Not Just a Med Pass
Nancy E. Booth, RN, PHN, MSN, CCHP-RN
The client population in our jails receives thousands of doses of medication each day. With each medication pass (med pass), officers are required to accompany a nurse to ensure their safety. Med pass is a team assignment, whether the procedure is utilizing a pill call line, watch-take, cell-to-cell, or distribution of periodic keep-on-person medications. Medication passes are not the only assignment these nurses have, and we realize it is only one of the many duties of the housing security officers. Accompanying the med nurse is often “sandwiched” between hard and soft counts, chow, transports, responding to man-downs, and hourly rounds. It is sometimes viewed as a perturbation of the day-to-day operation.
Additional delays in the process occur when crushing of the medication is ordered, when patients need to be observed swallowing their medications when questions are posed by individuals, and when a patient refuses the medication. Medication refusals can be the bane of a nurse’s existence. Following policies on refusals usually requires a nurse to counsel the individual on the importance of compliance followed by a signature by the inmate acknowledging that they have been advised. In cases where the individual refuses to sign the form, a second signature by an officer is required, hence slowing down the process even further.
I have observed countless med passes as a nurse consultant. At times I have experienced a less than-welcoming response from the housing security officer when nursing arrives at the housing module. Equally as foreboding, is a nurse with a bad attitude which provides a setup for a perfect storm. Passing medications take a tremendous amount of time if done correctly. If security staff lacks an understanding of the nurse’s requirements for following safe practices of medication administration, there can be added frustration on the part of the officer. Given the high frequency of medications passed each shift, the probability of making an error is staggering and should be taken seriously.
What is a Medication Error?
What constitutes a medication error? According to the National Coordinating Council for Medication Error and Prevention, an error is “any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health professional, patient, or consumer.” Safe practices for nurses in jails follow community standards as well as the endorsement by National Commission on Correctional Healthcare (NCCHC) and the American Correctional Academy. For a nurse who makes a medication error, consequences may include disciplinary action by the state board of nursing, job dismissal, mental anguish, and possible civil or criminal charges. Medication risk factors that nurses face in jails include the high volume of medications to be passed, challenging patient populations, lack of policy enforcement as it relates to a medication pass, personal stresses, and workplace culture. All of these can be a formula for disaster.
According to the World Health Organization, “medication errors occur when weak medication systems and human factors, poor environmental conditions or staff shortages affect the safety of the medication use process”. Focusing on the causation of errors, the article estimates that 75% of all medication errors occur due to distraction. If you have ever been on a medication pass in a housing module, the noise, chaos, and interruptions clearly define a distraction.
The article, “Medication Errors: Best Practices” estimates that 7,000 to 9,000 individuals die each year from medication errors. Although these deaths include the totality of individuals prescribed medications in the United States each year, jails providing medication administration are not immune to human error. In a project completed in New South Wales, Australia they identified the five most common errors occurring in jail. These are, giving an extra dose, giving the medication at the wrong time, giving the wrong medication, giving the wrong dose of medication, and most commonly, delaying or omitting a dose.
The Academy of Managed Care Pharmacy (AMCP) defines medication errors in two categories, commission which is administering the wrong medication, and omission, an unavoidable situation that can occur in jails. In jails, there are numerous reasons a med pass is delayed and, in some cases, canceled. Although this decision is usually due to safety concerns, the decision to lock down a unit or facility should be sanctioned by leadership. I have experienced situations whereby a lockdown was mandated by a housing officer with leadership being unaware. Medications not given for safety/security reasons should be documented and discussed in the monthly multidisciplinary administrative or quality improvement meeting. Although one dose of medication if omitted might seem inconsequential, it can be significant. Subclinical outcomes can occur when lab testing for therapeutic drug levels is ordered for the following day with future dosages dependent on the values. Conditions such as Parkinson’s can have significant symptoms after one hour, and missing an antidepressant can cause increased anxiety, headaches, and mood changes triggered by chemical changes in the brain.
Best Practices
The FDA recommends the use of barcoding by scanning the medication and the patient’s wristband to ensure the medication is given to the right patient at the right time. The objective of this process is to reduce medication errors in healthcare settings. There are problems in the jail setting, based on the lack of sophistication of the medication administration record, the inability to interface with the jail management system to identify the inmate, and the connectivity of Wi-Fi throughout the facility. Based on these limitations, it is incumbent that the nurse consistently practices the 5 R’s we learned in nursing school:
1. The right patient by asking the patient for two pieces of identification.
2. The right medication by comparing the label against the medication administration record.
3. The right dose by checking the order.
4. The right route by confirming whether the medication is ordered orally, topically, or by injection.
5. The right time.
These safe practices ensure patients receive the correct medications, protecting the nurse from potentially losing her job, license, and criminal litigation.
If security staff lacks an understanding of the nurse’s requirements for following safe practices of medication administration, there can be added frustration…
A Proactive Approach
How can you ensure your staff is allowing the med nurse the time to safely administer medications? Having a supervisor ask the nurse about the assistance they received from a security staff member can be fraught with retaliatory concerns. Their response does not always provide the complete picture. Although none of us have limitless amounts of time in our day, shadowing a med pass by both security and nursing administrations can provide a more realistic representation of the process. Things that I have observed on these impromptu observations include whether a nurse is using gloves and using good infection prevention techniques, whether they are practicing the 5Rs and identifying the patient prior to administration if pre-packaging is being used, if watch-take is adequate, if protocols are being followed for refusals, and if security is involved in the process and assisting in patient flow. It does not take long to assess the flow and determine whether there is a partnership in this assignment. Additionally, discussing the expectations of leadership during briefings and attending a staff nurses meeting can also provide valuable information.
A medication pass requires the nurse’s concentration and utilization of safety practices to ensure patient safety. The process cannot be rushed and needs to be viewed with the importance it deserves. This collaboration by the officer and nurse is based on cooperation, communication, and mutual respect and it should be viewed by everyone with the importance it deserves.
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Nancy Booth has been a registered nurse for over fifty years. Starting while still in nursing school she cared for justice-involved patients at Los Angeles County USC Medical Center and found a true calling. Retiring as the Director of Nursing after fifteen years with the San Diego County Sheriff’s medical services, she now divides her time being an NCCHC surveyor and senior consultant for NCCHC’s Resources.
References
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