1. Improve the Safety of Using Medications
NPSG #3:
Improve the Safety of Using Medications

2. Labeling of Medications
For Perioperative and other Procedural Settings
(Includes Bedside Procedures)
Label ALL syringes, medicine cups and basins
Labeling occurs AFTER the medication is transferred to the syringe of other container
NEVER PRELABEL EMPTY SYRINGES OR BASINS
Label Includes:
Medication Name
Strength
Quantity
Diluent & Volume
Preparation Date

3. Labeling of Medications
For Perioperative and other Procedural Settings
(Includes Bedside Procedures)
Visual and Verbal Verification
Required if the container is handed off to another person to administer or at break/shift relief
Discard any unlabeled containers immediately!

4. Medication Reconciliation
From The Beginning To The End

5. Why Do We Reconcile Medications?
To accurately and completely reconcile medications across the continuum of care
To reduce the risk of transition related adverse drug events
To correct any discrepancies that are identified while the patient is in the hospital

6. Who can do the reconciliation process?
The nurse or physician can do the reconciliation process

7. Admission Process Obtain list of medications from patient
Document on Medication Reconciliation Module
Call Physician and reconcile medication
Print Medication Reconciliation and sign that you have reconciled with the physician
Place Medication Reconciliation in the chart
Medications listed on the Medication Reconciliation will auto populate
on the Medication Transfer Form

8. Transfer Process to a Higher/Lower Level of Care
When a patient is being transferred to another unit use the Medication Transfer Form
Call the physician and reconcile the medications on the Medication Transfer Form prior to transferring the patient
Place an “Y” or “N” to indicate whether or not the current medication will be ordered and continued upon transfer
The receiving unit will scan the Medication Transfer Form to the pharmacy

9. Transfer Process to Surgery
When a patient is being transferred to surgery
Place a copy of the Medication Transfer Form in the chart prior to sending the patient to surgery
After surgery the surgeon will reconcile all medications using the Medication Transfer Form
Place an “Y” or “N” to indicate whether or not the current medication will be ordered and continued upon transfer

10. Discharge Home Process
New medications will be listed on the Discharge Instructions
The patient will get a copy of their discharge instructions and the medication reconciliation form
Provide education on medication management to the patient and or family

11. Medication List to the next Care Provider
A copy of the discharge instructions and medication reconciliation form will be given to the patient and or family to take to the next care provider
We no longer fax to the next care provider

12. Documentation of Refusal of Medications

13. Difference between a Refused Medication vs. A Held Medication
A Refused medication is one that the patient refuses to be administered
A Held medication is one that is not administered due to:
A hold parameter
BP medications (BP to low)
Insulin (Blood sugar is too low)
Patient is off the unit for a procedure

14. When to use the Hold Acknowledge Function on the eMAR
Use only when there is a problem with the order that you are acknowledging
For Example:
Incorrect dose or frequency entered
Missing PRN indication
This function is not to be used for held meds
If a medication is to be held, document it in the eMAR on the designated time of administration
If a medication is being held because the patient is off the unit but still needs to be administered, document it only when given. It will be RED on the eMAR but you can type your reason in the comment section

15. How to properly document a refusal of medications on the eMAR
Document Medication as
“ Not Given”
Select “REFUSED” from drop down menu

16. Open the “TEXT” box and Document that the patient was educated regarding the refusal of medications

17. Document in the Nurses Notes when you notify the Physician
The dose will be shaded with a grey box indicating it was documented against but not given
Document in the Nurses Notes when you notify the Physician

18. Example of how it appears in Meditech using “print order” (PO)