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  • Medication Administration

    Corporate Policy & Procedures


    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.


    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.


    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


    1.1 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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    2.1 Patients 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 Patients 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 patients 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.


    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 Patients 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 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.


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