person preparing the medication or solution is not the person who will
be administering it.

2.3.5 No more than one medication or solution is labeled at one time.

2.3.6 Any medications or solutions found unlabeled will be appropriately disposed of

immediately.

2.3.7 All original containers from medications or solutions remain available for reference in the
perioperative or procedural area until the conclusion of the procedure.

2.3.8 All labeled containers on the sterile field are appropriately disposed of at the conclusion of
the procedure.
2.3.9 At shift change or break relief all medications and solutions both on and off the sterile field
and their labels are reviewed by entering and exiting personnel.

2.3.10 All medication and solution labels should include:

 Drug name, strength, amount (if not apparent from the container)

 Expiration date when not used within 24 hours

 Expiration time when expiration occurs in less than 24 hours

 The date prepared and the diluent for all compounded IV admixtures and parenteral nutrition
solutions

2.3.11 When preparing individualized medications for multiple specific patients, or when the
person preparing the individualized medications is not the person administering the medication,
the label also includes the following:

 Patient name and ID number

 Patient location

 Directions for use and any applicable cautionary statements either on the label or attached as an
accessory label (e.g. “refrigerate”, “for IM use only”, etc)

2.3.12 Compounded IV admixtures, total parenteral nutrition (TPN) and total nutritive additive
(TNA) solutions should be labeled with the scheduled date, time and rate of administration when
appropriate.

2.4 Medication Security Definition of secure medication: Drugs and biologicals are stored in a
manner to prevent unmonitored access by unauthorized individuals.

2.4.1 Secure areas are those that are restricted to authorized individuals and those where patients
and visitors are not allowed without the supervision of an authorized individual.

2.4.2 An area in which staff is providing care to patients or preparing to receive patients (e.g.
setting up for procedures before the arrival of a patient) would generally be considered a secure
area.

2.4.3 When a patient care area is not staffed, all medications are expected to be locked.

2.4.4 Nursing units utilizing medication carts will keep the medication cart at the nursing station
when not in use. It is preferred to utilize locked medication rooms, if available, to secure
medications (including medication carts).
2.4.5 When mobile medication carts (unit dose carts, anaesthesia carts, epidural cars, etc) are not
stored in a locked room, the mobile medication cart will be locked and stored in a secure area
when not in use.

2.4.6 Access to locked storage areas where medications are stored will be limited to authorized
individuals.

2.4.6.1: Individuals who require access to medications to perform their job duties, as defined in
their job descriptions, will be considered authorized individuals. Examples include nurses,
pharmacists, pharmacy technicians, radiology technicians, respiratory therapists, etc.

2.4.6.2: Ancillary support individuals who require access to locked storage areas where
medications may be stored in order to perform their assigned job duties would be considered
authorized individuals, for purposes of this policy.

2.4.6.2.1 Individuals who are responsible for restocking supplies in a locked storage area would
be considered authorized. Examples include central supply staff.

2.4.6.2.2 Individuals responsible for maintenance of the environment in a locked storage area
would be considered authorized. Examples include facilities/maintenance, biomedical
engineering, security, etc.

2.4.7 Unauthorized personnel, in accordance with the hospital’s policy and law or regulation,
CANNOT obtain access to medications

2.4.8 All medications will be properly and safely stored according to the manufacturer’s
recommendations.

2.4.9 Only approved medications are routinely stocked and stored. Approval shall be obtained
from the unit manager AND a pharmacy manager.

2.4.10 All narcotic (Narcotic - CDSA I) and controlled substance (Schedule G - CDSAIII)
medications must be locked within a secure area. Narcotic and controlled substances requiring
refrigeration will be stored in a locked box within the refrigerator

2.4.11 Medications delivered to the patient care areas should be secured as soon as feasible.

2.4.12 Medications not administered following removal from a secured area should be secured as
soon as feasible.

2.5 Medication Returns

2.5.1 If a unit dose medication has been removed from pyxis and is no longer required, the nurse
should „return‟ the medication to pyxis and place it in the pyxis return bin.
2.5.2 If a bulk medication, IV medication, or patient-cassette medication has been discontinued
or changed, the nurse should place the medication in the appropriate pharmacy return bin.
Medication stored at room temperature should be placed in the “return to pharmacy” bin in the
medication room. Medications requiring refrigeration should be placed in the pharmacy return
bin in the unit medication fridge.

2.5.3 If a patient is discharged, the nurse should remove all medications from the pharmacy drop
off bin and the patient’s cassette and place in the “return to pharmacy” bin in the medication
room. Refrigerated medications should be placed in the pharmacy return bin located in the unit
medication fridge.

2.6 Medication Storage Prepared medications are to be stored under conditions suitable for
product stability. The method of storage of medications in patient care areas should conform to
the same system as that utilized in pharmacy. This includes:

2.6.1 Medications should be stored at proper temperatures.

2.6.1.1: Multiple dose vials

 Multiple dose vial injections (including vaccines) are considered stable/useable for 28 days,
unless otherwise indicated by the manufacturer recommendations.

 Auxiliary labels indicating the expiration date should be attached to the exteriors of the bottles
once opened.

 Multiple dose vials should be stored at temperatures as specified on the label.

2.6.1.2: Single dose vials/containers

 Single dose vials/containers should be stored as indicated on the label and any remaining drug
should be appropriated disposed of after each administration.

2.6.2 Medications should be stored to ensure product stability.

 All expired, contaminated, or spoiled medications should be removed from the medication
storage area and be sent to the pharmacy department for proper disposal

 Light sensitive medications should be protected from light through the use of amber bottles,
amber vials, or an amber plastic bag.

2.6.3 No food or drinks will be stored in medication fridges.

2.6.4 All medication storage areas will be periodically inspected by the pharmacy department to
ensure medications are stored properly.

3. ADMINISTRATION / DOCUMENTATION
3.1 General Guidelines

3.2.1 The following healthcare professionals are authorized to administer medications: licensed
independent practitioners, nursing personnel (as defined under the “Definition” section), medical
assistants, respiratory therapists, physical therapists, pharmacists, imaging technologists,
radiologic technologists.

3.2.2 All medications administered to the patient must have a complete and signed order by an
authorized prescriber.

3.2.3 Authorized healthcare professionals will ensure that the client consents to the
administration of medications.

 When possible and appropriate for age/cognitive status, the authorized healthcare professional
will inform the patient or the patient’s family of the medication (along with purpose) and dose
being given at the time of the medication administration.

 Medication information resources may include: CPS, LexiComp, etc.

3.2.4 Authorized healthcare professionals will ensure that the principles of infection prevention
and control are applied when administering medications (refer to Appendix A).

3.2.5 The patient’s MAR / CMAR will be brought to the patient’s bedside during the medication
administration process. 3.2.6 Medications will be brought to the patient’s bedside still in the
packaging to allow for a double check at the time of medication administration. Medications will
not be “pre-poured” away from the patient’s bedside. Exceptions:

 bulk nursing unit stock medications

 medications requiring crushing (the empty packages will be brought to the bedside for
confirmation)

3.2.7 Authorized healthcare professionals will correctly identify the patient using two separate
patient identifiers.

 This process should include active participation and communication of identifiers with the
patient whenever possible.

 When not possible, the MAR must be checked against the patient identification band.

 The patient’s identity must be verified with each patient encounter.

 Refer to the WRH Patient Identification Policy for details.

3.2.8 Prior to administration, the authorized healthcare professional will verify the “8 rights” plus
the following:
 Right patient

 Right medication

 Right reason (ensure the medication being given is suitable for the patient’s condition)

 Right dose

 Right frequency

 Right route

 Right site, and

 Right time

 A visual inspection of the medication for particulate matter or discolouration

 Expiration dates if available

 Any contraindications and allergies

3.2.9 If the nurse discovers a discrepancy between the documented allergy information through
interview with the patient, the nurse will contact the prescriber to notify him/her of the updated
allergy information to determine a therapeutic alternative.

3.2.10 Scheduled medications include all maintenance doses administered according to a

standard, repeated cycle of frequency (e.g. q4h, QID, TID, BID, daily, weekly, monthly,
annually).

3.2.11 Time-critical scheduled medications are those where early or delayed administration of
maintenance doses of greater that 30 minutes before or after the scheduled dose may cause harm
or result in substantial sub-optimal therapy or pharmacological effect. Time-critical scheduled
medications should be administered 30 minutes before or 30 minutes after the designated
administration time. Examples of time-critical scheduled medications include:

 Medication with a dosing schedule more frequent than every 4 hours

 Scheduled (not prn) opioids used for chronic pain or palliative care (fluctuations in the dosing
interval may result in unnecessary break-through pain)

 Immunosuppressive agents used for the prevention of solid-organ transplant rejection or to

treat myasthenia gravis

 Medications that must be administered apart from other medications (e.g. iron supplements and
thyroid medications).
 Medications that require administration within a specified period of time before, after, or with
meals. For example, rapid-, short-, or ultra-short acting insulins.

3.2.12 Non-time-critical scheduled medications are those where early or delayed administration
within 60 minutes should not cause harm or result in substantial sub-optimal therapy or
pharmacological effect. Non-time-critical scheduled medications should be administered within
60 minutes before or after the designated administration time. Examples of non-time-critical
scheduled medications include:

 Medications with a dosing schedule no more frequently than every 4 hours. (e.g. weekly, daily,
BID, TID, q6h, q8h, etc).

3.2.13 For medications not administered within the 30-60 minute guidelines as noted above, the
dose will be administered as follows:

3.1.13.1: If the time of administration is less than Y2 way of the interval, the medication should
be administered as soon as possible and the next dose is to be administered at the next scheduled
time. (e.g. a once daily medication due at 1000 was not administered and the omission was
discovered at 1700. The dose is given once every 24 hours. Since the dose omission is
discovered within 12 hours of the scheduled admin time, the dose may be given, documented as
a late administration, and reported as a medication incident using the online medication incident
reporting system.

3.1.13.2: If the time of administration is more than Y2 past the schedule interval, then the
prescriber should be contacted for further instructions regarding the missed dose. The
instructions should be documented and the omission reported as a medication incident using the
online medication incident reporting system. The next dose should be administered at the next
regularly scheduled time.

3.2.14 Medications should not be administered orally to patients that cannot receive anything by
mouth due to a physician’s order or clinical condition (e.g. NPO order prior to a procedure or
NPO after failure of a swallowing assessment)

 For patients on insulin therapy and NPO status, the nurse should contact the prescriber for new
insulin orders. This should include orders on whether to administer or hold insulin orders until
nutritional status is determined and achieved.

3.2.15 Medications requiring “handling precautions” will be indicated as such on the CMAR and
will be labeled with the appropriate auxiliary label: (make sure these are still the right stickers
being used) For complete information on personal protective equipment needs and other
handling instructions, please refer to the WRH policy for Safe Handling of Cytotoxic Agents, or

3.2.16 Discharge prescriptions will not be used as orders for administration of medications while
the patient is at Windsor Regional Hospital.
3.2 Transfer of Medications

3.2.1 When a patient is transferred to another unit, the medications that are to be continued
(according to transfer orders) should be transferred with the patient to the receiving unit.

 Exception: any medication prepared outside the pharmacy and not initiated in the original unit
should not be transferred with the patient and should be appropriately disposed of.

3.2.2 Medications that are not to be continued in the new patient area should not be transferred to
the unit and should be returned to the pharmacy department.

3.2.3 On discharge, hospital supplied medications are not to be sent home with the patient. These
medications must be returned to pharmacy.

3.3 High Alert Medication

3.3.1 Refer to the posted WRH High Alert Medication Policy

3.3.2 Refer to the posted WRH Independent Double Check Policy

3.4 Medications from Home (See Appendix E for flow diagram)

3.5.1 Medications brought from home by the patient should be sent home with the visiting family
or caregiver and removed from the hospital.

 The prescriber has ordered the non-formulary medication for use during the admission, AND

 A pharmacist or other qualified healthcare professional, when a pharmacist is unavailable, has

reviewed and identified the medication in the bottle/vial to match the prescriber’s order. The
pharmacist/other qualified healthcare professional will affix a verification label on the patient’s
own medication vial to signify that the medication has been verified and is ready for use.

3.5.2 In the event that a patient’s own medication supply is an insufficient quantity for the
duration of the admission, an additional supply may be brought into the hospital. When the
additional supply is received, the nurse will need to contact the pharmacy department to perform
a new review and identification of product prior to administering any of the medication.

3.5.3 For deceased patients, medications will be destroyed. Destruction must be documented in
the patients chart on the home medication form. Documentation must include medication
destroyed. For narcotics, destruction must be witnessed and witness must document on the home
medication form. Home medication form should be placed in patient chart.

3.5 Missing Medications

3.5.1 If a medication is not available on the unit, but is listed on the MAR, a “missing medication
communication form” (form # 0357 R94-06) should be sent to the pharmacy department for
processing.

3.5.2 Medication documentation should not indicate “not available” when pharmacy is open.
When pharmacy is closed “Global find” is available to find a medication not available on the
unit. The on-call pharmacist may be paged if the medication cannot be found.

3.6 Holding Medications

3.6.1 The physician should be notified for clarification of the order if a medication cannot be
administered due to:

 Incomplete, unclear or illegible order

 An allergy of adverse drug reaction to a medication

 Unavailability of the medication

 Patient condition precludes administration (i.e. vomiting, seizure, etc.)

 A medication incident that requires follow up intervention

 Patient/family refuses the ordered medication

3.6.2 Unless otherwise ordered, medications requiring a pulse check should be held on adult
patients if the apical rate is less than 60 beats per minute AND the physician will be notified for
further instructions.

3.6.3 Unless otherwise ordered, antihypertensive/diuretic agents should be held if the blood
pressure is less than 90/60mmHg AND the physician will be notified for further instructions.

3.7 Self-Administered Medications

3.7.1 Requirements for patient self-administration:

 A physician’s order for the patient to self-administer medications

 The patient must be 18 years of age Patient must express a desire to participate

 Patient must be able to read, write and understand basic instructions

 The patient must have the ability to be responsible for his/her own medications past discharge

 The patient must be able to state basic information about the medications they are self-
administering
 Patient must sign a consent form agreeing to participate in the program

 Instructions as to how to self-administer should be provided by nursing staff

3.8 Documentation For additional specifics, please refer to the posted Medication Administration
Record Policy

3.8.1 All medications will be transcribed and administration documented on the MAR / CMAR.

3.8.2 All new medication orders will be transcribed to the MAR / CMAR by a nurse.

3.8.3 A nurse is responsible for reconciling the accuracy of the transcription and will sign/initial
the order on the MAR / CMAR. Verification will be done against the original order.

3.8.4 All orders will be checked and verified against the previous MAR / CMAR and against any
original orders written since the last 24 hour check.

3.8.5 When updating the MAR / CMAR for a discontinued medication:  Write “discontinued”
on the MAR / CMAR next to the last dose of medication given

3.8.6 The nurse/authorized personnel who administer a medication must record their initials next
to the administration time. The actual administration time should be documented if it differs
from the predefined standard administration time. This documentation will occur immediately
after the patient has been witnessed taking the medication. If an injection has been given,
document the site next to the admin time If a patch is applied, document the patch location next
to the admin time If vital signs are required, record these next to the admin time

3.8.7 If a second nurse administers a dose of medication for the primary nurse, the administering
nurse will place their initials next to the recorded dose given and sign and print their name in the
MAR / CMAR signature area.

3.8.8 For those high-risk medications requiring an independent double check, both
nurses/authorized personnel will place their initials next to the recorded dose given (or
designated area of a specified flow sheet) and sign in the MAR / CMAR signature area. See
WRH Independent Double Check policy

3.8.9 If a medication dose is held, “held” should be documented next to the administration time
and the physician should be notified when appropriate. Documentation of reason for hold will be
written in the progress notes.

3.8.10 If a medication is not given for any reason, the nurse will use the appropriate MAR code
surrounded by a circle indicating the reason the medication is not given. Acceptable MAR codes,
as listed on the bottom of each MAR page, include: NPO – nothing by mouth R – patient refused
N&V – nausea and vomiting OTU – patient off the unit SPN – see progress note HOLD –
medication held *the pharmacy department is to be notified if a drug dose that due is not
found/available

3.8.11 Intramuscular and subcutaneous injection sites and transdermal patch locations will be
noted next to the dose given.

 For removal of transdermal medication patches, the nurse should document their initials that
the previous patch was removed before applying the new one.

 Insulin administration and injection site will be documented on the Diabetic Flow Sheet.
Subcutaneous anticoagulant administration and injection site will be documented on the
Anticoagulant Flow Sheet.

3.8.12 Orders which have a predetermined number of doses to be administered will be numbered
next to the administration time as number dose / total number due. (I.e. 3 ordered doses of post-
op antibiotics would be documented as dose 1/3, dose 2/3, and dose 3/3 next to the
administration times)

3.8.13 Physicians will document any physician-administered medications on the appropriate

treatment record, flow sheet or MAR / CMAR. An order must be written & faxed to pharmacy
for any med administered

3.8.14 Respiratory therapy or other qualified personnel will document medications administered
by them on the MAR / CMAR.

3.8.15 All medication administration records will remain with the patient’s medical record. The
most current MAR / CMAR is to be placed in the patient’s chart if the patient is being sent off
the unit for any diagnostic test or procedure.

3.8.16 Variances related to medication administration should be entered in the online medication
incident reporting system.

3.8.17 Disposal of medications Medication will be wasted in the dedicated medication disposal
bins 4. MONITORING

4.1General Guidelines

4.1.1 Medication administration will be supervised and medication will NOT be left in a patient
room / at the bedside for them to take on their own unless authorized per applicable self-med
policy. Nurses and qualified personnel must witness that the medications have been taken by the
patient.

4.1.2 Each patient’s response to medication is monitored.

4.1.3 The clinical needs of the patient will direct the level of monitoring that is performed and
documented.

4.1.4 Monitoring includes:  The patient’s clinical response to the medication, including relevant
laboratory results  The patient’s own perceptions of the efficacy of the medication  The
patient’s own perceptions of the side effects to the medication

4.2 Adverse Drug Event (ADE) Reporting

4.2.1 Adverse drug events (includes adverse drug reactions and medication variances) are
defined as follows:

 Medication error / incident (Source: College of Nurses of Ontario Practice Standard,

Medication: Revised 2008 and Institute for Safe Medication Practice Canada) A medication error
is defined as any preventable event that may cause or lead to inappropriate medication use or
client harm while the medication is in the control of the health care professional, client or
consumer. Such events may be related to professional practice, health care products, procedures
and systems, including prescribing; order communication; product labeling, packaging and
nomenclature; compounding; dispensing; distribution; administration; education; monitoring and
use.

 Adverse Drug Reaction (ADR) (Source: World Health Organization) Any untoward medical
occurrence that may present during treatment with a pharmaceutical product, but which does not
necessarily have a causal relationship with this treatment. Adverse drug events are comprised of
Medication Variances, Adverse Drug Reactions, Side Effects from the singular effects of one
medication or the combined effects of more than one medication, and Undesirable Physiologic
Responses to drug therapy.

4.2.2 When a variance occurs in one of the steps of the medication use process, this variance
should be reported using the online occurrence reporting system. Refer to the WRH Adverse
Event and Near Miss Reporting policy.

4.2.3 When an ADE is suspected:

4.2.3.1: The qualified personnel should notify the attending physician or resident to determine if
additional orders are necessary to care for the patient.

4.2.3.2: A clinical assessment of the patient should be documented in the progress note section in
the patient’s medical record.

4.2.3.3: The attending physician or resident must notify the patient that an adverse drug event has
occurred.