Medication Administration Program

Certification Training
“Administering Medication the Right Way”

Company
LOGO
 Medication
Administration
Basics
BASICS OF MEDICATION
ADMINISTRATION
Safe Medication Administration

Standardization
Knowing the People You Support

Helps

To recognize changes

When reporting

When documenting
 Respecting Rights
Everyone has the right to

Be treated with respect and dignity

Be free from too much medication

Know what meds they are taking

Know about risks and benefits

Refuse medication
 Principles

 Mindfulness
 Maximizing Capabilities
 Communication
Safe Medication Administration

Cycle of Responsibility
 Cycle of Responsibility
Observe

Document the Med Administration Report changes

Administer Medication Support Visits to HCP

Store Medication Communicate with Pharmacist

Record Information
Daily Routine
Come to work ready to

Talk with other staff

Greet person

Ask how person is doing

Pay attention to behavior
How to Prevent and
Control Infection
BASICS OF MEDICATION
ADMINISTRATION
Prevent and Control Infection

Hand washing

When

How
Prevent and Control Infection

Glove use

When

How
 The Cycle of
Responsibility
 General Guidelines
o Medication
BASICS OF MEDICATION
Administration
ADMINISTRATION
The Five Rights
Right Person
Right Medication
Right Dose
Right Time
Right Route
Right Person
If uncertain get help
Ask other staff
Check picture
Right Medication
 If HCP writes brand
name on
prescription
 Pharmacist will
usually substitute
with generic
 If unsure
 Ask pharmacist
Right Medication
If familiar with med
but notice change in
Color
Size
Shape
Markings, etc.

Ask the Pharmacist

Right Dose
 HCP orders dose
 Usually written in “mg”
 Milligrams
Right Time
Particular time of day
Number of times per day
Time between doses
Right Time
 Most meds can be given
safely

One hour before &

Up to one hour after time on
med sheet
 If unsure

Ask pharmacist
 Right Route

 Form of med determines the route

o Tabs, caps, liquids (usually oral)

o Ointment to skin (topical)

 General Guidelines
Three cross checks of the
Five Rights before
administration
 How to Administer
Medication
BASICS OF MEDICATION
ADMINISTRATION
Medication Administration

Process
 Prepare
 Administer
 Complete
Prepare
 Figure out the meds to give
 Know the reason ordered
 Clean area
 Wash hands
 Gather supplies needed
 Identify individual
 Unlock storage area
 Open count book
 If needed
Administer
Cross check one
Cross check two
 Prepare med
Cross check three
 Give med
Look again
Complete
Document
Lock
Wash hands
Observe for effects
Medication Administration
 Med Pass Instructions

Chip Brown
8pm med
Sept. 3, yr
 Giving Multiple Meds
Complete Checks 1 through 3
for each med

Before moving to next med
 All meds due at the same time for
the same individual may be given
together
 Med Pass Instructions

Chip Brown
8am meds
Sept. 4, yr
 Support Plan PRN Med-Anxiety

Specific behaviors that show us Chip is anxious:

1. Pacing in a circle for more than 4 minutes.
2. Head slapping for longer than 30 seconds or more than 5 times
in 4 minutes.

A. Staff will attempt to engage Chip in one on one conversation re:

current feelings and difficulty.
B. Staff will attempt to direct and involve Chip in a familiar activity such
as laundry, meal preparation, etc.

If unsuccessful with A or B staff may suggest/offer Chip:

Ativan 0.5mg once daily as needed by mouth. Must give at least
4 hours apart from regularly scheduled Ativan doses.
(Refer to HCP order)
If anxiety continues after the additional dose, notify HCP.
Dr. Smith 9-3-yr
Posted Karen Mason 9-3-yr 2pm Verified Lisa Long 9-3-yr 6:30p
 Med Pass Instructions

Chip Brown
PRN med for anxiety
Sept. 4, yr
3pm
Med Sheet Documentation

Initials in box that directly

corresponds to time & date given
Initials & signature at bottom

If first time giving during the month
PRN medication

Time/initials in same box

Medication progress note
 Oral Medication

HCP order required to crush and

mix a med with food or liquid
Oral Medication
HCP order required to
empty capsule contents
Oral Medication
May give half tabs ONLY
if split by pharmacy
Liquid Med Administration

Place med cup


Flat surface

Eye level
Use thumbnail to
mark correct
measurement
Shake bottle

If needed
Pour slowly
Liquid Med Administration

Oral syringe
Liquid Med Administration

Dropper
Other Routes

Never administer a med by any

route unless you have received
training in that route
Cautionary Guidelines

Administering meds if
Unable to read HCP order
Missing any piece of info
Unable to read label
Label is missing
Med was not prepared by you
Cautionary Guidelines

Administering meds if
 You have doubts about the 5 rights
 If person

Has a serious change

Has difficulty swallowing

Refuses
 Med seems to be tampered with
Medication Refusals
Dealing with Refusals
 Offer 3 times

Wait 15-20 minutes
 Contact HCP

For recommendation
 Notify Supervisor
 Document
Documenting a Refusal

Circle initials
Med progress note

Refusal description

Who was notified
 HCP

Recommendation
 Supervisor
Medication
What You Need to Know
Medication
Used to treat health problems
Taken to eliminate or lessen
symptoms
Improves quality of life
Medication
Chemicals that enter the body

Change one or more of the ways the
body works
Medication Categories
Prescription
Over the Counter (OTC)
Brand name
Generic name
Countable substances
Prescription Medication

Written by HCP
If uses a small
prescription
notepad

May not
photocopy to
use in place of
a HCP order
OTC Medication
Must have HCP order
Stored, administered
and documented

As prescription meds
Medication occurrence

If not given as ordered by
HCP
Brand Name Medication

Made by a specific
pharmaceutical company
Generic Medication
Basically same as
brand name meds
Made by different
companies
Usually less
expensive
Countable Substances

 Specific Requirements

Storing

Packaging

Tracking

Counting
Other Substances
Holistic/Herbal
Compounds

Very popular

HCP order required

Administered,
documented and
stored
 As prescription meds
Holistic/Herbal Compounds

Label requirement options


Pharmacy
 Applies label

Licensed staff verification
Nurses’ initials
Individual’s name Chip Brown and date signifies
written by nurse MD 9/15/yr
they have
compared
manufacturer’s
label to HCP order
Other Substances
Alcohol
Nicotine
Caffeine
Medication Sensitivity
How a person responds
to a med depends on

Age

Weight

Health
Effects of Medication
Three outcomes
1. Desired/Therapeutic Effect
2. No Apparent Desired Effect
3. Unwanted Effects
Desired Effect
Examples
 Tylenol

Helps a headache
 Dilantin

Helps reduce seizures
No Apparent Desired Effect

Examples
Could be because it may take
more time before full effect of
med can occur
OR
Even after enough time
passes for med to work, it
does not
Unwanted Effects
 Meds can cause effects that
are not intended or wanted

Examples
 Side effect
 Allergic reaction
 Anaphylactic reaction
 Paradoxical effect
 Toxicity
Medication Interaction

Meds mix in body


May increase or decrease
the effect of another med
Medication Interaction
The more meds taken at one
time increases the possibility
Changes observed could be
caused by a med interaction
Medication Resources
Prescribing HCP
Pharmacist
Package inserts
Reputable online sources
Medication reference books
The Cycle of
Responsibility
Basic Responsibilities

Observe
Report
Document
Observation
Objective information

See

Hear

Feel

Smell

Measure
Observation
Subjective information

How a person tells you they feel
Reporting
Immediate
Certain time
Routine
Reporting
If unsure…
REPORT
Documenting Observations
Reporting Information
Knowing who to report to

Your responsibility
 Med Pass Instructions

Melissa Sullivan
8pm meds
Sept. 3, yr
 Med Pass Instructions

Melissa Sullivan
8am meds
Sept. 4, yr
The Management of
Med Administration
Transcription
 Info copied from

HCP order & pharmacy label
 To med sheet
Documentation
Ink
Complete
Accurate
Clear
Include

Date

Time

Full name
Correction
Draw single line
Write “error”
Initial

Do not
 Scribble
 “Mark over”
 Erase
 Use “white out”
Medication Sheet
Name: Month/Year: Allergies:

Dates Medication Hour 1 2 3 4 5 6

Start: Generic:
Brand:
Strength:
Amount:
Stop: Dose:
Frequency:
Route:

SPECIAL INSTRUCTIONS: REASON:

Abbreviations
Safer not to use
Abbreviations
DC Discontinue
mg Milligram
cont Continue
tab Tablet
cap Capsule
mL Milliliter
Frequency

 Number of times per day to be given

 Specific hour chosen
Examples

HOUR HOUR HOUR

8am 8am 8am

12pm

4pm 4pm 4pm

8pm 8pm
Discontinue Order
Mark COMPLETELY through all
boxes next to where med was
scheduled to be given
Diagonal lines across

Left section of med sheet
 DC, date, initials

Grid
 DC, date, initials
 Step 1
Month and Year: DECEMBER (year) Medication Sheet
Medication or Treatment
Start: Generic: Clozapine Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14
12/3/yr Brand: Clozaril 8am X X X DS DS
Stop: Strength: 25mg tabs
Cont. Amount: 3 tabs Dose: 75mg 4pm X X ES ES
Frequency: 3X/day Route: by mouth 10pm X X ES ES
Special Instructions:
Start: Generic: Amoxicillin Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14
12/3/yr Brand: Amoxil 8am X X X DS DS X
Stop: Strength: 250mg caps 12pm X X DS DS X X
12/13/yr Amount: 2 caps Dose: 500mg 4pm X X ES ES X X
Frequency: 4X/day Route: by mouth 8pm X X ES ES X X
Special Instructions: Take with meals for 10 days
 Step 2
Month and Year: DECEMBER (year) Medication Sheet
Medication or Treatment
Start: Generic: Clozapine Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
12/3/yr Brand: Clozaril 8am X X X DS DS
Stop: Strength: 25mg tabs
Cont. Amount: 3 tabs Dose: 75mg 4pm X X ES ES
Frequency: 3X/day Route: by mouth 10pm X X ES ES
Special Instructions:
Start: Generic: Amoxicillin Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
12/3/yr Brand: Amoxil
D/C /yr 8am X X X DS DS X X
250mg caps 2/5 12pm X X DS DS X X X
Stop: Strength:
1
12/13/yr Amount: 2 caps Dose: 500mg 4pm X X ES ES X X X
KM
Frequency: 4X/day Route: by mouth 8pm X X ES ES X X X
Special Instructions: Take with meals for 10 days
 Step 3
Month and Year: DECEMBER (year) Medication Sheet
Medication or Treatment
Start: Generic: Clozapine Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
12/3/yr Brand: Clozaril 8am X X X DS DS
Stop: Strength: 25mg tabs
Cont. Amount: 3 tabs Dose: 75mg 4pm X X ES ES
Frequency: 3X/day Route: by mouth 10pm X X ES ES
Special Instructions:
Start: Generic: Amoxicillin Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
12/3/yr Brand: Amoxil D/C /yr 8am X X X DS DS D /C X X
Stop: Strength: 250mg caps12/
5 12pm X X DS DS 12/5/ X X X
12/13/yr Amount: 2 caps Dose: 500mg 4pm X X ES ES yr X X X
Frequency: 4X/day
KM
Route: by mouth 8pm X X ES ES X X X
KM
Special Instructions: Take with meals for 10 days
Transcription Workbook One
Worksheet
Dose
Found in HCP order, usually in “mg”

Health Care Provider Order

Chip Brown No Known Allergies

Zantac 150mg twice a day by mouth

Signature: Dr. Jones Date: 6/11/yr

The dose is: ___ mg

 Strength & Amount
Found on pharmacy label

Rx# 135 ABC Pharmacy 555-555-1212

20 Main Street
Any Town, MA 09111

Chip Brown 6/11/yr

Ranitidine HCL 75mg
I.C. Zantac Qty: 120
Take two tablets by mouth twice a day Dr. Jones

Lot#323-5 ED: 6/11/yr Refills: 3

The strength per tablet is: ___ mg

The amount of tabs to give: ___ tabs
Transcription Practice
INSTRUCTIONS

You have taken Chip Brown to the doctor and have

received medication from the pharmacy. Pretend
that the date is June 11, year. It is 1 pm.

Use the health care provider’s order, pharmacy

label and generic equivalents to discontinue the
order and transcribe the new order on to the
Medication Sheet.

Please Note: Do not place your initials in the

medication box. You are not administering a
medication at this time. This is transcription only.
 HEALTH CARE PROVIDER ORDER
Name: Chip Brown Date: 6/11/yr

Health Care Provider: Dr. Jones Allergies: no known allergies

S
T Reason for Visit: Chip states he has a burning feeling in his throat during the day.
A
F Current Medications:
F Pantoprazole 40mg by mouth every evening

Staff Signature: Date: 6/11/yr

John Smith, Program Manager
Health Care Provider Findings:

Medication/Treatment Orders:

D D/C Pantoprazole
O
C Zantac 150mg twice a day by mouth
T (dose) (frequency) (route)
O
R Instructions:

Follow-up visit: Lab work or Tests:

Signature: Dr. Jones Date: 6/11/yr

 Pharmacy Label

Rx#135 ABC Pharmacy 555-555-1212

20 Main Street
Any Town, MA 09111 6/11/yr
Chip Brown
Ranitidine HCL 75mg (strength)
I.C. Zantac Qty. 120

Take two tablets by mouth twice a day

(amount) Dr. Jones

Lot# 323-5 ED: 6/11/yr Refills: 3

Generic
Equivalents
Brand Name Generic Equivalent
Zantac Ranitidine HCL
Loram Loramine
Loxaprill Loxaprilline
Tylenol Acetaminophen
Amoxil Amoxicillin

Zantac is a stomach acid reducing medication used to treat and prevent ulcers, to
treat GERD (gastro esophageal reflux disorder) and excessive acid secretion
conditions.
 Medication Administration Sheet

Month and Year: June (year)

Medication or Treatment
Start: Generic: Pantoprazole Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
2/7/yr Brand: Protonix
Stop: Strength: 40mg
Cont. Amount: 1 tab Dose: 40mg
Frequency: every eve Route: mouth 8pm KB KB KB KB ST ST KB KB KB KB
Special Instructions: Reason: stomach acid
Start: Generic: Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Brand:
Stop: Strength:
Amount: Dose:
Frequency: Route:
Special Instructions: Reason:
 Medication Administration Sheet

Month and Year: June (year)

Medication or Treatment
Start: Generic: Pantoprazole Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
2/7/yr Brand: Protonix
J DC 1/yr
DC 1/yr
6/1
Stop: Strength: 40mg
6/140mg
Cont. Amount: 1 tab Dose:
S JS
Frequency: every eve Route: mouth 8pm KB KB KB KB ST ST KB KB KB KB
Special Instructions: Reason: stomach acid
Start: Generic: Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Brand:
Stop: Strength:
Amount: Dose:
Frequency: Route:
Special Instructions: Reason:
 Medication Administration Sheet

Month and Year: June (year)

Medication or Treatment
Start: Generic: Pantoprazole Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
2/7/yr Brand: Protonix DC
/
Stop: Strength: 40mg 1
6/ S
1 DC 1/yr
Cont. Amount: 1 tab
J
yr 40mg
Dose: 6/1
JS
Frequency: every eve Route: mouth 8pm KB KB KB KB ST ST KB KB KB KB
Special Instructions: Reason: stomach acid
Start: Generic: Ranitidine HCL Hour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
6/11/yr Brand: Zantac 8am
Stop: Strength: 75mg Dose: 150mg
Cont. Amount: 2 tabs Route: mouth
Frequency: twice a day 8pm
Special Instructions: Reason:
“Post” HCP Order
Completed for new orders
 After transcribing

Agency may choose certain ink color
Written on HCP order

Under HCP signature
Write

Posted

Signature

Date

Time
 HEALTH CARE PROVIDER ORDER
Name: Chip Brown Date: 6/11/yr

Health Care Provider: Dr. Jones Allergies: no known allergies

Reason for Visit: Chip states he has a burning feeling in his throat during the day.

Current Medications:
Pantoprazole 40mg by mouth every evening

Staff Signature: Date: 6/11/yr

John Smith, Program Manager
Health Care Provider Findings:

Medication/Treatment Orders:

D/C Pantoprazole

Zantac 150mg twice a day by mouth

Instructions:

Follow-up visit: Lab work or Tests:

Signature: Dr. Jones Date: 6/11/yr

Transcription Practice

INSTRUCTIONS

You have taken Chip Brown to the doctor and have

received medication from the pharmacy. Pretend
that the date is June 20, year. It is 1 pm.
Use the health care provider’s order, pharmacy label
and generic equivalents to discontinue the order and
transcribe the new order on to the Medication Sheet.
Please Note: Do not place your initials in the
medication box. You are not administering a
medication at this time. This is transcription only.
 HEALTH CARE PROVIDER ORDER

Name: Chip Brown Date: 6/20yr

Health Care Provider: Dr. Jones Allergies: no known allergies

Reason for Visit: complaint of pressure on forehead, mild fever, dizziness, increase in

head slapping behavior

Current Medications:
Synthroid 0.125mg by mouth once a day in the morning

Staff Signature: Date: 6/20/yr

Paula Jones, Program
Manager

Health Care Provider Findings: sinus infection, elevated blood pressure

Medication/Treatment Orders:
D/C Synthroid
Armour Thyroid 30mg by mouth once a day in the morning on an empty stomach
Inderal 20mg by mouth once a day in the morning
Amoxil 500mg by mouth three times a day for 10 days
dose

Instructions:

Follow-up visit: 2 weeks Lab work or Tests:

Signature: Dr. Susan Smith Date: 6/20/yr

 Rx#139 ABC Pharmacy 555-555-1212
20 Main Street
Any Town, MA 09111 6/20/yr
Chip Brown
Armour Thyroid 30mg
Qty. 30

Take one tablet daily in the morning on an empty stomach

by mouth Dr. Smith

Lot# 659 ED: 6/20/yr Refills: 3

Rx#285-97226 ABC Pharmacy 555-555-1212

20 Main Street
Any Town, MA 09111 6/20/yr
strength Chip Brown
Propanolol 10mg
I.C. Inderal Qty. 60

Take two tablets daily in the morning by mouth

Dr. Smith

Lot# 323-334 ED: 6/20/yr Refills: 3

Rx#285-97227 ABC Pharmacy 555-555-1212

20 Main Street
Any Town, MA 09111 6/20/yr
Chip Brown
Amoxicillin 500mg
I.C. Amoxil Qty. 30

Take 1 tablet three times a day for ten days by mouth

Dr. Smith

Lot# 323-335 ED: 6/20/yr Refills: 0

Answer
Answer
Answer
Answer
Answer
Answer
Answer
 Transcribing HCP Orders

Strength (supplied by pharmacy)

Amount (#tabs, caps, teaspoons, etc.)
Dose (mg doctor wants person to
receive each time med given)

Strength X Amount = Dose

New Orders
If the med has not changed
but the dose, frequency, or
route (or symptoms if PRN) is
changed, it is considered a
NEW order

D/C old order

Transcribe new order
“Post” HCP Order
Completed for new orders
 After transcribing

Agency may choose certain ink color
Written on HCP order

Under HCP signature
 Write
 Posted
 Signature
 Date
 Time
“Verify” HCP Order
Second certified staff double-check
Written on HCP order

Under HCP signature
 Write
 Verified
 Signature
 Date
 Time
May give meds if not verified yet
 Telephone Orders
Check your agency policy
Remind HCP to call pharmacy
Posted/Verified twice

When med is received and transcribed

After HCP has signed
Must be signed by HCP

Within 72 hours
Sample Order Form
Fax Orders
Legal
Signed by HCP
Preferred
Liquid Med Review

HCP: 100mg
Label: 50mg per 4mL

4 mL
3 mL
2 mL = 50mg
1 mL
Liquid Med Exercises
Dose Strength Amount
1. 150mg 75mg/10mL ____
2. 100mg 50mg/6mL ____

3. 100mg 50mg/2mL ____

4. 150mg 75mg/4mL ____

5. 200mg 100mg/5mL ____

6. 150mg 50mg/3mL ____

The Cycle of
Responsibility
Continues
Health Care Provider Visits

Advocate
Respect
Ask questions
Information for HCP
Reason for visit
Allergies
Current medications
HCP order form
Insurance information
Encourage Participation
Redirect HCP to the person
Encourage person to speak

Then provide additional info
Information From HCP
Prescription
HCP order
Diagnosis
What to expect from
new med
Communicating with Pharmacist

HCP can

Give prescription to
 Staff person to bring to pharmacy
 Person to bring to pharmacy

Send directly by fax or electronically

Call prescription into pharmacy
Pharmacy Label
Ensure Pharmacy Provided
Right Medication
Compare HCP order with label
If familiar with med

Open and look
If not

Look up or ask
 Med Pass Instructions

Vi Lee
8pm med
Sept. 3, yr
 Med Pass Instructions

Vi Lee
8am med
Sept. 4, yr
 Med Pass Instructions

Vi Lee
4pm med
Sept. 4, yr
 Med Pass Instructions

Vi Lee
8pm med
Sept. 4, yr
 Med Pass Instructions

Vi Lee
8am med
Sept. 5, yr
Countable Substances
 Countable meds require

Counting

Tracking

Documenting

Special packaging

Double-locked storage
Countable Substance Packaging

Schedule II-V meds must be


Received from pharmacy

In tamper resistant packaging
Countable Substances
Higher incidence of abuse or addiction

Count requirement
 Each time staff changes, 2 Certified staff count together

Documentation requiring 2 signatures

1. When beginning a new count sheet
2. Adding a refill onto a count sheet
3. Transferring from
 Bottom of old page/top of new page
 An old count book to a new count book
4. Disposal
Count Book
Must

Be bound
 Pages that cannot be removed

Have
 Preprinted page numbers
 Index
 Count sheets

 Shift count sheets

Sample Index Page
Name Medication Name Page Number Signature of person
and Strength responsible for
removing medication
from count
Sarah
Brown
Phenobarbital 100mg 1 4 7 Karen Mason
Mike
Ativan 1mg 2 5
Stone
Joseph
Ativan 0.5mg 3 6 9 10 See below KM
Smith
William
Percocet 5/325mg 8
Mitchell
Joseph
Ativan 0.5mg 11
Smith
Security-Inventory
When entering a new
countable in the book or
transferring to a new count
page
o Complete the heading section
of the next available count page
o Do not skip pages
 Sample Count Sheet
Page 11

Name: Joseph Smith q Original Entry

Doctor: Paula Whiten x Transfer from
frompage
page 210
Pharmacy: Cornerstone Prescription Number: D388857
Medication Prescription Date: 11/22/yr
& Strength: Ativan 0.5mg Prescription Number:
Directions: Take 1 tab by mouth every morning Prescription Date:
Take 2 tabs by mouth at bedtime

Date Time Amount Amount Amount Signature

on Hand Used Left
12/19/yr 8:00 AM Transferred from p. 10 9 Karen Mason/Lisa Long
12/19/yr 8:00 AM 9 One 8 Karen Mason
12/19/yr 8:00 PM 8 Two 6 Lisa Long
12/20/yr 8:00 AM 6 One 5 Karen Mason
12/20/yr 11:00 AM 5 received 60 65 Karen Mason/Re
ggieNewton
12/20/yr 8:00 PM 65 two 63 Lisa Long
 Sample Shift Count Sheet

Date Time Count Correct Staff coming on duty Staff Going off duty
3/2/yr 8:15am Yes Karen Mason Sarah Torrney
3/2/yr 4pm Yes Lisa Long Karen Mason
3/2/yr 11pm Yes Sarah Tourney Lisa Long
3/3/yr 8am Yes Karen Mason Sarah Tourney
3/3/yr 4:30pm Yes Lisa Long Karen Mason
3/3/yr 11pm Yes Sarah Tourney Lisa Long
3/4/yr 8am Yes Karen Mason Sarah Tourney
3/4/yr 4pm Yes Lisa Long Karen Mason
3/4/yr 11pm Yes Sarah Tourney Lisa Long
3/5/yr 8:15am Yes Karen Mason Sarah Tourney
3/5/yr 4pm Yes Lisa Long Karen Mason
3/5/yr 10:30pm Yes Sarah Tourney Lisa Long
3/6/yr 7am Yes Karen Mason Sarah Tourney
3/6/yr 2pm Yes SinglePerson Count Karen Mason
3/6/yr 4pm Yes Lisa Long SinglePerson Count
3/6/yr 11pm Yes Sarah Tourney Lisa Long
 Count Sheet Scenario
Page 11

Name: Joseph Smith q Original Entry

Doctor: Paula Whiten x Transfer from
frompage
page 210
Pharmacy: Cornerstone Prescription Number: D388857
Medication Prescription Date: 11/22/yr
& Strength: Ativan 0.5mg Prescription Number:
Directions: Take 1 tab by mouth every morning Prescription Date:
Take 2 tabs by mouth at bedtime

Date Time Amount Amount Amount Signature

on Hand Used Left
12/19/yr 8:00 AM Transferred from p. 10 9 Karen Mason/Lisa Long
12/19/yr 8:00 AM 9 One 8 Karen Mason
Error
12/19/yr 8:00 PM 8 Two LL 5 Lisa Long
6
Error
RN
12/19/yr 8:00 AM 6 One 5 ReggieNewton
12/20/yr 8:00 AM 6 One 5 ReggieNewton
Count Procedure
Count must be done

Shoulder to shoulder with
 Off-going Certified staff and
 On-coming Certified staff
Count Procedure

On-coming Certified staff
has blister packs

Off-going Certified staff
has count book
 Leads the count using the index
Count Procedure
During the count

Both staff look at blister
pack and count book
 Full legal signatures on shift
count verification page
 Count Sheet Scenario
Page 11

Name: Joseph Smith q Original Entry

Doctor: Paula Whiten x Transfer from
frompage
page 210
Pharmacy: Cornerstone Prescription Number: D388857
Medication Prescription Date: 11/22/yr
& Strength: Ativan 0.5mg Prescription Number:
Directions: Take 1 tab by mouth every morning Prescription Date:
Take 2 tabs by mouth at bedtime

Date Time Amount Amount Amount Signature

on Hand Used Left
12/19/yr 8:00 AM 9 Karen Mason/Lisa Long
12/19/yr 8:00 AM 9 One 8 Karen Mason
12/19/yr 8:00 PM 8 Two 7 Lisa Long
12/20/yr 7am Math on 12/19/yr 8p entry is
incorrect. Karen Mason, Supervisor notified.
Correct
12/20/yr 8:00 count
AM is6 6 left.
One 5 6 Newton
Reggie
Reggie Newton
 Count Sheet Scenario
Page 11

Name: Joseph Smith q Original Entry

Doctor: Paula Whiten x Transfer from
frompage
page 210
Pharmacy: Cornerstone Prescription Number: D388857
Medication Prescription Date: 11/22/yr
& Strength: Ativan 0.5mg Prescription Number:
Directions: Take 1 tab by mouth every morning Prescription Date:
Take 2 tabs by mouth at bedtime

Date Time Amount Amount Amount Signature

on Hand Used Left
12/19/yr 8:00 AM Transferred from p. 10 9 Karen Mason/Lisa Long
12/19/yr 8:00 AM 9 One 8 Karen Mason
12/19/yr 8:00 PM 8 Two 6 Lisa Long
12/20/yr 7:45p Morning dose not subtracted when removed.
K. Mason
12/20/yr notified.
8:00 PM Lisa
5 Long
Two 3 Lisa Long
12/21/yr 6a Late entry On 12/20/yr 8a med was given and not
documented at that time. Reggie Newton
Non Suspicious Count Discrepancy

Count is off

Can be easily resolved by checking
 Addition
 Subtraction
Report
Document in count book
Count Discrepancy
 Count is off
 Suspicion of

Tampering

Theft

Unauthorized use of drugs
 Report to DPH
Medication Storage
Medication Storage
Locked/double locked
Labeled container per person

Separate oral meds
 From other routes

Must remain in original packaging
Refrigerated medications

Must be locked
Medication Security
Restricted access

Two medication key sets
 One in use
 Must stay with staff
 Responsible for med administration
 Second known only to
 Administrative staff
Medication Disposal
Purpose

To make the
medication useless
Medication Disposal
When

Dropped

Refused

Expired

Discontinued

Person leaves
 Disposal Methods
Unless prohibited by local community

Read the med information sheet first
 See if there are specific disposal instructions. If not,
 Take med out of original container
 Crush and/or dissolve in water in a sealable bag
 Mix with liquid soap, used coffee grounds or kitty litter
 Place sealable bag in non descript container
 Place in trash

Following disposal remove all identifying
personal information from label

Only flush if the med information sheet provides
that as a disposal option
Disposal Process
If meds are expired or
discontinued

Disposal must be completed with
two Certified staff present
 One must be a Supervisor
 Disposal Process
If a med is refused or
accidentally dropped

Disposal must be completed
with two Certified staff present
 If unavailable, a supervisor is not
required to be present
• Unless your agency requires it
Required Documentation
DPH Controlled Substance
Disposal Record Form for all
prescription medication

Schedule II-VI disposals
 May use for over the counter meds
DPH Disposal Form
Leave of Absence (LOA)
Pharmacy must prepare meds if

LOA is planned/scheduled
 Even if under 72 hours

Person will be away from their
residence for more than 72 hours
Leave of Absence (LOA)
Only if pharmacy cannot

Certified staff may package meds
 For unplanned LOA
 Less than 72 hours
Day Program Medication
Residential staff responsibility to
provide day program staff with

Copy of HCP order

Pharmacy labeled meds

Notify if a med is DC’d
 Fax DC’d HCP order
Medication Occurrence (Error)

One of the 5 rights

went wrong
Medication Occurrence
Wrong

Individual

Medication

Dose

Time
 Includes omission

Route
Medication Occurrence
Opportunity to improve
procedures

That put people at risk
Focus on cause

Rather than who made the mistake
Reporting
Self reporting system
Medication Occurrence
Primary concern

Safety of the person
What To Do
Check to see if
individual is okay
What To Do
Know Emergency
Procedures
What To Do
Immediately contact MAP
Consultant

Read the HCP order
 Explain what happened
Follow recommendation
Document
Medical Intervention
Lab work
Medical test
Physician visit
Clinic visit
Emergency room visit
Hospitalization, etc.
“Hotline” Medication Occurrence

Notify DPH within 24 hours if

These follow an occurrence
 Medical intervention
 Illness
 Injury
 Death
What To Do
Notify your supervisor
 What To Do

 DPH form
 Required
• In addition
to HCSIS
data entry
What To Do
 Medication Occurrence
Report (MOR)
 Documentation
• Paper form and/or
• Data Entry