The article “Medication Timeliness” – Timely Medication Administration Guidelines for Nurses: Fewer
Wrong-Time Errors?” highlights the problems and inherent safety risks associated with the unrealistic
30 minute rule for the majority of non-critical medications. One quote from the article truly brings the
issue to the forefront of the clinical practice arena.
Healthcare has changed since "right time" was first defined many years ago. Hospitalized patients are
sicker, more medications are prescribed to each patient, and the formulary has expanded
dramatically. The medication administration process (from physician order to patient administration)
has grown in complexity with the addition of computerized physician order entry, medication
barcoding, automated dispensing cabinets, electronic medical records, and time-consuming patient
identification procedures. The 30-minute rule was outdated and impractical even before it
became "law."
Answer the questions that follow in paragraph format using the readings for context and citations.
Part one
1. Think about the information from the power point, article and the readings about errors and
answer the question: Can you see the patient safety risks related to continuing to try and follow
the 30 minute rule?
Use and cite at least one concept or content from the article
Part two: Using this short scenario, answer the questions in 2-3 paragraphs
At an acute care hospital, a change in the process of medication administration is occurring because
the unit is piloting use of a bar coding system for medication administration.
One month after the barcoding system was initiated, the nursing unit receives information from the
Performance Improvement Department identifying that a significant decrease in the timeliness of
administration of antibiotics has been noted. The nurse manager has written several reprimands for
the staff involved. Using concepts from the chapters and required articles, answer the following
questions.
1. Is this nurse manager taking an appropriate approach to this problem? Address the concept of
“Blame or a Culture of Safety”.
2. During this same time, the nurse educator and the students notice that additional patient ID bands
have been placed on the side rails of the beds. The instructor explains that this is a form of a
“work around”, allowing the staff to scan the patient’s ID band more easily for the bar coding
system. What are the inherent risks associated with work arounds and this one in particular?
[removed],
Module 3: Required Learning Activity
Posting to discussion folder
The article “Medication Timeliness” – Timely Medication Administration Guidelines for Nurses: Fewer Wrong-Time Errors?” highlights the problems and inherent safety risks associated with the unrealistic 30 minute rule for the majority of non-critical medications. One quote from the article truly brings the issue to the forefront of the clinical practice arena.
Healthcare has changed since "right time" was first defined many years ago. Hospitalized patients are sicker, more medications are prescribed to each patient, and the formulary has expanded dramatically. The medication administration process (from physician order to patient administration) has grown in complexity with the addition of computerized physician order entry, medication barcoding, automated dispensing cabinets, electronic medical records, and time-consuming patient identification procedures. The 30-minute rule was outdated and impractical even before it became "law."
Answer the questions that follow in paragraph format using the readings for context and citations.
Part one
1. Think about the information from the power point, article and the readings about errors and answer the question: Can you see the patient safety risks related to continuing to try and follow the 30 minute rule?
Use and cite at least one concept or content from the article
Part two: Using this short scenario, answer the questions in 2-3 paragraphs
At an acute care hospital, a change in the process of medication administration is occurring because the unit is piloting use of a bar coding system for medication administration.
One month after the barcoding system was initiated, the nursing unit receives information from the Performance Improvement Department identifying that a significant decrease in the timeliness of administration of antibiotics has been noted. The nurse manager has written several reprimands for the staff involved. Using concepts from the chapters and required articles, answer the following questions.
1. Is this nurse manager taking an appropriate approach to this problem? Address the concept of “Blame or a Culture of Safety”.
2. During this same time, the nurse educator and the students notice that additional patient ID bands have been placed on the side rails of the beds. The instructor explains that this is a form of a “work around”, allowing the staff to scan the patient’s ID band more easily for the bar coding system. What are the inherent risks associated with work arounds and this one in particular?
,
1
ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications
he Institute for Safe Medication Practices (ISMP) developed these Acute Care Guidelines for Timely Administration of Scheduled Medications after conducting an extensive survey in late-2010 involving
almost 18,000 nurses regarding the requirement in the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation Interpretive Guidelines to administer medications within 30 minutes before or after the scheduled time. The nurses who responded to the survey made it clear that changes to drug delivery methods and gradual increases in the complexity of care, number of prescribed medications per patient, and number of patients assigned to each nurse have made the long-standing CMS “30-minute rule” error prone.
Many nurses reported feeling great pressure to take shortcuts to comply with the rule, which have led to errors, some harmful. While delays in administering certain time-sensitive medications can also result in harm, a one-size-fits-all, inflexible requirement to administer all scheduled medications within 30 minutes of the scheduled time is a precarious mandate given that relatively few medica- tions truly require exact timing of doses.
CMS staff have requested a copy of the final guidelines, and based on our conversations with them, we are optimistic that positive changes will be made to the current “30-minute rule.” For now, hospitals will still be held accountable for the “30-minute rule” in the CMS Interpretive Guidelines. However, given widespread support for these more reasonable and clinically appropriate guidelines, we hope CMS surveyors will allow hospitals to justify their carefully considered policies and procedures regarding timely medication administration using these guidelines to anchor the process.
These guidelines are applicable ONLY to scheduled medications (see definition below).
he guidelines are intended to be used as a resource when acute care organizations develop or revise policies and procedures related to timely administration of scheduled medications. The guidelines are not standards
or evidence-based practices that have been proven by scientific studies, but they have been vetted by hundreds of medication and patient safety experts; hospital medication safety teams; professional nursing, pharmacy, and respiratory therapy organizations; The Joint Commission; hospital pharmacists; and frontline nurses who bear ultimate responsibility for administering medications in a timely manner.
An interdisciplinary team with adequate nursing representation needs to translate the guidelines into facility-specific policies and procedures. In general, the guide- lines represent a safe, effective, and efficient approach to timely administration of scheduled medications. However, the details may differ from one organization to another based on differing patient populations and medication systems, including available technology.
Please keep in mind that the policies and procedures developed by acute care organizations using these guidelines will require flexibility of the goals for timely administration, as appropriate, to accommodate the additional time needed to learn to operate new medication-related technologies.
Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency (e.g., q4h, QID, TID, BID, daily, weekly, monthly, annually). For the purpose of ISMP’s guide- lines that follow, scheduled medications DO NOT include:
STAT and Now doses First doses and loading doses One-time doses Specifically timed doses (e.g., antibiotic for surgical patient to be given a specified amount of time before incision, drug desensitization protocols) On-call doses (e.g., pre-procedure sedation) Time-sequenced or concomitant medications (e.g., chemotherapy and rescue agents, n-acetylcysteine and iodinated contrast media) Drugs administered at specific times to ensure accurate peak/trough/serum drug levels Investigational drugs in clinical trials PRN medications.
Time-critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substan- tial sub-optimal therapy or pharmacological effect.
Non-time-critical scheduled medications are those where early or delayed administration within a specified range of either 1 or 2 hours should not cause harm or result in substantial sub-optimal therapy or pharmacological effect.
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Background
Definitions
How to Use the Guidelines
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Advisory Group A list of advisory group professionals who provided input during development of these guidelines can be found at: www.ismp.org/tools/guidelines/acutecare/ag_tasm.pdf.
ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications
Identify a hospital-specific list Identify a hospital-specific list of time-critical scheduled medications. While this list will include a limited number of drugs, a universal list is not desirable because hospitals that treat different patient populations (e.g., mental health, oncology, transplant patients, pediatrics, premature infants) may need to include different medications to address risks. Similarly, some hospitals that serve very diverse patient populations may decide to identify both hospital-wide and unit-specific time-critical scheduled medications.
Examples of time-critical scheduled medications that should be included on all hos- pitals’ lists include:
Medications with a dosing schedule more frequent than every 4 hours Scheduled (not prn) opioids used for chronic pain or palliative care (fluctuations in the dosing interval may result in unnecessary break-through pain) Immunosuppressive agents used for the prevention of solid-organ transplant rejection or to treat myasthenia gravis Medications that must be administered apart from other medications (e.g., antacids and fluoroquinolones). Certain medications that require administration within a specified period of time before, after, or with meals—for example, rapid-, short-, or ultra-short-acting insulins, certain oral antidiabetic agents (e.g., acarbose, nateglinide, repaglinide, glimepiride), alendronate, and pancrelipase.
Medications administered around mealtimes require nursing judgment regarding the actual scheduled time of administration, which may fluctuate based on meal delivery time, actual consumption of the meal, and the patient’s condition.
Because some scheduled medications can be time-critical for certain patients given their diagnoses (e.g., parenteral antiinfective agents for a patient with worsening sepsis), the list may include some drugs that are time-critical only when used for a specific diagno- sis or indication. Policies should allow prescribers, pharmacists, or nurses to declare any scheduled medication to be time-critical (i.e., must be given at exact time or within 30 minutes before or after the scheduled time) by including this designation with the medication order and/or medication administration record (MAR) entry.
Establish guidelines for time-critical medications Establish guidelines that facilitate administration of the hospital-identified, time-critical scheduled medications at the exact time indicated when necessary or within 30 minutes before or 30 minutes after the scheduled time (or more exact timing when indicated, as with rapid-, short-, and ultra-short-acting insulins). MAR entries for hospital-identified time-critical scheduled medications should be designated to remind staff that these drugs require meticulous attention to timely administration.
Establish guidelines for daily, weekly, or monthly medications Administer these medications within 2 hours before or after the scheduled time.
Although it is generally safe to administer daily/weekly/monthly medications within a timeframe that exceeds 2 hours, ISMP recommends keeping the timeframe to 2 hours before or after the scheduled time to prevent accidental omission of doses that might be more easily forgotten if delayed more than 2 hours.
Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time. Current information technology associated with medication use may require vendor updates to: accommodate more than a single time interval to trigger an alert for delayed and early doses with bar-coding technology; change the appearance of a medication entry for delayed doses in electronic medication administration records (eMARs); and set different time limits for the removal of scheduled medications from automated dis- pensing cabinets. Challenges also exist with highlighting time-critical scheduled medica- tions on eMARs and differentiating between first doses and subsequent scheduled doses when using these technologies. ISMP is aware of these limitations and has been encour- aging vendors to address them in updated versions of their technology.
Table 1 summarizes the guidelines and Table 2 (page 3) provides brief guidance regarding appropriate allocation of human resources, the content of policies and proce- dures related to timely drug administration, and the evaluation associated with event reporting and data analysis.
Obtain medical staff approval of all policies and procedures related to timely administra- tion of scheduled medications.
Although not associated with the timing of scheduled medications, hospitals should also define targeted timeframes for administering first doses and loading doses of key med- ications, such as IV antiinfective agents, IV anticoagulants, and IV antiepileptic medica- tions, where timeliness is critical (e.g., an emergency department patient with suspected sepsis should not wait several hours for the administration of a prescribed antiinfective). While timely administration of first or loading doses of these drugs may be critical, many are not necessarily time-critical when it comes to subsequent maintenance doses. The targeted timeframes for first or loading doses of medications should be accompanied by procedures that facilitate achievement of the administration time goals.
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Table 1. Acute Care Guidelines for Timely Administration of Scheduled Medications
Type of Scheduled Medication Goals for Timely Administration Time-Critical Scheduled Medications
Hospital-defined time-critical medications*
*Limited number of drugs where delayed or early administration of more than 30 minutes may cause harm or sub-therapeutic effect
Includes but not limited to: Medications with a dosing schedule more fre- quent than every 4 hours
Administer at the exact time indicated when necessary (e.g., rapid-acting insulin), otherwise, within 30 minutes before or after the scheduled time
Non-Time-Critical Scheduled Medications Daily, weekly, monthly medica- tions
Within 2 hours before or after the scheduled time
Medications prescribed more frequently than daily, but no more frequently than every 4 hours
Within 1 hour before or after the scheduled time
Time-Critical Scheduled Medications
Non-Time-Critical Scheduled Medications
Medical Staff Approval
First Doses
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ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications Table 2. Supporting Operational Guidelines for Timely Administration of Scheduled Medications
Topic Description Maintain adequate staffing levels Maintain adequate staffing levels in the pharmacy and patient care units, based on workload and patient acu-
ity, to facilitate timely order review, dispensing, drug administration, and patient monitoring. Consider medication administration when making patient assignments
When planning nursing staff assignments for patient care, consider the following patient acuity factors: types of pre- scribed medications; quantity of time-critical medications; complexity of drug administration (e.g., preparing the drug, programming drug delivery devices, verification processes, administration procedures); total number of daily medica- tions; frequency of drug administration; and the patient’s ability to swallow oral medications.
Use of automated dispensing cabi- nets (ADCs)
If using ADCs, ensure the number of cabinets on patient care units facilitates both safe (e.g., removal of one patient’s medications at a time) and timely (e.g., minimal waiting time to remove medications) drug administration.
Justification of early or late admin- istration
Identify and clearly define justifiable reasons that time-critical and non-time-critical medications may be given early or late, or may be omitted (e.g., patient absence from unit, nausea/vomiting).
MAR documentation Require staff who administer medications to document the exact time the drug was administered, rather than just initialing the MAR entry, to provide nurses with the information they need to evaluate the actual dosing interval before administering medications early or late. If a medication was administered early or late, or has been omit- ted, require staff to document the reason. Ensure electronic and paper MARs provide sufficient space and prompts for this documentation.
Reference MARs Require staff administering medications to always reference MARs that show times of the previously administered doses. This helps to avoid early administration of a dose that was previously administered late, resulting in a dosing interval that is too short (e.g., if a 9 a.m. dose of a maintenance opioid pain medication is given at 10 a.m., and the 1 p.m. dose is given at 12 p.m., the dosing interval is just 2 hours, thus risking over-sedation).
eMAR alerts When possible, define and configure (with vendor support as needed) eMAR alerts to show doses that will soon be over- due, that are beyond defined time limits or have been omitted, and to highlight previous doses that have been delayed/omitted.
Standard administration schedules Adhere to standard drug administration schedules based on the prescribed dosing frequency whenever possible. Exceptions to standard drug administration times may be appropriate for patients who self-administer chronic medica- tions, to stagger numerous piggyback IV medications, or to keep a time-critical chronic medication on the same schedule used prior to admission. (While it may seem best to try to keep patients who take any type of chronic medication on the same administration schedule they were using at home, medication administration throughout the day during nonstandard times is prone to omissions; thus administration during standard times is recommended.)
Procedure to follow if medication administration is early or delayed
Establish a procedure for clinical staff to follow if administration of a time-critical scheduled medication will be or has been delayed or administered early beyond allowable expectations.1 This procedure should include: 1) prescriber notification when an adverse outcome is anticipated or has occurred, 2) documentation in the patient’s chart and/or MAR regarding the reason administration of the dose was early or delayed, and 3) evaluation of the need to change the timing of future doses.
Event reporting Establish a streamlined process for reporting untimely administration of all time-critical scheduled medications, even if the reason for the delay was documented and justifiable. Use these events for learning purposes, with the goals to under- stand the causes of untimely administration and make improvements.
Data analysis Review data from event reports, end-of-shift reports, and aggregate data collection to identify the causes of early or delayed drug administration, to revise the list of time-critical drugs as appropriate, and to make system-based changes to facilitate timely order review, dispensing, and administration of time-critical medications. Avoid punishment of individuals for late drug administration; instead, remedy the processes and environmental conditions that contributed to untimely administration.
Additional Resources
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11)) National Patient Safety Agency (NPSA). Rapid response report NPSA/2010/RRR009: Reducing harm from omitted and delayed medi- cines in hospital. February 2010. Available at: www.nrls.npsa.nhs.uk/resources/type/alerts/?entr yid45=66720. 22)) ISMP. Guidelines for timely medication administration: response to the CMS “30-minute rule.” ISMP Medication Safety Alert! 2011;16(1): 1-4. Available at: www.ismp.org/Newsletters/ acutecare/articles/20110113.asp. 33)) ISMP. Special report: patient safety risk. CMS 30-minute rule for drug administration
needs revision. ISMP Medication Safety Alert! 2010;15(18):1-6. Available at: www.ismp.org/ Newsletters/acutecare/articles/20100909.asp. 44)) ISMP. CMS 30-minute rule may result in unintended consequences. ISMP Nurse Advise- ERR. 2010;8(7):1-2. Available at: www.ismp.org/ newsletters/nursing/issues/NurseAdviseERR2010 07.pdf. 55)) ISMP. ISMP survey on the impact of the CMS 30-minute rule. ISMP Nurse Advise-ERR. 2010;8(7):3. Available at: www.ismp.org/newslet ters/nursing/issues/NurseAdviseERR201007.pdf. 66)) ISMP. Final Acute Care Guidelines for Timely
Administration of Scheduled Medications posted on ISMP website. ISMP Medication Safety Alert! 2011;16(10):1,3. Available at: www.ismp.org/ Newsletters/acutecare/articles/20110519.asp.
© ISMP 2011 Permission is granted to reproduce material for internal use within health- care organizations. Other reproduction is prohibited without written permission.
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www.ismp.org/Newsletters/acutecare/articles/20110519.asp
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Reporting and second-order problem solving can turn short-term fixes into long-term remedies
Healthcare practitioners are repeatedly challenged by unexpected problems they encounter due to both large and small work system failures that hinder patient care. A medication needed for a patient is missing on a patient care unit; an
order is never received in the pharmacy; access to the automated dispensing cabinet is crowded and time-consuming; the new barcode scanner has a high rate of scanning failures; a critical drug is in short supply—the list of failures is varied and quite long, often making it difficult or impossible to execute tasks as designed.1
These system failures stem from breakdowns in the environment, staffing, technology, information management, and the supply of materials within the organization.1,2 A study by Tucker found that nurses encounter almost one system failure every hour (6.5 per 8 hour shift), effectively removing one in every 15 nurses from patient care duties just to deal with the failures each day.2,3 Edmondson found that nurses spent 15% of their time (1.2 hours per 8 hour shift) coping with a tide of system failures of varying magnitudes.1 As a result, healthcare practitioners tend to be very skilled and proficient at working around these failures to get the job done. They bend the rules just a bit; they cut a corner when needed; they fail to engage the patient, their col- leagues, or available technology when helpful. They fail to carry out the tasks as de- signed because some aspects of the tasks fail to meet their patients’ needs. In fact, these workarounds are often considered to be signs of resourcefulness, resilience, and flexibility.1-5
The ability to address unexpected problems is highly valued in healthcare, especially when a patient’s life may be at risk. We expect practitioners to use critical thinking skills to navigate around systems or processes when they don’t work well in the mo- ment. We praise and reward practitioners so skilled in using their ingenuity to work around a deficient or faulty system and still carry out tasks. We emphasize individual vigilance and encourage healthcare professionals to take personal responsibility to solve problems as they arise—it’s often considered a weakness to seek help.1-3
The problem with this thinking is that workarounds merely transfer the problem to another time, person, or place. Short-term workarounds patch problems temporarily so work can be accomplished. If the problem is not fundamentally solved, it will resur- face. Long-term remedies are necessary to change the underlying system and process, thus preventing recurrence.
Workarounds and nonstandard processes often take the form of at-risk behaviors by practitioners. These are behaviors where practitioners knowingly break rules but have little or no perception of the risks they are taking, or they mistakenly believe the risks are insignificant or justified. Practitioners respond to dysfunctional processes by ad- dressing only the immediate symptoms they encounter (first-order problem solving). They feel forced to improvise with what they have at hand to create a solution to a problem, often without seeking help from other busy practitioners.2 Although at-risk behaviors are the greatest source of potential patient harm in healthcare, they may
July 2016 Volume 14 Issue 7
continued on page 2—Reporting >
Supported by educational grants from Baxter, Novartis, and Fresenius Kabi
To encourage organizational learning, con- sider implementing the following recom- mendations.
Make communicating/reporting risk easier. Encouraging people to report and creating a psychologically safe environ- ment for reporting is not sufficient. There must be convenient opportunities in the course of the day for workers to give feed- back. Managers and leaders should es- tablish frequent opportunities for commu- nicating about problems with frontline practitioners. One way to do this is for managers and other leaders to be physi- cally present in work areas and responsive to practitioner messages. Leaders can also hold safety huddles or debriefings, where
continued on page 2—check it out >
A liquid dose cup you can read. Co- mar has begun distribution of mL-only liquid dose cups (Figure 1) with an easy- to-read, printed scale. These are being distributed by Medi-Dose (www.ismp.org/ sc?id=1749) and are available in three ca- pacities: 20, 30, and 60 mL. Previous dosage cups we have seen have had
embossed scales that were difficult to read or d i s p l a y e d both mL and teaspoonful amounts. We have always called for the elimination of teaspoons,
tablespoons, and drams on devices used for measuring liquid doses of medication. We are glad to see manufacturers are fi- nally providing mL-only devices.
Figure 1. A mL-only dosage cup with printed scale.
July 2016 Volume 14 Issue 7 Page 2
also benefit the patient whose care would have otherwise been interrupted, delayed, or omitted.1-4Thus, healthcare practitioners are often satisfied, even proud, with their abilities to deliver patient care despite the obstacles, even when it means taking short- cuts, breaching procedures, or otherwise working around the system as designed.
In addition to the risks introduced from engaging in at-risk behaviors, there is another gaping flaw in first-order problem solving (addressing the immediate problem)—it works around the problem and does not truly solve it. While healthcare practitioners are often great at solving immediate problems, they rarely attempt to report them or fix their underlying causes (i.e., second-order problem solving).4 Or, they have reported the problem to no avail—it continues unchanged, so they continue to work around the problem. They are not necessarily trying to hide this information—they are simply pressed for time. In essence, they are often forced to quickly patch problems so they can carry out their immediate responsibilities.1We tend to encourage this aspect of in- dependence, but it comes at the expense of system learning.
In 2015, Hewitt et al. describes this experience as “fixing and forgetting,” meaning that practitioners faced with a problem often fix it in the moment and forget about it, rather than fixing it and then reporting it.5 The research team found that “fixing and forgetting” was the predominant choice made by physicians, pharmacists, nurses, and other healthcare pra