Accreditation Bulletin #5 – Medication Management

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BULLETIN #5 – Medication Management

Medication Management is one of our Accreditation Themes. It covers organizational safety practices related to medication management. Within Medication Management there are 5 Required Organizational Practices (ROPs) that must be met to successfully complete Accreditation which will occur October 17 – 21, 2022.

ROP #1: THE “DO NOT USE” LIST OF ABBREVIATIONS

Surveyor Question: At Menno Place, do you ensure that incorrect abbreviations and symbols that may cause errors are not used on any written, printed or electronic materials?
Answer:  Yes, we follow the Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designation which is reviewed regularly by our Medical & Medication Safety and Advisory Committee (MMSAC).

Evidence:  How do we do this?

  • “Do Not Use” list is on each unit and easily available
  • Every item on the “Do Not Use” list is removed from all written, printed, and electronic documents.
  • Nurses and physicians are made aware of the list and the policy RCS 6.02 Medication Administration System.
  • Preprinted orders are reviewed annually by the MMSAC and are free of ‘Do Not Use’ abbreviations.
  • Audits are completed regularly to ensure compliance with the “Do Not Use” lists.

ROP #2: HIGH ALERT MEDICATIONS

Surveyor Question: At Menno Place, do you have a comprehensive strategy for managing high-alert medications?
Answer:  Yes, we follow the process of our policy RCS 6.13 High-Alert Medications.

Evidence:  How do we do this?

  • Follow policy RCS 6.13 High-Alert Medications
  • Follow the Institute for Safe Medication Practices (ISMP) list of high-alert medication
  • Educate and train nurses on high-alert medication management
  • Audit the process of double check verification done by nurses
  • The policy is reviewed annually by the MSACC

ROP #3: HEPARIN SAFETY AND MEDICATION CONCENTRATIONS

Surveyor Question: How does Menno Place ensure that heparin products are limited and stored safely?
Answer:  Heparin is identified as high alert medication. We limit the use of heparin products and order only the low molecular weight heparin under specific circumstances.

Evidence:  How do we do this?

  • Follow policy RCS 6.13 High-Alert Medications
  • We do not store high dose heparin products onsite
  • High-alert medications are stored in a locked medication cart in locked medication rooms.

ROP #4: NARCOTICS SAFETY

Surveyor Question: How does your team ensure that narcotics are stored and used safely?
Answer:  Narcotics are identified as high alert medication. We limit narcotics, ensure restricted access, and educate staff on their usage reduces medication errors.

Evidence:  How do we do this?

  • Follow policy RCS 6.13 High-Alert Medications
  • Follow policy RCS 6.10 Narcotics & Narcotic Record
  • All narcotics are either stored in a locked narcotic cupboard or locked medication carts
  • Two nurses are required to count narcotics every 24 hours
  • A nurse must always be responsible for the keys to the narcotics cupboard and medication room.

ROP #5: MEDICATION RECONCILIATIONS ACROSS CARE TRANSITIONS

Surveyor Question: What process is in place to ensure that the best possible medication history is obtained and that the resident gets the right medication orders?
Answer:  Medication reconciliation is conducted in partnership with the resident, family, caregiver, and pharmacy to communicate accurate and complete information about medications across transitions of care.

Evidence:  How do we do this?

  • Follow policy RCS 6.08 Medication Reconciliation
  • All new resident move-ins, transfers back into the care home from acute care or move-outs have medication orders reconciled to ensure accuracy and continuity of medications.
  • Nurses complete the medication reconciliation form for each care transition which gets verified by the physician.
  • New nursing team members are trained at orientation before their first shift worked.

 

Thank you for your support in making this Accreditation Survey another successful one!