Healthcare providers and nurses are required to obtain a complete list of medication from each patient on admission in order to comply with the Joint Commission 2019 National Patient Safety Goal # 3 ( NPSG 03.06.01) and other accreditation standards. Healthcare staff should educate each patient about the rationale for collecting information about medication history and current list to improve compliance with the process. All healthcare facilities should develop a medication management plan in order to promote patient safety and prevent adverse outcomes.
It is often difficult to persuade patients to provide a complete list of home medication. It has been surprising to notice that a lot of patients do not know the correct instructions about their medications. Some patients love to keep their medication and are not always willing to share information with healthcare staff.
Providers are responsible to obtain complete medication history and current list from each patient. They will complete a medication reconciliation based on clinical symptoms and treatment plan. A medication reconciliation requires medication review and validation for continuation or discontinuation. Therefore, the providers will decide what medication to order and discontinue during the entire length of stay. They are also responsible to approve the use of home medication and other therapeutic substitution. Providers often mention medication plan in their admission note. Finally, a complete Medication order must include the right patient, medication, dose, frequency, time, indication, and route.
Nurses are responsible to collect medication history and enter the information in the medical record. If patients are unable to provide the name of the medication, nurses can obtain description of the medication and indication ( 1 pink tablet daily for blood thinner). Nurses should inform patients or health care partner to bring the actual medication in pharmacy dispensed bottle. Nurses should not prepare medication because it is not within the profession’s scope of practice. However, Nurses can reconstitute medication based on manufacturer or pharmacy guidelines.
Nurses do no complete medication reconciliation but rather add information in a database for safety and cross reference. Nurses should educate patients about not keeping medication in their possession while under the care of medical professionals to prevent therapeutic duplication and possible harm . Nurses should secure all patients’ home medication and return medication based on discharge instructions. Nurses should verify medication order and also use critical thinking during medication administration to prevent medication errors.
Unfortunately, providers are human being and do make mistakes. Nurses are the last discipline to conduct medication verification prior to administration. Therefore, prudence is highly recommended during medication administration. I successfully caught many medications errors during my years of nursing, so nursing vigilance can prevent adverse outcomes. I always verify the last time someone removed the medication from the dispenser or the last time it was signed as given to prevent error. Nurses should review medication that requires therapeutic lab monitoring closely by following agency’s guidelines. Finally, nurses should educate patients about new medication, the indication, side effects and adverse reactions.
In most facilities pharmacy staff is responsible to procure, prepare , dispense medication, review provider’s order and validate the order for nursing to administer. Pharmacy also clarifies order with provider when indicated and provides specific supplies to facilitate safe medication management. Pharmacy is also very resourceful and can be consulted for medication guidance. Pharmacy also manages therapeutic dosing and lab associated with some medication. Please review your facility’s policy for guidance.
Medication management requires a multidisciplinary team approach and can be complex in some instances. Healthcare professionals are responsible to discuss medication management with every patient and provide education to patient or health care partner in accordance with Joint Commission and organizational standards. Successful medication management can prevent adverse outcomes and patient’s harm.