10. GOVERNING RULES OF PROFESSIONAL NURSING ORGANIZATION

5. MEDICATION POLICIES

    Medication policies are found in the UAMS Hospital Formulary except:

1. Only licensed nursing personnel administer medications as ordered by the physician.
2. Antineoplastic agents are administered by all RN's working on units which give chemotherapy after completion of the educational process defined by the Staff Education Department.   Antineoplastic agents will be checked by two licensed personnel before administration  (Addendum K.7).  In some clinical areas staff may desire or be required to complete the didactic portion of annual chemo reauthorization module. Under these circumstances, staff are not authorized to administer antineoplastic agents.

Nursing Manual Procedure #118 - Administration of Intravenous Cytotoxic Drugs

Nursing Manual Procedure #119 - Handling Cytotoxic Drugs

Nursing Manual Procedure #120 - Administration of Intravesical Chemotherapy

Nursing Manual Procedure #190 - Administration of Intraperitoneal Chemotherapy

Nursing Manual Protocol #62 - Management of the Patient Undergoing Chemotherapeutic Regimen

Nursing Manual Protocol #146 - Management of the Patient Undergoing Intraperitoneal Chemotherapy

Nursing Manual Protocol #61 - Management of Extravasation of Chemotherapeutic Agents

     c.  Registered nurses may administer I.V. bolus doses of any emergency drugs or other standard I.V.           drug while in the presence and under the supervision of a physician.

Nursing Manual Procedure #151 - Medication Administration

Registered nurses may administer I.V. bolus doses of certain standard I.V. drugs on written orders when the physician is not present.    

1. Any drug administered must be on the approved hospital list found in the Hospital Formulary.
2. Competency of the nurse to administer I.V. bolus medication is assessed during orientation and annually thereafter.

A general listing of drugs approved for consideration for inclusion on a nursing unit list can be found in the appendix of the Hospital Formulary.  Any additions of drugs to the over-all list will be submitted and approved by the Pharmacy Committee.

Hospital Formulary

Certain drugs will only be administered by IV bolus unless a specific therapeutic reason exists to administer the drug by piggyback or continuous infusion. These drugs are listed in the appendix of the Hospital Formulary.

Hospital Formulary

 LPN's may perform Heparin/Saline Flushes only upon validation of competency. LPN's may not give any other IV push medications. LPN's employed in acute and chronic dialysis setting may administer IV push  medication specific to practice in that clinical area.   (  Addendum J.12).

Nursing Manual Procedure #112 - Care of Central Venous Catheters

Nursing Manual Procedure #113 - Use and Care of the Quinton Catheter

4. Specified drugs which are administered intravenously are classified as emergency intravenous solutions and will not be administered to patients in non-intensive care beds, except in an emergency situation. These drugs can be started while arrangements are being made to transfer the patient to an intensive care unit. See Addendum J.13 for the list of drugs classified for emergency administration only.

Nursing Manual Protocol #64 - Management of the Patient Receiving Low-Dose Dopamine Infusion

      e.    Color Coded Labels

1. Each nursing area will stock color-coded labels to be used on the following infusion lines:

1. Arterial Lines - RED
2. Epidural Lines - YELLOW
3. Intrathecal Lines for Chemotherapy - GREEN
4. Hepatic Artery for Chemotherapy - BLUE

2. All infusion lines shall be labeled with date to change tubing.  See Procedure 12.

6.  Patients requiring local anesthetic blocks or continuous epidural infusion for diagnostic or palliative reasons will adhere to the Protocol for Nursing Management of the Patient Receiving Temporary Epidural/Intrathecal Analgesia and Addendum J.14.  
7. Administration of high risk drugs and drugs requiring double check of the drug against the order by two licensed individuals prior to administration will adhere to Addendum J.22.
8. An apical pulse is taken prior to administration of any drug from the digitalis group and the drug will be withheld if the pulse is < 60 /minute, pending notification of the patient’s physician.
9. Dosing/dosage ranges on medications are intended to allow nursing judgment and patient assessment to administer medication to effect.  When there is a medication order with a dose or time range the Registered Nurse (RN) will begin with a minimum dose ordered.  The RN will be aware of prior dose when choosing a dose range.  If the patient condition warrants increasing the dose or shortening the time between doses the RN will provide documentation supporting the decision.
10. Notify the physician and document circumstances in medical record when a patient refuses a medication.     
11. Include the injection site, reason medication given, and results obtained  from the medication when PRN medications are administered.
12. Administration of drugs other than those supplied by the University Hospital Pharmacy is prohibited.  Refer to Hospital Formulary for guidelines regarding medications brought to the hospital by the patient. Pharmacy Policy #517 - Medication Brought to the Hospital or Outpatient Clinic by the Patient
13. The process for monitoring the patient's response to a first dose(s) of a new medication will be as follows:

1. Determine if the patient has ever taken the medication by asking the patient/family.  Exceptions       may include:

   1. Emergency situations

   2. Neonates

   3. Patient demonstrates cognitive impairment

2. If it cannot be determined that this drug has previously been taken by the patient, treat it as a       new medication.

3. Provide verbal information about the drug to the patient/family including:

   1. Purpose of the medication

   2. Potential side effects

   3. Signs/symptoms of adverse reaction to watch for and report to the nurse.

4. Monitor for adverse reaction and document in focus notes.

14. Adverse Drug Reactions
    Document any adverse drug reaction in nurse’s notes and report to physician.   See Hospital Formulary for additional information.              
15. Medication Errors            

1. Person discovering error or discrepancy should complete the Patient Safety Net report and notify physician.
2. Send Patient Safety Net report is automatically sent for inpatient units to Risk Management/Nursing QI Director.

16. Blood & Blood Products (See Procedure # 107).

17. Processing Categories of Drug & Pharmaceutical Orders

The Pharmacy has designated three categories relating to processing time to send medications to a unit. These are as follows:

1. Routine Orders
2. Now Orders
3. Stat Order

See Addendum J.16 for additional information on processing categories.

Medication stop orders for various drug categories including controlled substances are described in Hospital Formulary D.  Controlled drugs are managed according to guidelines in the Hospital Formulary and Addendum J.22  and the Department of Pharmacy policy and procedures Controlled Drugs 5:14

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