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Long-Term Care Nursing: Medication Pass

2 Contact Hours including 2 Advanced Pharmacology Hours
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Saturday, September 30, 2023

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥92% of participants will know correct and efficacious medication pass process.

Objectives

After completing this course, the participants will be able to:

  1. Describe the duties of a long-term care nurse.
  2. Explain the process of a medication pass.
  3. Identify the rules of the med pass and follow them closely.
  4. Determine the different high-alert meds and how to administer them.
  5. List the resident rights for medication pass.
  6. Explain the administration of oral meds, liquids, eye drops, and ear drops.
  7. Identify the common errors and learn how to prevent them.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Sandi Winston (MSN, RN)

Long-Term Care Nursing

Providing Care to Patients in Need of Extended Care

Long-term nursing is not an easy field, but it 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. 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 special residents in a long- term care facility. The work can be difficult at times but can be so rewarding. Let's explore the duties of a long-term care nurse.

Duties Are Varied: Assessments, Medication Administration, & Wound Care

Long-term care nurses focus on providing care to patients in need of extended care. This care may entail routine care, wound care, dementia, including Alzheimer's disease, cancer, and aftercare following surgery or strokes. The main focus is assessing and monitoring the residents' functional status and maintaining or restoring physical health. Due to physiological changes, particularly in hepatic metabolism and renal elimination, dosing in the elderly population can be challenging. The elderly may experience an increase in side effects or toxicity more easily. Awareness of side effects in the elderly is particularly important as most elderly patients are on more than one drug. Great care should be taken when combining drugs.

Routine care involves nursing assessments, medication administration, wound care, and collaboration with the team including physicians, families, pharmacy, and therapy. Also included would be daily care with Activities of Daily Living (A.D.L.s) as needed and proper documentation.

Responsibilities may include:

  • Consults and coordinates with healthcare team members to assess, plan, implement, and evaluate patient care plans.
  • Prepares, administers, and records given prescribed medications. Reports adverse reactions to medications or treatments.
  • Records residents' medical information and vital signs.
  • Assesses resident's ability to perform routine A.D.L.s.
  • Assists residents with basic needs such as dressing, eating, and bathing and encourages patients to do things for themselves to retain feelings of independence and self-worth.
  • Recognizes and manages geriatric syndromes common to older adults, including cardiovascular, respiratory, gastrointestinal, urinary, musculoskeletal, neurological, integumentary, sensory, and pain problems.
  • Prepares equipment and assists the physician during examination and treatment of a patient.
  • Facilitates older adults' active participation in all aspects of their healthcare.
  • Involves, educates, and, when appropriate, supervises family/significant others in implementing best practices for older adults.

These responsibilities 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.

Medication Pass

The medication pass takes up the most hours of the day and evening shifts. The medication pass is the most intimidating task to new nurses. They will need assistance when first starting off. Having the responsibility of giving 30 patients their medications can be frightening and overwhelming for new nurses and even for seasoned nurses.

Medication errors are serious and can cause resident harm or even death. It is human nature to want to simplify things when there is much to be done. In an attempt to do this, sometimes shortcuts are made. However, this is not good practice. ESPECIALLY when it comes to medications. Do not take shortcuts. More specifically, do NOT, under any circumstances, try to pre-pour medications to save time. Pre-pouring medications are against regulations. In addition, it increases the risk of making mistakes.

Ten Rights of Medication Pass

First and foremost, nurses must remember the 10 Rights of Medication Pass:

Right Patient:

  • Use two identifiers. The room number is not an identifier. Ask the patient to identify themself, check the name on order, and the patient. If available, use technology such as barcoding. For patients not wearing I.D. bands or those who cannot identify themselves, extra caution is necessary. A system should be in place to identify patients without name bands or who are incompetent.

Right Drug:

  • Every drug administered must have an order from the provider. Compare the order with the medication administration record (M.A.R.) for accuracy. Compare the label on the drug to the information on the M.A.R. three times:
    1. Before removing the container from the drawer
    2. As the drug is removed from the container and
    3. At the bedside before administering it to the patient
  • Do not prepare unmarked drug containers or illegible containers. Be sure to verify drugs at the patients' bedside with the M.A.R. and two patient identifiers (Potter et al., 2017).

Right Dose:

  • Have a second nurse check any calculations that need to be done. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. See if the pharmacists can split any required pills for safety (Potter et al., 2017).
  • If drugs need to be crushed, be sure to clean the devices used before and after. Nurses should access information on therapeutic doses, therapeutic serum levels if applicable, and laboratory results when needed. If there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering.

Right Route:

  • Drug errors involving the wrong route of drug administration are common. Be sure to verify if there is any question as to the drug route. The nurse must know the appropriate route for the drug. Giving drugs via the wrong route can cause serious harm to patients. If possible, when using a syringe or other device, label the appropriate route so that there is no confusion.

Right Time:

  • Nurses need to understand why drugs are given at certain times. Although some drugs require clinical judgment as to when to administer, such as an as-needed sleeping drug, other drugs are labeled time-critical (Vaismoradi et al., 2018). Studies show that giving drugs at incorrect times results in 30-40% of all drug errors (Tariq & Scherbak, 2019; Gorgich et al., 2016). Giving drugs at an incorrect time can impact the bioavailability and efficacy of the drug. Doing this results in the drug not working for the patient as it should. Likewise, drugs should not be prepared or mixed in advance for the same reason.

Right Documentation:

  • Write down the drug after you give the dose. Note injection sites.

Right Patient Education:

  • Educate the patient on what to expect regarding side effects, benefits, reactions, and when to seek medical help.

Right to Refuse:

  • Patients have a right to refuse any drug. Document refusal of the drug.

Right Assessment:

  • Assess the patient. Note the patient's history and any perimeters around drug administration.

Right Evaluation:

  • Check for drug allergies and interactions.

Case Study #1: Nurse Jane

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 get upset. After trying to calm her down, to no avail, Jane went to her cart to look at the M.A.R. to see what med she could give her. 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 the drug, thinking that the concentration was 1 mg/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 ongoing nurse asked Jane where the other half 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.

Rules of the Medication Pass

Before beginning a med pass, take a look at the MAR. NEVER go by memory. Check documentation for patient 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. 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. Do not borrow 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 (MDIs) expire one month after opening.

Official “Do Not Use” Abbreviations

Some of the abbreviations we use for medication passes are not utilized anymore, as they can cause confusion and increase the risk of medication errors. Per The Joint Commission (T.J.C.) (2020), here is the most recent list of abbreviations to avoid:

Official "Do Not Use" List (T.J.C., 2020)
Do Not UsePotential ProblemUse Instead
U, u (unit)Mistaken for "0" (zero), the number "4" (four) or "cc"Write "unit"
I.U. (International Unit)Mistaken for IV (intravenous) or the number 10 (ten)Write "International Unit"
Q.D., Q.D., q.d., qd (daily)
Q.O.D., Q.O.D., q.o.d, qod(every other day)
Mistaken for each other
Period after the Q mistaken for "I" and the "O" mistaken for "I"
Write "daily"
Write "every other day."
Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)
Decimal point is missed
Write X mg
Write 0.X mg
MS
MSO4 and MgSO4
Can mean morphine sulfate or magnesium sulfate
Confused for one another
Write "morphine sulfate"
Write "magnesium sulfate"

The rules regarding not using these abbreviations applies to all orders and medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.

*Exception: A "trailing zero" may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation (T.J.C., 2020). Because there are many medication errors involving Morphine Sulfate, it is very important to never use the abbreviation!

Steps of the Medication Pass Process

  • Wash your hands with soap and water before and after med pass.
  • Ensure med cart is locked when not in use.
  • Make sure that the med room is always locked.
  • Keep your cart clean and organized without any personal items.
  • Make sure any applesauce and/or ice cream that you will be using to mix medications in, as well as the clean water pitcher, are dated.
  • It is permissible to use alcohol-based hand sanitizer between patients if hands not visibly soiled.
  • Make sure to wash hands again after three uses of hand sanitizer.
  • Monitor and record vital signs that are required prior to medication administration.
  • Use apical pulse for certain medications such as Digoxin and antihypertensive drugs.
  • Check and make sure the order is correct.
  • Always check the resident's name, drug, dosage, strength, and route using the MAR for reference.
  • Enter resident's room after knocking and identify yourself.
  • Make sure the resident is sitting up before giving the medications.
  • Administer the medications via the correct route.
  • Document the administration of the medications.

Important Things to Remember During Medication Pass

  • Never leave the room until you are sure the resident has taken medications.
  • Never leave the meds in the room for the resident to take later.
  • If there ever is a difference between the MAR and the medication, STOP!
    • Take Action:
      • Review the order in the chart.
      • Check with your supervisor.
      • Call the pharmacy if needed.
      • Do not give the medication until you know the order is correct and the order has been corrected on the MAR.

Administering High-Alert Medications

Many patients require high-risk/high-alert medications. High-risk medications are drugs that bear an increased risk of causing significant patient injury when they are used incorrectly. If is up to you to identify high-alert medications based on your facility's approved list. Examples of high-alert medications are anticoagulants, antidiabetic agents, sedatives, and chemotherapeutic drugs. It is especially important to monitor medication dosing carefully, particularly if dosing adjustments are necessary because of narrow therapeutic windows. Also, make sure to obtain and review any laboratory values required for dosing adjustments, collaborate with the practitioner if values are out of the therapeutic range, and watch for adverse effects.

The nurse is expected to know the action of each medication, so a medication reference book must be kept on each cart. Be sure to look up all medications you are not familiar with!

High-alert medications can be dangerous to your residents. Familiarize yourself with your facility's list of high-risk medications, check and recheck physician's orders, ask for help when you are unsure if an order is correct or if the resident is showing signs/symptoms of an adverse reaction.

List of High-Alert Medications (Institute for Safe Medication Practices [ISMP], 2021)

  • Anticoagulants:
    • Heparin is the most common anticoagulant used in long-term care. Monitor for bleeding, chest pain, rapid breathing, and fast heart rate. Vital signs are taken before administration. Vitamin K is to be given for critical level International Normalized Ratio (INR) per physician's orders.
  • Hypoglycemics:
    • These are used to control blood sugar. Perform blood sugar tests before giving Insulin or if you suspect low blood sugar. The most common signs/symptoms of low blood sugar include sweating, confusion, weakness, headache, and dizziness. Always have a tube of Glucagon on your cart to help reverse these symptoms.
  • Opioids:
    • The drug that nurses have trouble with is liquid morphine. Be sure to check and recheck the concentration. All forms of opioids are considered high-risk. Pay attention to the frequencies and dose. Be sure to watch the resident swallow the narcotic and if is timed release, ensure the resident does not chew the pill.
  • Digoxin:
    • Vital signs must be taken before dose, pay attention to the pulse! If the pulse is below 60 or above 100, do not give and document findings.
  • Chemotherapy Agents:
    • Chemotherapy is only given in oral doses in long-term care. Follow instructions carefully and do not touch the drug.

Residents' Rights and the Med Pass (Centers for Medicare and Medicaid [CMS], 2021)

Before we continue with the med pass, let's review residents' rights regarding medications:

  • Residents have the right to be treated with dignity and respect.
  • Residents have the right to privacy.
  • Residents (and families) have the right to refuse medication.

Keeping these rights in mind while passing medications helps the residents keep their dignity.

How to Prepare/Administer Medications

Preparing Oral Doses

When preparing oral doses, be sure to follow facility guidelines as well as CMS and pharmacy guidelines:

  • If you must touch a pill, use gloves.
  • Always pop pills from bubble pack over the cart.
  • If you drop a pill, throw it away. If it is a narcotic, have another nurse waste it with you. You always need a witness when wasting narcotics.
  • Be sure to split only pills that are allowed to be split, no pills that are not scored!
  • Not all medications that are scored can be crushed [e.g., Toprol XL (metoprolol succinate)].
  • If you have an order to crush medications, use a pill crusher or mortar and pestle. Crush the medications into a fine powder, mix in applesauce or other items (water for enteral tubes).
  • Be certain to shake liquids before pouring, pour at eye level, wipe any drips from the bottle afterward, and ensure resident swallows the entire dose.

Medications with Agency for Health Care Administration (AHCA)/CMS Guidelines

  • Metered-Dose Inhalers (MDIs):
    • They are used to treat asthma and chronic obstructive pulmonary disease (COPD).
    • Wait one minute between puffs.
    • Have resident rinse their mouth after doses are administered.
  • Fentanyl Patches:
    • Used for severe pain and is time-released.
    • CMS has determined that some drugs remain on the pad after removal and can lead to potential diversion and abuse.
    • Be sure to document the time the patch is removed and waste with another nurse (depending on the rules of your facility). To properly dispose of it, fold it in half with the sticky sides touching and flush it down the toilet (U.S. Food & Drug Administration [FDA], 2018). Do not place it in a garbage can where others might become exposed upon touching it (FDA, 2018).
  • Medication Administration via Feeding Tube: Most time-consuming! Always check placement before administering the drug, give each medication separately, and flush tube between each medication (American Association of Post-Acute Care Nursing [AAPACN], 2021).

Eye Drop Administration

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 being administered. Have the resident close their eyes to help wash the medication drop over the entire eye. Wait at least five minutes before administering another drop.

Ear Drop Administration

Always use gloves when administering ear drops. Have the resident lie down with the affected ear up, pull up and back on the ear lobe, and instill drops without touching the dropper to the skin, ear lobe, etc.

Common Medication Errors

Every new nurse will think that it will not be them to 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, and remembering the ten 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." (National Coordinating Council for Medication Error Reporting and Prevention [NCCMERP], 2021).

Antipsychotics, antidepressants, sedatives/hypnotics, and anticoagulants are the most common drugs for errors. The most common errors are giving medications at the right time, the right dose, and the right route. Sound familiar? Remember the ten rights of medication administration!

Documentation for Medication Pass

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 medication, you will have more steps to do in order to complete your paperwork properly.

Remember to use the Nursing Process (nursing 101): Assessment, Diagnosis, Planning, Implementation, and Evaluation. The assessment includes vital signs, lung sounds, 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 pain level before it is given and then after 1 hour. The nurse must be sure to fill in every space. Remember: If it is not charted, it is not done!

Case Study #2: Nurse Judy

Judy, a new Registered Nurse (RN) on the unit, has been previously "instructed" by the other nurses to pre-pour medications to stay within the time-limit boundaries of 1 hour before and 1 hour after for timely medication administration. She felt pressured to follow the other nurses' routines, afraid she would not get more help if needed if she did not. Unfortunately, soon after Judy finished pre-pouring the medications, Betty walked in. She took her cart into the med room, 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, "that is actually not allowed." Judy learned a valuable lesson that day: Do NOT pre-pour meds! If Betty had not 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 error.

Conclusion

Long-term care nursing is a rewarding and challenging career. A Long-term care nurse must have a passion for working with 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.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
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References

  • American Association of Post-Acute Care Nursing. (AAPACN). (2021). Medication administration and pharmacy guidelines. Visit Source.
  • Centers for Medicare & Medicaid Services. (CMS). (2021). Residents' rights & quality of care. Visit Source.
  • Gorgich, E., Barfroshan, S., & Ghoreishi, G. (2016). Investigating the causes of drug errors and strategies to prevention of them from nurses and nursing student viewpoint. 8(8). Visit Source.
  • Institute for Safe Medication Practices. (ISMP). (2021). High-alert medications in long-term care (L.T.C.) Settings. Visit Source.
  • The Joint Commission. (TJC). (2020). Official "Do Not Use" Fact Sheet. Visit Source.
  • National Coordinating Council for Medication Error Reporting and Prevention. (NCCMERP). (2021). About medication errors. Visit Source.
  • Potter, P., Perry, A., Stockert, & Hall, A. (2017). Fundamentals of Nursing (9th ed.). Visit Source.
  • Tariq, R., & Scherbak, Y. (2019). Drug errors. StatPearls. Visit Source.
  • U.S. Food & Drug Administration. (FDA). (2018). FDA drug safety communication: FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety-- emphasizing that accidental exposure to used patches can cause death. Retrieved August 31, 2021. Visit Source.
  • Vaismoradi, M., Amaniyan, S., & Jordan, S. (2018). Patient safety and pro re nata prescription and administration: A systematic review. Pharmacy (Basel), 6(3), 95. Visit Source.