The purpose of this course is to enable the participants to become familiar with a medication pass and know the rule and regulations of long-term care
By the completion of this activity, the learner will be able to meet the following objectives:
Long-term nursing a not an easy field, but comes with many rewards as well as challenges. Long-term care nurses care for patients in need of extended care, including geriatric, wound care, chronic diseases and disabilities.1 Nurses must be dedicated to patient care because the same patients are seen day in and day out. Although most residents are elderly, many are younger.
A long-term care nurse must have a passion for working with the special residents in a long-term care facility. The work can be difficult at times but can be rewarding. Let’s explore the duties of a long-term care nurse.
Long-term care nurses focus on providing care to patients in need of extended care.1 This care may entail routine care, wound care, dementia including Alzheimer’s disease, cancer and after care following surgery or strokes. The main focus is assessing and monitoring the residents’ functional status and maintaining or restoring physical health.
Routine care involves nursing assessments, medication administration, wound care, collaboration with the team including physicians, families, pharmacy, and therapy. Also included would be daily care with ADLs as needed and proper documentation.
Responsibilities may include2:
These responsibilities do sound overwhelming, especially for a new nurse, but it does become easier with time and experience. A solid orientation is of the utmost importance, and the nurse must feel comfortable asking questions. The medication pass is most intimidating to a new nurse, and he/she will need assistance when first starting.
The medication pass takes up the most hours of the day and evening shifts. Trying to give 30 patients their medications can be frightening for new nurses, and even the seasoned nurses have problems at times. Do NOT, under any circumstances try to pre-pour medications to save time. Pre-pouring medications is against regulations.
|Judy, a new Registered Nurse on the unit, has been “instructed “by the other nurses to pre-pour medications to stay in the time-limit boundaries of 1 hour before and 1 hour after. She felt pressured to follow the other nurses’ routines, afraid if she didn’t she would not get more help if needed. Unfortunately, soon after Judy finished pre-pouring the medications, State walked in. She took her cart into the med room, and emptied all the filled cups into her pockets, and dumped them in an appropriate receptacle. This action slowed her time down, and now she has to start med pass over again. When she asked the unit manager why the nurses were allowed to pre-pour medications, the manager answered “they are not allowed.” Judy learned a valuable lesson that day; do not pre-pour meds! If the state had found all those prefilled med cups, they would have been fined, and the nurse may have been fired. Pre-pouring medications is dangerous and the biggest reason for medication errors.|
Medication errors are serious and can cause resident harm or even death. First, and foremost, nurses must remember the 7 Rights of Medication Pass:
Before beginning a med pass, look at the MAR, NEVER go by memory and check for allergies.
Do not bring the cart into the dining room. Do not perform blood sugar checks or administer medications in the common areas of the facility.3 This can be considered a breach of resident confidentiality.
If another nurse asks you to give a medication she has already poured, you should decline. Only administer medications you have prepared yourself. You may not be sure the medication is correct, and it may not be the correct patient. No borrowing medications from another resident’s drug drawer. If a drug is missing, use the Emergency Drug Kit and follow the specific procedure for your facility.
Look for expiration dates on all medications including over the counter drugs. Most insulins expire after 28 days after opening the vial. Metered dose inhalers expire one month after opening.
Some of the abbreviations we use for medication pass are not allowed anymore, as they can cause confusion and medication errors. Per Joint Commission, here is the newest list of abbreviations to avoid:
|Do Not Use||Potential Probem||Use Instead|
|U, u (unit)||Mistaken for "0" (Zero), the number "4" (four) or "cc"||Write "unit"|
|IU (international Unit)||Mistaken for IV (intravenous) or the number 10 (ten)||Write "International Unit"|
Q.D., QD, q.d., qd (daily)
Q.O.D,.QOD, q.o.d, qod (every other day)
|Mistaken for each other. Period after the Q is mistaken for "I" and the "O" is mistaken for "I"|
Write "every other day"
Trailing zero (X.O mg)
Lack of leading Zero (.X mg)
|Decimal point is missed|
Write X mg
Write 0.X mg
MSO4 and MgSO4
Can mean morphine sulfate or magnesium sulfate
confused for one another
Write "morphine sulfate"
Write "magnesium sulfate"
Because there are many medication errors involving Morphine Sulfate, never use the abbreviation!9
Now to begin the med pass:
The nurse is expected to know the action of each medication, so it is imperative a med book is kept on each cart. Be sure to look up all medications with which you are not familiar!
High alert medications can be dangerous to your residents. Familiarize yourself with your facility’s list of high risk meds, check and recheck physician’s orders, ask for help when you are not sure if the order is correct, or if the resident is showing signs/symptoms of an adverse reaction.
Before we continue with the med pass, let’s review residents’ rights regarding medications:
Keeping these rights in mind while passing medications helps the residents keep their dignity.
When preparing oral doses, be sure to follow facility guidelines as well as CMS and pharmacy guidelines:
There are certain medications with AHCA/CMS guidelines:
Always use a tissue, put on gloves and ask the resident to look up. Do not touch the eye with the dropper. Count the drops as they are being administered. Have the resident close the eye to help wash the drop over the entire eye. Wait at least five minutes before administering another drop.3
Always use gloves when administering ear drops. Have the resident lie down with the affected ear up. Pull up and back on the earlobe. Instill the drops without touching the dropper to the skin, earlobe, etc.3
Every new nurse will think they won’t have a medication error, but they will, especially with the time constraints for med pass in long-term care. Remember the phrase “to err is human.” Slowing down, ensuring the correct medication is being given, remembering the 7 rights of medication pass can help reduce medication errors.
"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional.” Antipsychotics, antidepressants, sedatives/hypnotics and anticoagulants were most common drugs for errors. The most common errors are giving medications at the wrong time, dose or route. Sound familiar? Remember the 7 rights!
|Jane, a new graduate, was doing her first med pass alone after one week of training on the cart. She was passing the morning meds, the heaviest med pass of her day, when one of her residents began to “act out.” After trying to calm her down, to no avail, Jane went to her cart to look at the MAR to see what medication she could give. She found the order for Lorazepam 1 mg to be given I.M. every 12 hours and verified it had not been given for almost 36 hours. After Jane retrieved the Lorazepam from the refrigerator, she drew up the entire 2 ml of drug thinking that the concentration was 1 mg equals 2 ml. The actual concentration was 1 mg equals 1 ml. She gave the resident the injection, and the resident finally calmed down and fell asleep. At the end of the shift, during report and narcotic counting, the on-going nurse asked Jane where the other ½ of the Lorazepam was as she did not see that it was wasted. When Jane realized what happened, she went to the shift supervisor to report the error. The resident was monitored throughout the night. There were no adverse reactions, and the resident slept well. Jane learned a valuable lesson, and will always remember her first med error.|
The right documentation during and after a med pass is of the utmost importance. Remember, if it is not documented, it is not done! Always document the meds given AFTER they have been given. If you document before, and the resident refuses or spits out the med, you have a lot more steps to completing your paperwork.
Remember to use the Nursing Process (nursing 101): Assessment, Diagnosis, Planning, Implementation and Evaluation. The assessment includes vital signs, lung and abdominal sounds, and adverse reactions to medications. Your documentation is your proof of care provided to each resident.
The nurse has two hours to complete the medication pass. Ask the floor staff to go to the supervisor with questions as med nurses should not be interrupted during the pass. Check the MAR for the times medications are due. After each patient, enter the drugs given. If you have a missed dose, wait until the end of the pass to get the med. If a PRN is given, mark the time, dose, reason and then go back after 1 hour to recheck the effectiveness. For pain medications, don’t forget to document the level of pain, as well as the pain level after 1 hour.
Long-term care nursing is a rewarding and challenging career, and the nurse must have a passion for working with the special residents in long-term care. The nurse wears many hats and the days are hectic. When the medication pass is thrown into the mix, the new nurse may become frantic and worried about getting the pass done in a timely fashion. This does sound overwhelming, especially for a new nurse, but it does become easier with time and experience. A solid orientation is of the utmost importance, and the nurse must feel comfortable asking questions.
Following the rules and regulations of the facility helps the new nurse with all the duties and responsibilities of the day, including an error-free medication pass.