BackgroundThe 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. Show
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 medications 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. How to Use the GuidelinesThese guidelines are applicable ONLY to scheduled medications (see definition section). The 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 guidelines 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. Definitions1. 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 guidelines that follow, scheduled medications DO NOT include:
2. 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 substantial sub-optimal therapy or pharmacological effect. 3. 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. Time-Critical Scheduled Medications1. 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 hospitals’ lists include:
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 diagnosis 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. 2. 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. Non-Time-Critical Scheduled Medications1. 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 2. 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 dispensing cabinets. Challenges also exist with highlighting time-critical scheduled medications on eMARs and differentiating between first doses and subsequent scheduled doses when using these technologies. ISMP is aware of these limitations and has been encouraging vendors to address them in updated versions of their technology. Table 1Table 1. Acute Care Guidelines for Timely Administration of Scheduled Medications
Medical Staff ApprovalObtain medical staff approval of all policies and procedures related to timely administration of scheduled medications. First DosesAlthough not associated with the timing of scheduled medications, hospitals should also define targeted timeframes for administering first doses and loading doses of key medications, such as IV antiinfective agents, IV anticoagulants, and IV antiepileptic medications, 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. Table 2Table 2. Supporting Operational Guidelines for Timely Administration of Scheduled Medications
Additional Resources
Advisory GroupA list of advisory group professionals who provided input during development of these guidelines can be found here. How to cite: Institute for Safe Medication Practices (ISMP). ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications. ISMP; 2011. https://www.ismp.org/node/361 Which of the following routes of administration should the charge nurse include as having the slowest onset of action?ANY MEDICATION CAN CAUSE HARM TO A PERSON! Administering medications is a serious responsibility. Administration by the oral route is the slowest way for medication to reach the body's cells. The oral route may be referred to as PO or by mouth.
What is an example of a standing prescription?Examples of standing orders include immunization administration, health screening activities, preventive care measures, ordering lab tests or treatments for certain categories, diabetes measures, prescription refills, and pre-/post-operative orders.
What are the components of a complete medication order quizlet?List the seven parts of a legal drug order.. Name of the patient.. Name of the drug to be administered.. Dosage of the drug.. Route by which the drug is to be administered.. Frequency, time and special instructions related to administration.. Date and Time when the order was written.. Signature of the person writing the order.. What statement is true concerning nursing diagnoses?What statement is true concerning nursing diagnoses? Nursing diagnoses can be actual or potential. The nurse admits a client to the unit and learns the client has recently been diagnosed with chronic renal failure but has not informed the primary health care provider of this diagnosis.
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