NURSES_TRAINING_SESSION.pptx,ppt nursing training classes and procedures

Procedure to obtain medicine and other procedures of nursing handover..

1. NURSES TRAINING SESSION Presented by: Dr K hatija K hanum Clinical pharmacologist

2. TOPICS Procedure to obtain medicine when pharmacy is closed Look-alike and sound alike medication High-risk medicine safety Verbal orders for medicines Medication recall ADR reporting Medication Error Safe administration of medicines Reporting of medication errors Safe usage of chemotherapeutic medication Safe usage of radio-active drugs Safe usage of narcotic drugs and psychotropic substances

3. Procedure to obtain medicine when pharmacy is closed The Pharmacy services in the hospital will function along with its sub-centres across the hospital, catering to both out-patients and in-patients. One pharmacy may cater to out-patients and there is one centre on each floor catering to in-patients, strategically located according to the requirement and the number of beds. The hospital pharmacy will be open for 24hours. The organisation will decide on the working hours of the pharmacy and formulate a policy. In order to ensure there is a continuous supply of medication after working hours, the following measures will be taken

4. There will be a cupboard or a separate rack to store the medication required till the pharmacy opens the next day. There will be a pharmacist on call who will open the pharmacy when required. A senior nurse will be trained to dispense emergency drugs in a safe manner; the use of this method should be kept to the minimum. Medications will be procured from an outside pharmacy. All the required medication will be indented patient wise before the pharmacy is closed. At least one pharmacy will be kept open on public holidays and after working hours.

5. Look-alike and sound alike medication The organisation will identify sound-alike and look-alike medication. The list should be developed from hospital formulary and should be reviewed by the multidisciplinary committee. Medications will be stored far away from each other and adhere to best storage practices.

6. High-risk medicine safety High risk medications are drugs that carry a heightened risk of causing significant harm to patients when used erroneously. Though mistakes may or may not be more common with these drugs, the consequences of an error are devastating to patients. The organisation will identify its list of high-risk medication based on the scope of services. This list will ideally include controlled substances, psychotherapeutic medication, look-alike and sound-alike medication and concentrated electrolytes. To ensure safety of patients and to avoid any inadvertent administration, the organisation will have methods to reduce error which includes: The list of high risk medications will be uniform and displayed in all relevant area making it available to all clinical staff and pharmacy High-risk medication will be stored in predetermined areas of the organisation’s specific wards, OT and ICUs based on the clinical needs.

7. Verbal orders for medicines As per the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), verbal orders are defined as those given by a physician or other providers with prescriptive authority to a licensed person who is authorised by the organisation’s policy. This licensed person has the right to receive and record verbal orders in accordance with laws and regulations. Verbal orders include all telephonic and face-to-face patient care orders which are: Communicated verbally by an authorised prescriber Received by a licensed individual authorised by the organisation to receive verbal orders. This individual will record the order and read it back to the person providing the order Co-signed or authenticated by the authorised prescriber at a subsequent time to validate the order Verbal orders will be restricted to the maximum extent. However, verbal orders are accepted in urgent situations or emergencies where written orders are not feasible.

8. Medication recall Recall is required if there is an order from the regulatory authorities to withdraw a certain batch of medication or implants; this is called a statutory recall. Recall may also occur following internal feedback from the dispensing pharmacist, patients, nurses or doctors; e.g. Intravenous (IV) fluids or ampoules may be contaminated, expired, tampered, etc. In such cases, the medicines are recalled; sometimes the entire batch is recalled from the user areas- voluntary recall Each recall is documented in the ‘Drug Recall Register’ mentioning all the details. In such cases, the regulatory authorities should be informed about the recalls done stating the reasons. A recall report is submitted to the multidisciplinary committee and to the regulatory authorities .

9. Adverse drug reaction An adverse drug reaction (ADR) is a  noxious harmful, unintended result caused by taking medication. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs.

10. TYPES OF ADR Depending on... Onset of event: Acute (<60 minutes), Sub-acute (1-24 hrs ) and Latent (>2days) Type of reaction Type A (Augmented) Type B (Bizarre) Type C (Chemical) Type D (Delayed) Type E (End of medication) Type F (Familial) Severity : Minor, Moderate, Severe, Lethal ADRs

11. ADR MONITORING AND REPORTING ADR can be monitored and evaluated by using ADR reporting forms ADR reporting plays an essential role in understanding the toxicity of a drug A collective report of ADR reports must be documented to analyse the clinical use and therapeutic outcome of a drug ADRs report of a drug are an essential part in analysis of the benefit over risk ratio in patients with complications

12. MEDICATION ERROR Medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures and systems including prescribing, dispensing and administration. Medication Error include Prescribing Error Dispensing Error Documentation Error Transcription Error Indent Error Administration Error

13. Medication error documentation Medication errors are an important preventable cause of morbidity and mortality. If errors are reported, corrective measures can be undertaken to prevent them. This will improve the safety of the patients. What to report? All medication errors should be reported. Even potential errors (events that have potential to cause error) can be reported. A few examples of medication errors are given above. Who can report? Any health care professional (doctors, nurses, pharmacists and allied health care professionals) can report medication errors. When to report? Whenever you come across a medication error, committed by self or anyone, you can report. There is no strict timeline within which it should be reported. But it is advisable to report immediately.

14. An ME that has not harmed the patient but has the potential to do so is categorised as a near miss and will also be captured and reported as an ME The medication errors will be captured either through active or passive surveillance Active surveillance includes audit of medical record, pill counting and tracing of medication process, structured checklist, patient interview, etc. It is usually conducted by nurses, pharmacists and the quality team. Passive surveillance is conducted through chart audit, indent tracer and administration record review. This is usually conducted by the Medical Records Department (MRD), pharmacy and quality team. The organisation will have an established reporting process for MEs and ADEs which includes a format for reporting, timeline and Minimum Data Set (MDS) defined for reporting. All ME reports will have details of Identifiable reporter Date and location of incident, Details of drugs Description of errors

15. REPORTING OF MEDICATION ERROR

16. Authorized Personnel for administration of Medications Only registered doctors with minimum MBBS degrees or registered nurses shall administer medication If any registered personnel is administering medication, then it should be as per the law of land. The administration of medication will be as per the instructions of the treating doctor’s team is the most important step in patient care. The organisation ensures that the required resources such as personnel, stationery training and appropriate space are provided for the staff to carry out administration of medication.

17. The areas in which the medication is administered in a hospital are: Out-patient areas including diagnostics Day care In-patient areas The records which are used to document all phases of medication administration are: Consultant notes Operation Theatre (OT) notes Anaesthesia notes Nurses’ notes Intensive Care Unit (ICU) monitoring records Medication records

18. Handling Prepared Medications In emergency care areas of hospitals like the OTs, ICU and even wards the ideal procedure for preparation of medication should be followed The medicine must be properly labelled, timed and dated before the preparation of the second drug. In order to ensure that there are no medication errors, the medication should be verified from the order, physically checked for expiry, double checked for right dose The loaded syringe should be labelled with name and dose of drug, time of loading, name of the nurse who has prepared the medicine The prepared medicine is first labelled before loading the next medication. In OTs and ICUs Anaesthetists, Nurses (as instructed by the treating doctor or the intensivist) are responsible for administration of medicine To ensure immediate administration when the need arises, thus avoiding any delay that can lead to complications, the medicine is preloaded during surgery or at the bedside of patient

19. Patient identification prior to administration Each patient is identified before the administration of medication. As per the patient identification policy, a minimum of two identifiers are used to identify a patient before any procedure in a hospital. If the patient is conscious – name and UHID is checked, for unconscious patient senior nurse should validate patient identity All drug allergies will be mentioned in BOLD CAPITAL LETTERS on the cover of the patient’s medical record.

20. Order and physical verification of medication The staff administering the medication will verify the order and ensure that the medication is administered appropriately. If any of the parameters with respect to an order such as name, dose, route or frequency and time are missing or incomplete, then the medication administration shall be withheld till a clarification is sought from the treating team. Verbal order medication should adhere to the verbal order protocol. Utmost care is required with respect to high-risk and high-alert medication. A two-step verification process is followed wherein two nurses verify the order and physically check the medicines before administering them

21. Verifying the order prior to administering medication The dosages is calculated based on the age and weight of the patient, medical condition, illness and severity of the illness. The dosage is verified once or twice from the order prior to medication administration Verifying route of administering medications The site and route of administration must be verified physically prior to medication administration. The nurse in charge will verify the route and validate with the senior nurse or the treating team before medication administration to avoid serious adverse drug reactions.

22. Verifying the frequency for administering medications The ‘right time’ is one of the most important right principles of MA Medication is administered at a particular time and frequency. Most of the medicines have a direct relation with food. There are a few medicines which must be taken on an empty stomach, some before food (time will be specified), many after food, many at a specified time, etc. Measures for misconnection during administration The organisation will ensure that inadvertent administration of a drug through a wrong route is avoided. This could be done by using design features that prevent misconnections and prompt the user to take correct action. IV should not be used for epidurals, irrigation, drains and central lines or to extend enteric tube feeding. Staff administering the medication will trace all lines from their origin to the connection port to verify attachments before making any connections and reconnections or administering medication, solutions and products.

23. Safe usage of narcotic drugs and psychotropic substances Safe usage of chemotherapeutic medication Safe usage of radio-active drugs

24. TERM DEFINITION Atomic Energy Regulatory Board (AERB) A national authority designated by the Government of India having the legal authority for issuing regulatory consent for various activities related to the nuclear and radiation facility and to perform safety and regulatory functions, including their enforcement for the protection of the site personnel, the public and the environment from undue radiation hazards . Chemotherapy drugs High-risk medication, which is highly complex in nature, meant to achieve maximal anti-cancer effect. Narcotic drugs Addictive drugs that reduce the user's perception of pain and induce euphoria (a feeling of exaggerated and unrealistic well-being). These substances lead to increased tolerance and physiological dependence. They have a potential for abuse and/or addiction. Psychotropic substances Drugs that can affect the mind, emotions and behaviour. Radiopharmaceutical drugs Drugs that are hazardous to the human and the environment as they emit beta and gamma radiations.

25. Safe Usage The organisation will ensurepatient safety while usingthe high risk medication like NDPS, chemotherapeutic agents and radioactive agents These agents will be used with caution according to written guidance which is in consonance with national regulations like NDPS Act and Atomic Energy Regulatory Board (AERB) guidelines There are six Essential Narcotic Drugs (END) morphine, methadone, codeine, hydrocodone , oxycodone and fentanyl approved by the Drug Controller of India for medical and scientific uses The organisation will ensure infrastructure and facilities present to cater to such patients who require ENDs. The radioactive agents are used with medical devices and for diagnostic purposes, in oncology services with newer procedures like Computed Tomography (CT) and Positron Emission Tomography and Computed Tomography (PET-CT).For therapeutic procedures along with newer procedures - multiorgan studies, nuclear medicine procedures and in medical products.

26. Chemotherapy mediation will be prescribed by registered and certified medical oncologist The hospital will adhere to chemotherapy drug preparation protocol with regard to a clean and sterile physical environment, availability of biosafety cabinets, administration as per the defined protocol involving verification and supporting medication with necessary investigation and monitoring for specific side effects and adverse reactions. Cytotoxic wastes will be disposed of as per the guidelines of Biomedical Waste Management and handling rules and Occupation Safety and Health Administration (OSHA) guidelines

27. Prescription protocol The NDPS is usually prescribed by the medical officer, who will have medical council and/or dental council registration, if there is a clinical need in line with statutory regulation The radionuclide's will be handled only by authorized staff who have received training in radiation safety. Medical oncologists and registered and certified doctors will be authorized to prescribe chemotherapy medication. General practitioners who are experienced and trained in the department of oncology can prescribe, but it shall be under the guidance of the medical oncologist

28. Storage protocol The organisation will have a defined system to store these drugs ensuring safety and security of the authorised personnel handling the medication and the patients. The organisation will ensure separate cupboards are provided for storing NDPS ONLY and the cupboard should have a double-locking system All the containers containing these drugs willbe adequately labelled . Pest control and fire safety measures should be appropriate for security of the drugs. There will be one person responsible in each shift to ensure safe storage and use of the locker facility, with its safety key.

29. The keys will be kept back in the same designated place so that the next shift in charge can access the cupboard, or the keys can be physically handed over to the next in charge staff. Radioactive material will always be clearly identified with a radioactive material hazard warning tape and marked with details of the radionuclide, date, approximate activity and name of the member of staff or group responsible for it. Radioactive materials, when not in use, must always be stored in a secure location, taking special care to minimize the possibility of accidental contamination during storage. Rooms in which radioactive materials are used or stored must be locked when unoccupied The infrastructure specification is applicable for safe and secure storage practices of chemotherapy drugs.

30. Preparation and Administration Only qualified and trained personnel will be responsible in preparing and administering chemotherapy drugs. Responsible Staff are also trained. A biosafety cabinet (preferably class II A, with appropriate Personal Protective Equipment [PPE]) is used for preparing chemotherapy drugs Radioactive drugs are prepared and administered by authorized personnel by the Statutory body

31. Disposal Practices and related records The NDPS stock is received from the local authority. The details is captured in the register: date wise, the name of the drug or formulation, manufacturing date, expiry date, batch number, the quantity of each formulation received, signature and name of the authorized person who has received and checked. Annual return is filed to the local authority before the 31st of March every year. There will be a triplicate prescription – one will be in the pharmacy; one will be in the narcotic register; and the third one will be filed in the patient case sheet. The drugs or ampoules will be issued against empty ampoules during refilling of the prescription.

32. The expired drugs are discarded in the presence of an officer identified by the state drug controller. The empty vials or ampoules are discarded as per the local guidelines and biomedical waste guidelines. The whole process of disposal is documented in a register recording all the details with relevant signatures and seals.

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