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Medication Administration

Corporate Policy & Procedures

Manual

Number: VII-A-50

Date Approved February 12, 2015

Approved by: Vice President & Chief Medical Officer; and Vice President & Chief Operating Officer

Date Effective March 6, 2015

Next Review (3 years from Effective

Date)

March 2018

Purpose To ensure patient safety by establishing a consistent process for medication preparation, administration, and monitoring patient response.

Policy Statement

Covenant Health will ensure that safe medication practices, which include but are not limited to patient and family engagement; medication preparation; administration, documentation and patient monitoring, align with best practice recommendations from recognized institutes.

Applicability This policy and procedure applies to all Covenant Health employees, members of the medical staff, and any other persons acting on behalf of Covenant Health.

Responsibility

Health care professionals will demonstrate compliance with this policy and procedure by utilizing knowledge of pharmacology (eg. drug interactions, medical indications, therapeutic effects and possible adverse reactions/side effects) and safe medication practices during all medication-related care. Health care professionals are responsible to ensure that they are working within their scope of practice and within relevant legislation, policies and procedures.

Principles

Medication administration is more than just the task of giving a medication to a patient. It is a cognitive and interactive aspect of patient care which includes assessment, preparation, patient and family teaching, administration, evaluation, and documentation. Covenant Health recognizes that patients (or alternate decision-makers) and their families, are valuable partners in supporting safe medication practices.

Policy Elements

1. All prescriber orders processed by a unit clerk shall be verified by a health care professional and shall follow a standardized procedure developed by the Covenant Health site. See Appendix A, Standard Practices for Processing Prescribers’ Orders – Inpatients.

2. Health care professionals will engage patients and their families, as appropriate, to

ensure that the medications prescribed are administered safely. 3. Medications shall be prepared for administration using procedures which minimize

risk of error. 4. Health care professionals shall ensure they are competent in skills and knowledge

to administer medication safely.

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5. Health care professionals shall utilize knowledge, critical thinking, and relevant guidelines when monitoring patients for therapeutic and adverse medication effects and shall take appropriate actions to address findings.

6. Health care professionals shall perform timely, accurate documentation of

medications administered or withheld, therapeutic response (where able to assess), adverse effects and related patient care.

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TABLE OF Contents for Procedure:

1.0 Patient and Family Engagement

2.0 Patients’ Own Medications

3.0 Medication Self-Administration

4.0 Medication Preparation and Handling in Patient Care Areas

5.0 Medication Administration

6.0 Medication Administration Times

70 Oral Medication Administration

8.0 Medication Administration into an Enteral Tube

9.0 Parenteral Medication Preparation in Patient Care Areas

10.0 Parenteral Medication Administration

11.0 Evaluation of Response

12.0 Documentation

1.0 PATIENT AND FAMILY ENGAGEMENT

1.1 Whenever possible, health care professionals will provide patients, alternate decision makers as relevant, and families with information about the prescribed medication(s) prior to the initial dose. Discussions/teaching shall be documented on the patient care record. Teaching will include:

a) medication name(s) and indication b) dose schedule c) potential benefits and/or adverse effects – including the risks of non-adherence d) how to use the medication safely and properly e) what to do in the case of an adverse drug reaction.

1.2 Whenever possible, health care professionals will provide patients and families with information

when the dose is adjusted. Discussions/teaching shall be documented on the patient care record.

1.3 Written or verbal information should be provided in a form that is easily understood by the

recipient (see Appendix B for resources). If required, refer to Covenant Health corporate policy VII-B-20, Interpretive Services.

1.4 Health care providers shall support recipients’ understanding of the information provided and

respond to concerns or questions.

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2.0 PATIENT’S OWN MEDICATIONS

2.1 Patient’s own medications brought into a facility are not to be used unless an authorized prescriber affiliated with and acting on behalf of the Covenant Health facility orders that patient may take his/her own medication.

2.2 Patient’s own medications that are not to be used will be secured and sent home with the

patient or family as soon as safely possible.

2.3 Prior to administration of the patient’s own medication the drug is verified and checked for drug

integrity by a pharmacist or other health care professional (when a pharmacist is not on site). Verification will be documented on the patient care record.

Exception:

In Long-Term Care settings, patients’ own medications do not require verification prior to administration, provided that:

a) Over-the counter medications are provided in new and sealed containers, containing clear labeling and a Drug Identification Number (DIN);

b) Prescribed medications are clearly labeled by a community pharmacist. c) Complementary medications are provided in new and sealed containers,

containing clear labeling and a Natural Product Number (NPN); 2.4 Medications not returned to the patient on discharge will be sent to the pharmacy for disposal

or, when there is no on-site pharmacy, disposed in a biohazard container. 3.0 MEDICATION SELF-ADMINISTRATION 3.1 See site-specific policies and procedures for medication self-administration, where applicable. 4.0 MEDICATION PREPARATION & HANDLING IN PATIENT CARE AREAS

4.1 Medications administered to patients in Covenant Health facilities must be dispensed or supplied by the site pharmacy department or an approved pharmaceutical provider. Exceptions: 4.1.1 Those medications supplied by Corporate Contracting Procurement and Supply

Management (CPSM) 4.1.2 Oxygen and nitrous oxide 4.1.3 Patient’s own medications (See Section 2)

4.2 Health care professionals shall prepare and administer medications from packages that are

properly labeled for drug name, strength/concentration, and expiry date if applicable.

4.3 When possible, health care professionals shall avoid directly touching medications (eg. medications removed from packaging) to avoid exposure to potential hazardous products. Gloves will be worn when directly touching medications.

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4.4 For Cytotoxic Drugs: Refer to the Cytotoxic Drug Manual and Learning Resources at

http://www.compassionnet.ca/ie/Page448.aspx 4.5 Medications should be prepared in an area with minimal distraction, noise and interruptions,

and with adequate lighting.

4.6 Medication shall only be prepared in the designated medication room/area, or at the point of administration.

4.7 The health care professional restarts the process if interrupted during preparation or

administration of a medication. 4.8 Medications should be prepared for one patient at a time immediately prior to administration.

Medications must not be prepared for the whole shift at the beginning of a shift.

4.9 Medications in unit dose packages or other labeled packages must remain in the packages up

to the point of administration to the patient so that a final check of the medication against the MAR can be accomplished.

4.10 If a medication is removed from its labeled container (eg. bottle, unit dose packaging) and not

administered immediately, a label shall be affixed to medication until administered. The label must include:

a) patient name b) generic drug name c) dose d) initials of preparer e) date and time.

4.11 Medications prepared for a patient shall not be left unattended unless left in their labeled or

unit-dose packaging and left in a secure area. If they are left unattended and these criteria are not met, the medications must be discarded.

Exception:

Controlled substances removed from locked storage must remain in the possession of the health care professional until administered, in adherence with Covenant Health policy and procedure VII-B-245, Controlled Substances.

4.12 See section 9 for Parenteral Medication Preparation.

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5.0 MEDICATION ADMINISTRATION

5.1 Health care professionals shall not administer a medication prepared by other staff members except where a medication has been prepared by Pharmacy Services.

Exceptions: a) In the operating room and other sterile areas where medications are given during

invasive procedures:

Two health care professionals (one who is circulating and one who is scrubbed) shall prepare medications (including chemicals and reagents) for delivery onto a sterile field.

Both health care professionals must verbally and visually verify the identity of all solutions or other medication type, amount or dose, and expiration date prior to delivery to sterile field.

Solutions and medications on the sterile field shall be clearly labeled using a sterile marking pen or sterile label. (Refer to Operating Room Nurses Association of Canada (ORNAC) Standards, pp. 136-7.)

b) Code Blue teams, Neonatal Resuscitation teams, Medical Emergency teams, Rapid

Response Teams, and when essential for immediate treatment of unstable patients: One health care professional may prepare medication for another health care professional to administer. The medication must be prepared in the presence of the health care professional administering the medication, and the identity of the medication to be administered must be verbally verified by both.

c) Medications administered through a scope: When that medication is not available in a

pre-mixed form, the medication must be prepared by a health care professional in the presence of the health care professional who shall be administering the medication. There must be a visual and verbal verification of the medication, dose and expiry date prior to administration.

5.2 Prior to medication administration, the health care professional shall ensure the ‘eight rights’ of

medication administration:

1. the right patient (see Covenant Health corporate policy VII-B-25, Identification of Patient, Resident or Client Using Two Identifiers);

2. the right medication and formulation (eg. tablet versus dissolvable wafer)

verify against patient care order for all initial doses, and against MAR for subsequent doses

3. for the right reason;

4. in the right dose;

5. at the right time;

6. using the right route;

7 followed by the right documentation; and

8. the right for the patient to refuse the medication.

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5.3 The Medication Administration Record (MAR) or prescriber’s order shall be taken to the point of administration, to confirm identify of patient and correct medication prior to medication administration (see Corporate Policy and Procedure #VII-B-25, Identification of Patient, Resident or Client Using Two Identifiers). MARs taken into rooms of patients on Additional Precautions must be disinfected upon removal from the room. Consult Infection Prevention and Control practitioners as needed.

Exception:

Health care professionals working with multi-day MARs shall follow the above

procedures, except must:

Prepare and administer medication for one patient at a time (see Section 4.8)

compare medications in unopened labeled packages to MARs in the medication preparation area, keeping the packages unopened when able;

compare a source of information of two identifiers (eg. patient label) to MARs in the medication preparation area ;

take the unopened packages to the patient, leaving the MARs in the medication preparation area; and

take the source of information of two identifiers (eg. patient label) to the patient so patient identification can be completed.

5.4 PRN and range dose medications will be administered in accordance with Covenant Health

policy VII-B-40, Pro Re Nata (PRN) Medications.

5.5 The health care professional shall assess the patient for allergies and previous adverse drug

reactions (see Covenant Health corporate policy #VII-B-360, Allergy and Adverse Reaction - Communication and Documentation).

5.6 The health care professional will refer to Covenant Health approved drug information sources to

obtain information as needed (see Appendix B, Approved Drug Information Resources).

5.7 Health care professionals shall not administer any medication they consider unsafe, or if the prescriber’s order is unclear or incomplete (see to Covenant Health corporate policy VII-A-5 Clarification, Alteration, and Refusal to Implement Medication Orders).

5.8 Health care professionals shall perform independent double checks:

as required by site/program policies and procedures (for example, the neonatal program,

pediatric medications ordered as weight based, critical care and emergency programs); and

any time at which a health care provider requests another health care provider to

perform an independent double check

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6.0 MEDICATION ADMINISTRATION TIMES: 6.1 Medications will be scheduled and given according to standardized times, unless a non-

standardized time is required for the individual patient and is specified in the prescriber’s order.

Exception: The scheduled medication time(s) may be adjusted for one or two doses to bridge safely

and effectively from a non-standard administration time (eg. first dose) to a standardized time.

6.2 Non-Time-Critical Scheduled Medications will be administered within 60 minutes before or after

the scheduled time.

6.3 Time-Critical Medications should be administered at the exact time indicated when necessary based on the pharmacokinetic or pharmacodynamic properties of the drug (eg. rapid-acting insulin), or otherwise within 30 minutes before or after the scheduled time. Time-Critical Scheduled Medications include:

Medications with a dosing schedule more frequent than every four hours

Scheduled (not prn) opioids

Immunosuppressive agents used for the prevention of solid-organ transplant rejection or to treat myasthenia gravis

Anti-infectives

Anticoagulants Medications that must be administered apart from other medications (eg. antacids

and fluoroquinolones) Medications that require administration within a specified period of time before,

after, or with meals Any medication which the prescriber orders as “time-critical”.

Time-Critical Non-Scheduled Medications include:

STAT and Now doses First doses and loading doses One time doses Specifically timed doses (eg. antibiotic for surgical patient to be given a specified

amount of time before incision, drug desensitization protocols) On-call doses (eg. pre-procedure sedation) Time-sequenced or concomitant medications (eg. chemotherapy and rescue

agents, n-acetylcysteine and iodinated contrast media) Drugs administered at specific times to ensure accurate peak/trough serum drug

levels Investigational drugs in clinical trials

6.4 The health care professional will contact the pharmacist or the prescriber if uncertain as to

whether or not a medication is time-critical.

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7.0 ORAL MEDICATION ADMINISTRATION 7.1 The health care professional administering an oral medication will remain with the patient until

the medication has been consumed. 7.2 Patients who are NPO and for whom essential oral medications have been ordered are to be

given these with no more than 30 mL of water. 8.0 MEDICATION ADMINISTRATION INTO AN ENTERAL FEEDING TUBE:

8.1 Health care professionals administering medications into an enteral feeding tube (eg. Kaofeed,

nasogastric, PEG, etc.) must verify the proper tube is being used each time a medication is being administered by following the tube from the patient to the syringe connection site prior to administration.

8.2 Specially designed oral syringes which are not compatible with IV tubing must be used when oral solutions are drawn into a syringe for administration.

9.0 PARENTERAL MEDICATION PREPARATION IN PATIENT CARE AREAS

9.1 The Parenteral Manual and Monographs shall be followed for preparation and administration of parenteral medications and for patient monitoring.

9.2 Aseptic technique shall be used during the preparation and administration of parenteral medication and fluids for parenteral administration. This includes:

9.2.1 Performing hand hygiene (washing hands or using alcohol based hand rub and allowing

hands to dry) before preparing and administering an injection;

9.2.2 Using a sterile, single use, disposable needle and syringe

9.2.3 Disinfecting vial diaphragm with 70% alcohol and allowing to air dry prior to inserting needle

9.3 A filter needle shall be used when withdrawing medication from a glass ampoule.

9.4 Medication and fluid from single use vials must not be reused. Discard after first use. 9.5 Only vials clearly labeled by the manufacturer for multiple dose use shall be used more than

once.

9.6 The expiry date of a multi-dose vial, once it has been punctured, is 28 days (four weeks) or as

per manufacturer’s or other guidelines, whichever is less.

9.6.1 The health care provider who punctures a multi-dose vial shall write the date of initiation of puncture and their initials on the vial.

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9.6.2 Multi-dose vials removed from the medication room to a patient care room for administration must be discarded following dose administration.

9.6.3 If sterility or stability of the vial or its contents is in doubt, or if breaks in aseptic technique

occur, the vial shall be discarded. 9.7 Medications ordered to be given subcutaneously or intramuscularly may be mixed in the same

syringe if compatibility has been confirmed. See Provincial Parenteral Manual Guidelines for Use for maximum volume of intramuscular injections.

9.8 Infusions containing medication prepared on the patient care unit shall be labelled with:

The patient’s name; The drug name, Strength and dose; Initials of health care provider who prepared the medication and The date and time of preparation.

9.9 If particulates are visible in the solution, or if medication added to a solution produces clouding

or precipitation, the solution must not be used. 9.10 No medication shall be routinely added to solutions prepared by pharmacy or pre-manufactured

medicated solutions except as approved for specific programs – eg. continuous renal replacement therapy (CRRT).

9.11 No medications shall be added to Total Parenteral Nutrition (TPN) solutions on the patient care

unit.

9.12 No medications shall be added to Blood components and Blood products.

10.0 PARENTERAL MEDICATION ADMINISTRATION:

10.1 Health care professionals administering medications into an infusion line must verify the proper line is being used each time a medication is being administered, by following the infusion line from the patient to the syringe/bag/device connection site prior to administration.

10.2 Medical students (undergraduates) must be directly supervised by a physician if administering

medications into a solution or directly into a tubing or vein.

10.3 The health care professional who attaches (hangs) a parenteral medication infusion to the

patient’s site (eg. IV, subcutaneous) is considered to be the person who administers the medication.

11. EVALUATION OF RESPONSE:

11.1 The health care professional shall monitor the patient for the medication’s desired and adverse effects.

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11.2 The health care professional shall follow monitoring requirements noted in the Provincial

Parenteral Monograph, Covenant Health approved drug information sources (see Appendix B), program-specific policies and procedures, and prescriber’s orders.

11.3 Alarms on required monitoring equipment shall be turned on at all times. 11.4 The health care professional shall report and respond to adverse medication effects and other

relevant findings.

12.0 DOCUMENTATION

12.1 The health care professional will document education provided to patients and families, as relevant, and their responses.

12.2 Documentation shall be completed on each patient as soon as possible after medication is

administered. Documentation will include, but may not be limited to, the following:

Medication name Dose Route and site of administration, as appropriate Date and exact time of administration Signature/initials of person administering

Exceptions to the above may occur when other standards (eg. ORNAC) or procedures (eg. Code Blue) exist.

Reason for PRN medications Medications held, reasons, and actions taken Medications refused by the patient (with reasons, if known), and The reason for early or late administration, when administration time falls outside of the

acceptable timeframe (see Section 6) Lot number and expiry date of vaccines

12.3 Follow-up documentation will include:

Evaluation of effect of PRN medication Evaluation of effect of regular medication, as appropriate Actions taken in response to adverse medication effects or other relevant findings.

12.4 Documentation shall not include prohibited abbreviations, symbols or dose designations (see

Covenant Health corporate policy VII-A-25, Prohibited Abbreviations, Symbols and Dose Designations.)

12.5 Signatures shall be handwritten or electronic and shall include professional designation. Initials

shall be used only if accompanied by a signature log.

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Definitions Alternate decision-maker means a person who is authorized to make decisions with or on behalf of the patient. Authorized prescriber means a health care professional who is permitted to prescribe medications as defined by Federal and Provincial legislation, her/his regulatory college, Covenant Health, and practice setting (where applicable). Complementary medications (also known as alternative, traditional, natural, holistic or homeopathic medicines) mean medicinal products containing herbs, vitamins, minerals, and nutritional supplements. Direct supervision by a physician means the physician is present during the administration. Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act or the Health Professions Act, and who practices within scope or role. Medication means any substance or mixture of substances manufactured, sold or represented for use in the diagnosis, treatment, mitigation or prevention of a disease, disorder or abnormal physical state, or its symptoms, in human beings, and restoring, correcting or modifying organic function in human beings. Multi-dose vial means a parenteral medication where one ingredient is a preservative, unless the vial is designated single use only by the manufacturer. Patient means inpatients, residents, clients and outpatients. Vaccine means “a preparation of killed micro-organisms, living attenuated organisms, or living fully virulent organisms that is administered to produce or artificially increase immunity to a particular disease.” (Medline Plus Medical Dictionary)

Related Documents

Appendix A, Standard Practices for Processing Prescribers’ Orders – Inpatients Appendix B, Approved Drug Information Resources Covenant Health Corporate Policies and Procedures available @ http://www.compassionnet.ca/ie/Page142.aspx:

III-45, Responding to Adverse Events, Close Calls and Hazards III-40, Disclosure of Adverse Events, Close Calls and Hazards VII-A-5, Clarification, Alteration, and Refusal to Implement Medication Orders VII-A-25, Prohibited Abbreviations, Symbols and Dose Designations VII-B-25. Identification of Patient, Resident or Client Using Two Identifiers VII-B-125, Medication Orders VII-B-235, Medication Reconciliation on Admission VII-B-245, Controlled Substances VII-B-315, Hypodermoclysis (HDC) Administration VII-A-30, High Alert Medications VII-B-XX, Independent Double Checks

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VII-B-360, Allergy and Adverse Reaction – Communication and Documentation

Alberta Health Services Documents:

Regional / Provincial Parenteral Drug Monographs Cytotoxic Drug Manual http://www.compassionnet.ca/ie/Page448.aspx

References

Accreditation Canada, Medication Management Standards, 2013 Appendix A, Standard Practices for Processing Prescribers’ Orders. 2014 College and Association of Registered Nurses (CARNA), Medication Guidelines, 2014 ISMP (Institute for Safe Medication Practices Canada), Nurse Advise-ERR, September

2010. Volume 8 Issue 9 ISMP (Institute for Safe Medication Practices Canada), Nurse Advise-ERR, January 2011.

Volume 9 Issue 1 ISMP (Institute for Safe Medication Practices Canada), Acute Care Guidelines for Timely

Administration of Scheduled Medications, 2011 The Joint Commission. Sentinal Event Alert: Preventing infection from the misuse of vials.

http://www.jointcommission.org/sea_issue_52/ accessed Jun 17, 2014. Medline Plus Medical Dictionary. http://www.nlm.nih.gov/medlineplus/mplusdictionary.html

Accessed August 11, 2014 Operating Room Nurses Association of Canada. (2013). The ORNAC Standards for

Perioperative Registered Nursing Practice, 11th Ed. Perry AG, Potter PA & Ostendorf WR (Eds.). (2014). Clinical Nursing Skills & Techniques,

8th Ed. St. Louis, MO: Elsevier.

Revisions October 1, 2014

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Appendix A

Standard Practices for Processing Prescribers’ Orders – Inpatients

Purpose:

To provide consistency in language/codes/abbreviations and practices for how all prescribers’ orders for inpatients (including inpatients in Emergency Departments) are processed within Covenant Health.

To permit latitude for Covenant Health sites to provide additional consistency in language/codes/abbreviations and practices for how all prescribers’ orders are processed, specific to the needs of each site. Rationale:

Effective communication is a critical element in improving patient safety. The use of consistent language/codes/abbreviations and practices fosters health care providers’ awareness of the actions which have been taken in processing a prescriber’s orders. Definitions:

Patient means inpatients, residents, clients and outpatients.

Health Care Professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act or the Health Professions Act, and who practices within scope or role.

Verification means ensuring the accuracy of order processing and ensuring that the order is appropriate for the patient’s condition. Standard Practices:

1. Each Covenant Health Site shall have a written procedure for the processing of all prescribers’ orders which includes but is not limited to:

a. All prescribers’ orders processed by a unit clerk shall be verified by a health care professional.

b. The transcription of all ongoing prescribers’ medication orders processed by a health care professional shall be verified by another health care professional within 24 hours.

c. Orders which are incomplete, illegible or which are unsafe in the health care professional’s judgment shall be clarified with the prescriber prior to processing. See Covenant Health Corporate Policy and Procedure #VII-A-5, Clarification, Alteration and Refusal to Implement Prescribers’ Orders.

d. Stat/Now tests or procedures: The time(s) a stat test or procedure is requisitioned (if applicable) and completed will be recorded on the Prescriber’s order.

e. Standardized notations will be utilized to indicate actions taken in processing prescribers’

orders:

Entry made on Medication Administration Record MAR Initial dose ID Last dose Last Dose Stat/Now medication given Done at time, see MAR Stat/Now tests/procedures Req at time; Done at time

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Paper requisition sent Req Telephone call made Done Service notified (e.g. consultant, lab, etc) (Service) aware Entry made on Kardex (if applicable) K

f. Site-specific standardized notations will be utilized to indicate actions taken in processing

prescribers’ orders, including, where appropriate, but not limited to:

Order sent to Pharmacy Site-specific notation (eg. scanned, faxed, sent, etc.)

Entered into computerized requisition/consultation system (if applicable)

Site-specific notation for computer program (eg. VAX, etc.)

g. The unit clerk shall record notations on the order with a different coloured pen from the health care professional, as stated in the site procedure (e.g. the unit clerk records in green; the health care professional records in red). This documentation should not alter the integrity or visibility/legibility of the original order.

h. Upon completion of processing the order, the unit clerk or health care professional processing the order will document on the order sheet:

i. Signature ii. Printed name* iii. Designation iv. Date and time processed.

i. The health care professional verifying the medication orders shall check each order against its Medication Administration Record (MAR) entry and initial each entry on the MAR.

j. Upon completion of verifying an order or set of orders, the health care professional will document on the order sheet:

i. Signature ii. Printed name* iii. Designation iv. Date and time verified.

k. When a health care professional both processes and verifies an order or set of orders, the health care professional will document on the order, “processed/verified” followed by:

i. Signature ii. Printed name* iii. Designation iv. Date and time completed.

l. Sites will include a procedure to record and communicate the inability to completely process an order (eg. when notification of consultant or other service provider cannot be made until day-time hours), to facilitate future completion.

2. MARs shall be checked daily for accuracy against the previous MAR (if applicable) and the previous 24

hours’ prescriber’s orders by a health care professional in the patient care unit, prior to being used.

* Printed name is not required if a signature log is completed on the patient’s health record.

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Appendix B

Approved Drug Information Resources

Resources available on compassionNET or purchased with approval from your manager (i.e. books or

manuals purchased by your unit) are considered Covenant Health approved resources.

Resources Available on compassionNET

Parenteral Monographs (accessible through the top bar of Home Page)

Accessible through the Learning tab. Choose Library Services from the drop-down menu:

eCPS®

Lexicomp® (contains detailed patient teaching sheets in multiple languages

Micromedex®

myhealth.alberta.ca.medications (accessible through Nursing Reference Center)

Natural Medicines Database

Cytotoxic Drug Manual (accessible through the Patient/Resident Care and Safety tab. Choose Medication

Management Initiatives from the drop-down menu).


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