THE DUAL THREAT OF MEDICATION ERRORS
       Medication errors can have serious consequences for patients, and for the healthcare providers who care for them. Obtaining and administering each resident’s medications in a timely and accurate fashion has long been one of the more persistent challenges in the long-term care setting.
       Facilities that fail to properly administer and monitor medications can be cited under a variety of federal tags. Since failure to timely deliver an ordered medication can almost always be interpreted as causing some form of harm to a resident, there is a real danger that a facility cited under one or more of these tags will be cited at a very high scope and severity level, with tags often being written at least at a G level (actual harm, isolated incident). In addition, because med errors are often symptomatic of systemic deficiencies in a facility’s medication control and administration processes, it is not unusual for a surveyor, having found one instance of noncompliance, to quickly detect other issues and write one or more tags at H levels or higher, or even to declare an immediate jeopardy.
       Pharmacy Services and procedures for administering medications are covered under federal tags F-425 through F-432. The principal tags that cover the accuracy and timeliness of medication delivery are F-425 and F-426.

ROOT CAUSES
       In most cases where residents are not timely receiving medications, in a timely matter, it quickly becomes clear that the problems stem-at least in part–from inadequate systems for ensuring that medications are actually available for on-time delivery as per physician orders. Corrective actions taken by the facility will have little impact if the pharmacy is unable or unwilling to deliver medications on time. In addition, nurses and med techs who are responsible for passing medications must be absolutely committed to working within any system that is established, as even the best system is unlikely to achieve 100% compliance without staff buy-in and cooperation. And neither threats, promises of rewards or endless inservices will do the job, unless facility leaders are committed to carefully following up and evaluating the effectiveness of both training and systems.

CHANGE BEGINS

Table 1.

       Medications are so critical to the health and well-being of most residents that any deficiency in their proper administration should be cause for alarm and immediate, if not drastic intervention. However, while identifying the deficiency is usually simple, getting to the root of the problem can be very difficult.
       In one facility, it was discovered that nurses were routinely circling medications, and neither documenting the reasons why the meds were not administered nor following up with the physician or the resident to determine the proper course of action following the missed administration. All nurses were educated once again and consequences were established for those who refused to comply. But further investigation into the problem revealed that a major source of the ongoing problem was a communication breakdown between the pharmacy and the nurses. Overcoming the urge to sink into finger pointing was a challenge at first, but once the problem was identified, all of the parties quickly came together to establish an improved system for communicating with the pharmacy and notifying physicians.
       Complying with the Pharmacy Services regulations in the long-term care setting requires that the pharmacist be intimately involved in the entire medication use process–from ordering to administration, to destruction of medications. The facility employed a consultant pharmacist to help re-establish effective lines of communication between the nurses and the pharmacy, and between the nurses and the residents’ physicians. Effective procedures for MedPass, MedRoom, and MAR/CART checks by the pharmacist were put in place. The consultant pharmacist remained on call to serve as a resource to help resolve subsequent issues with medication availability, such as change of condition charting and resultant changes in medication regimens. As the changes were implemented and became routine, both attitudes and accuracy steadily improved.

CONCLUSION

Table 2.

       The new medication communication and delivery plan was tested and proven to be a success. It was abundantly clear that no system was going to be successful without the focused involvement of all parties to the prescription and delivery of resident medications—physicians, nurses, pharmacy, and facility leadership. Consistency, follow up training, and constant monitoring were all key elements of ensuring the system’s success. While the nurses and facility leadership all agreed that it was a very challenging experience to go through, they also agreed that the results were well worth the effort—in more ways than one.