SIDE EFFECTS AND ADRs CONTINUED Side effects and ADRs often go unnoticed or are misdiagnosed in seniors: • Physical reactions such as fatigue, falling or weight loss that may be mistaken as “normal” aging • Symptoms may be mistaken for decline of an existing health condition or a new health condition • May mimic diseases such as the confusion associated with dementia or Alzheimer’s disease September 2019 Safety, Oversight and Quality Unit 26
ALERT Consider any sudden change in an older adult’s physical ability or personality, especially after beginning a new medication, to be an adverse medication reaction until proven otherwise. September 2019 Safety, Oversight and Quality Unit 27
MEDICATION INTERACTIONS A medication interaction is when one medication changes or alters the function of another medication. This includes: • Pharmacy-dispensed medications • Medications purchased over-the-counter • Alternative medications and supplements • Home remedies • Foods and beverages can also interact with medications September 2019 Safety, Oversight and Quality Unit 28
MEDICATION INTERACTIONS CONTINUED Medication interactions include: Medication to medication: • Calcium supplement can reduce the effectiveness of medications used to treat low thyroid levels; or • Two different medications that cause drowsiness can significantly increase the risk of injury or falls September 2019 Safety, Oversight and Quality Unit 29
MEDICATION INTERACTIONS CONTINUED Medication to food or beverage: • Grapefruit juice and fresh grapefruit can increase the amount of active ingredient for certain medications leading to increased adverse medication reactions Medication to disease: • An existing medical condition can make certain medications potentially harmful – for example someone with liver damage may have to restrict or avoid acetaminophen or other medications that can be harmful to the liver September 2019 Safety, Oversight and Quality Unit 30
MEDICATION INTERACTIONS CONTINUED Seniors, persons with chronic health conditions or developmental or physical disabilities are at higher risk for medication-related problems: • Taking several medications increases the risk for an adverse reaction • One or more chronic conditions — such as heart disease, high blood pressure, diabetes and arthritis — can affect how a medication works in the body September 2019 Safety, Oversight and Quality Unit 31
ACCESS TO INFORMATION Caregivers must have immediate availability to medication references, such as: • Online resources: • medications.com • Current medication reference: • Updated medication reference books are generally available annually in October/November • Current product inserts or medication summary • Must replace each time a refill is picked up; AND • Each time an OTC is purchased September 2019 Safety, Oversight and Quality Unit 32
MEDICATION ERRORS Medications are used to treat disease and ease discomfort or pain. However, when medication errors occur, it may cause harm or even death. Medication errors are a common problem resulting in ER visits, hospitalizations and even death It is estimated that 98,000 individuals die each year due to medication errors – this includes: Taking too much Not taking; or Taking inappropriately September 2019 Safety, Oversight and Quality Unit 33
MEDICATION ERRORS CONTINUED All medication errors have the potential to be serious and cause harm: • Negative effects of a medication error may not be visible for years; • Overuse or overdose can cause damage to major organs such as kidneys and liver: • Overdose can even occur when the doses of a medication ordered multiple times a day are given too close together Medication errors may lead to corrective action and/or a finding of abuse. September 2019 Safety, Oversight and Quality Unit 34
MEDICATION ERRORS CONTINUED Common medication errors include but are not limited to: • Giving a medication at the • Giving the wrong medication wrong time • Giving a discontinued • Not giving a scheduled medication medication • Giving an expired medication • Not giving a PRN medication • Giving a medication to wrong when indicated resident • Giving a medication using the • Improperly stored medication wrong route • Missing or incomplete • Giving an incorrect dose documentation • Not rotating subcutaneous • Improper disposal injections or transdermal patches September 2019 Safety, Oversight and Quality Unit 35
HOW TO READ LABELS - PRESCRIPTIONS September 2019 Safety, Oversight and Quality Unit 36
HOW TO READ LABELS - OTC Safety, Oversight and Quality Unit September 2019 37
HOW TO READ LABELS - SUPPLEMENTS Safety, Oversight and Quality Unit September 2019 38
HOW TO READ LABELS – HERBAL TEAS Herbal tea remedies can interfere with other medications or certain conditions. It is critical to read all labels even for herbal teas: Chamomile: • Negatively interacts with estrogen, tamoxifen and coumadin; and • Isn’t recommended for individuals with allergies to ragweed Licorice has a major interactions with coumadin and negatively interacts with digoxin, estrogen and Lasix Ginger can increase the risk of bleeding September 2019 Safety, Oversight and Quality Unit 39
HOW TO READ LABELS – HERBAL TEAS Safety, Oversight and Quality Unit September 2019 40
MEDICATION ROUTES Medications can be introduced into the body through many routes. The prescribing practitioner will write what route the medication must be given: If medications are not given as ordered it may result in: • Medication not working properly; or • Harm to the resident September 2019 Safety, Oversight and Quality Unit 41
MEDICATION ROUTES CONTINUED • G-tube/j-tube • Intramuscular (IM) injection** • Intravenous (IV)** • Nasal (drops or inhalers) • Ophthalmic (eye) • Oral (taken by mouth) • Otic (ear) • Rectal • Subcutaneous injections* • Sublingual • Transdermal (via skin) • Vaginal September 2019 Safety, Oversight and Quality Unit 42
MEDICATION ROUTES CONTINUED **Intramuscular (IM) injections cannot be delegated. Arrangements must be made with a licensed practitioner to administer. Options available: • Request a referral for home health or, if the resident is on hospice, make arrangements with hospice • Contract with a nurse to perform the task; or • Make arrangements with the resident’s primary health care practitioner September 2019 Safety, Oversight and Quality Unit 43
ALERT - DELEGATIONS An RN must delegate a task of nursing before you can perform the task. Common tasks of nursing include but are not limited to: • *Subcutaneous injections, for example insulin • Food, fluid or medication administration through a gastrointestinal (g-tube) or jejunostomy tube (j-tube) • Peritoneal dialysis • Other tasks as determined by the RN September 2019 Safety, Oversight and Quality Unit 44
ALERT – DELEGATIONS CONTINUED The delegation process requires the RN to: • Evaluate the resident and caregiver(s) • Provide training to the caregiver(s) • Observe the caregiver(s) perform the task on the resident • Leave step-by-step instructions on the task • Provide on-going supervision for the task that has been delegated • Each delegation is for one specific resident and cannot be transferred to other residents • The delegated caregiver cannot teach other caregivers to do the task September 2019 Safety, Oversight and Quality Unit 45
ALERT – DELEGATIONS CONTINUED For additional information on your responsibility for delegated tasks take the self-study course: RN Delegation for Lay Caregivers at – http://tinyurl.com/DHS- AFHTraining September 2019 Safety, Oversight and Quality Unit 46
ALERT – INTRAMUSCULAR INJECTIONS Intramuscular (IM) injections are allowed for anticipatory emergency medications. Giving IM injections is taught and cannot be delegated: Epinephrine: • Allergic reaction emergencies Glucagon: • Severe low blood sugar emergencies September 2019 Safety, Oversight and Quality Unit 47
ALERT – INTRAMUSCULAR INJECTIONS CONTINUED Caregivers must be trained by an approved trainer following the training curriculum outlined by the Health Division’s Anticipatory Emergency rules. September 2019 Safety, Oversight and Quality Unit 48
MEDICAL ABBREVIATIONS While gathering information and medical orders you may encounter medical abbreviations. If you do not understand, ask for clarification from an appropriate medical professional: • The abbreviations listed on the following tables identified with an asterisk (* ) should not be used – this recommendation is based on high frequency of errors. The abbreviations were included since some individuals may still be using them. September 2019 Safety, Oversight and Quality Unit 49
MEDICAL ABBREVIATIONS CONTINUED September 2019 Safety, Oversight and Quality Unit 50
MEDICAL ABBREVIATIONS CONTINUED September 2019 Safety, Oversight and Quality Unit 51
MEDICAL ABBREVIATIONS CONTINUED September 2019 Safety, Oversight and Quality Unit 52
MEDICAL ABBREVIATIONS CONTINUED September 2019 Safety, Oversight and Quality Unit 53
MEDICAL ABBREVIATIONS CONTINUED September 2019 Safety, Oversight and Quality Unit 54
MEDICAL ORDERS September 2019 Safety, Oversight and Quality Unit 55
PURPOSE AND KEY TERMS • Medical order The purpose of this section is to assist the learner in understanding • Medication administration medical orders and how to record (MAR) document medications, • PRN medications treatments and therapies on the • Parameters medication administration record (MAR). • Self-medicate September 2019 Safety, Oversight and Quality Unit 56
OBJECTIVES The learner will be able to: Describe what requires a medical order by the resident’s primary healthcare practitioner Demonstrate the ability to record medications on the MAR Describe how to document a missed/refused medication Define a PRN medication and how to record on the MAR Describe parameters and the importance of having parameters written for PRN medications Describe what must be documented when a resident has written approval from his or her primary healthcare practitioner to self-medicate September 2019 Safety, Oversight and Quality Unit 57
MEDICAL ORDERS The AFH provider is responsible for obtaining all necessary written orders and understanding: • The reason for the medication • How the medication is expected to work; and • Any special instructions from the prescribing practitioner about the medications The AFH provider is responsible for carrying out the written orders. September 2019 Safety, Oversight and Quality Unit 58
MEDICAL ORDERS CONTINUED The following must all have a written medical order from a prescribing practitioner: • Prescription medications • Prescribed over-the-counter (OTC) medications including vitamins and other nutritional supplements • Prescribed dietary supplements; and • Prescribed treatments and therapies September 2019 Safety, Oversight and Quality Unit 59
MEDICAL ORDERS CONTINUED OTC medications, vitamins, nutritional supplements or home remedies not prescribed, but requested by the resident, must be reviewed by the resident’s primary health care practitioner, approved and documented in the resident’s record. September 2019 Safety, Oversight and Quality Unit 60
ALERT Written orders from a hospital, emergency room or nursing home sent with the resident can be used initially if signed by a prescriber. These orders are temporary and must be followed up with written orders from the resident’s primary healthcare practitioner immediately. September 2019 Safety, Oversight and Quality Unit 61
MEDICAL ORDERS CONTINUED Changes to medical orders may not be made without the prescribing practitioner’s approval All medical orders must be followed as prescribed unless the resident or their legal guardian refuses: • If a medical order is refused, the prescribing practitioner must be notified immediately by the AFH provider and documented in the resident’s record September 2019 Safety, Oversight and Quality Unit 62
MEDICAL ORDERS CONTINUED Changes to medication or treatment orders obtained by telephone must be followed up with a signed order from the prescribing practitioner, immediately: • Phone orders must be recorded in the resident’s record with the printed name and signature of the person taking the phone order • Requests for signed orders must be made promptly after receiving any telephone order • All attempts to request written orders must be documented in the resident’s record September 2019 Safety, Oversight and Quality Unit 63
MEDICAL ORDERS CONTINUED Changes in dose or frequency of an existing medication must be clearly identified: • Be sure to inform the pharmacist of the changes before it is time to refill the order • DO NOT have the prescription refilled without the pharmacist contacting the prescriber for the correct information September 2019 Safety, Oversight and Quality Unit 64
MEDICATION ADMINISTRATION RECORD (MAR) September 2019 Safety, Oversight and Quality Unit 65
MAR A written medication administration record (MAR) must be kept for each resident: • Frequent changes to the dosage of some medications are common. The MAR must be kept current at all times Failure to keep the MAR up-to-date could result in a medical emergency for the resident. September 2019 Safety, Oversight and Quality Unit 66
MAR CONTINUED The MAR must identify all medication, treatments or therapies you or your staff administer including, but not limited to: • Prescription medications • Over-the-counter medications • Dietary supplements, including vitamins and minerals • Treatments • Vital signs • Blood sugar checks (CBGs) September 2019 Safety, Oversight and Quality Unit 67
MAR CONTINUED The MAR must be legible and clearly indicate: • Name of each medication • Dose • The reason the medication is being given • Route (how it is to be administered) if other than by mouth • Day and frequency (i.e. daily or t.i.d.) • The time the medication must be given September 2019 Safety, Oversight and Quality Unit 68
MAR CONTINUED Immediately after administering a medication or performing a treatment, therapy or procedure, the person doing the task must write his or her initials in the appropriate place and note any information required: • Every set of initials must have a legible signature on the MAR for identification purposes • If multiple caregivers have the same two initials, decide who will need to add an initial for a middle name • Make sure there is a matching signature for every set of initials on the MAR September 2019 Safety, Oversight and Quality Unit 69
MAR CONTINUED For each new month write the month and year on the new MAR sheet: • Carefully write the medication, dose, route, days and times the medications are to be administered on each resident’s MAR according to the written medical orders • If you receive an order to stop a medication during the month, note that on the MAR after the last dose is given and draw a line to the end of the month September 2019 Safety, Oversight and Quality Unit 70
SAMPLE MAR Safety, Oversight and Quality Unit September 2019 71
MAR INFORMATION All fields must be filled out: • Resident’s full name • Name of resident’s healthcare provider • Recommended to also list phone number • List of all allergies • Month and year September 2019 Safety, Oversight and Quality Unit 72
MAR INFORMATION CONTINUED • Name of the medication (write exactly as written) • Strength of medication – for example 20 mg • Write dose if strength and dose are not equal – for example give 10 mg (1/2 tablet) • Frequency – for example BID in AM and PM • How to administer – for example PO • Any special instructions such as hold if pulse less than 60 or blood sugar less than 100 etc. • Reason for the medication September 2019 Safety, Oversight and Quality Unit 73
MAR INFORMATION CONTINUED September 2019 Safety, Oversight and Quality Unit 74
MAR INFORMATION CONTINUED September 2019 Safety, Oversight and Quality Unit 75
MAR INFORMATION CONTINUED September 2019 Safety, Oversight and Quality Unit 76
MAR - PRN MEDICATIONS Some medications, such as those used for pain, are written as “PRN” this means the medication is given as needed. AFH rules require that all PRN medications, including over-the-counter medications, have specific parameters indicating: • What the medication is for; and • Specifically when, how much and how often the medication may be administered September 2019 Safety, Oversight and Quality Unit 77
MAR - PRN MEDICATIONS CONTINUED It is best if the prescribing practitioner writes the parameters when ordering PRN medication: • Ask your pharmacist to request this information when accepting a prescription order • If a PRN medication does not include specific written parameters, you may ask the RN to assess the resident’s condition and write the parameters RNs cannot write parameters for any medication including OTCs and supplements that do not have a medical order. September 2019 Safety, Oversight and Quality Unit 78
MAR - PRN MEDICATIONS CONTINUED The parameters should be recorded on the medication administration record (MAR); • Any caregiver dispensing medications for that specific resident must follow the written instructions • If you or one of your caregivers does not have a clear understanding of the instructions, ask the RN, pharmacist or prescribing practitioner to explain to them using more details September 2019 Safety, Oversight and Quality Unit 79
MAR - PRN MEDICATION CONTINUED PRN medication documentation on the MAR must include the: • Time given • Dose (how much was given) • Reason the medication was given; and • Whether or not it was effective • With up to five residents in your home, it can be challenging, but it is critical that you keep all this information – it must be written on the MAR so all caregivers know when the PRN medication was given September 2019 Safety, Oversight and Quality Unit 80
MAR - PRN MEDICATION CONTINUED September 2019 Safety, Oversight and Quality Unit 81
MAR - PRN MEDICATION CONTINUED Documentation example for a verbal resident: September 2019 Safety, Oversight and Quality Unit 82
MAR - PRN MEDICATION CONTINUED Documentation example for a non-verbal resident: September 2019 Safety, Oversight and Quality Unit 83
MAR - PRN MEDICATION CONTINUED The caregiver giving the PRN medication needs to document in the resident’s record the response to the medication. For example: • 01/02/2011 Ms. M.M.A. complained of a headache at 10 am. Gave her two Tylenol tablets at 10:15 a.m. At 11 a.m. Ms. M.M.A. reported that she no longer had a headache. • 01/05/2001 Ms. M.M.A. has not had a BM for three days, gave 2 tablespoons of Milk of Magnesia at 8 a.m. • 01/06/2011 Ms. M.M.A. had a BM this morning. September 2019 Safety, Oversight and Quality Unit 84
MAR - MEDICATIONS GIVEN ALTERNATING DAYS Most scheduled medications are for the same dose each day however, there are some medications that are not given every day: • For example, a medication used to treat hypothyroid disease frequently is scheduled for only five days a week; • The two days of the week that the medication is not to be given must be clearly marked on the MAR. September 2019 Safety, Oversight and Quality Unit 85
MAR - MEDICATIONS GIVEN ALTERNATING DAYS September 2019 Safety, Oversight and Quality Unit 86
MAR - MEDICATIONS GIVEN ALTERNATING DAYS Some medications may be ordered to give dosages on different days: • When different doses of the same medication are given on different days or different times, the medication needs to be listed on the MAR each time the dose is different • In the following example L-thyroxine is given in two different doses on alternating days. September 2019 Safety, Oversight and Quality Unit 87
MAR - MEDICATIONS GIVEN ALTERNATING DAYS September 2019 Safety, Oversight and Quality Unit 88
MAR - INSULIN Insulin orders require additional information on the MAR: • When CBG testing must occur • CBG value (blood sugar results) • Where the injection was given (rotation site) • What to do if blood sugar is too high or too low September 2019 Safety, Oversight and Quality Unit 89
MAR – INSULIN CONTINUED September 2019 Safety, Oversight and Quality Unit 90
MAR – INSULIN CONTINUED Some rotation charts do not have numbers or letters listed. If they are blank: • Add letters or numbers • Keep the chart with the residents MAR • List the corresponding number or letter on the MAR Safety, Oversight and Quality Unit September 2019 91
MAR – TRANSDERMAL PATCHES Transdermal patches also require additional information to be written on the MAR: • Where the patch was placed (rotation site) • A time to remove if it is not replaced with a new one at the same time each day – for example Nitroglycerin transdermal patches can only be left in place for 8 – 10 hours depending on the order • Failure to remove can create significant negative outcomes for the resident September 2019 Safety, Oversight and Quality Unit 92
MAR – TRANSDERMAL PATCHES CONTINUED September 2019 Safety, Oversight and Quality Unit 93
MAR – TRANSDERMAL PATCHES CONTINUED You may use the provided tracker. Instructions on appropriate placement is found in the product information sheet. This rotation (tracker) document is specific for Exelon. September 2019 Safety, Oversight and Quality Unit 94
MAR – DOSE CHANGE If the medication dose is changed, draw a line from the last dose given to the end of the month: • In a new line, write the new information regarding the medication, dose, route, day and time; draw a line to the start day. September 2019 Safety, Oversight and Quality Unit 95
MAR – DOSE CHANGE CONTINUED September 2019 Safety, Oversight and Quality Unit 96
MAR - MISSED OR REFUSED MEDICATIONS If a medication is missed or if the resident refuses to take it, the caregiver must document this on the MAR circling the caregiver’s initials, and indicate why the medication was missed or refused. The caregiver also documents in the resident’s record what action was taken (who was notified), as well as any follow-up instructions from the residents primary healthcare practitioner. September 2019 Safety, Oversight and Quality Unit 97
MAR - MISSED OR REFUSED MEDICATION Safety, Oversight and Quality Unit September 2019 98
MAR – SELF-ADMINISTRATION In the case of those residents with written authorization from their primary healthcare practitioner to self-medicate, you are still responsible for: • Knowing the reason for the medication • What the medication is expected to do; and • If there are any special instructions from the prescribing practitioner about the medications September 2019 Safety, Oversight and Quality Unit 99
MAR – SELF-ADMINISTRATION CONTINUED It is recommended that you keep an updated MAR because: In order for you and your caregivers to document in the resident record that the resident is taking medications as ordered It is necessary in an emergency when information needs to be shared with emergency responders If the resident is unable to take medications September 2019 Safety, Oversight and Quality Unit 100
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