The opioid crisis in America has heightened public awareness of the grave potential for health problems related to improper medication management. While the headlines speak of egregious over-prescription and gross negligence, any day-to-day process involving medications can be problematic if not managed well.
Medication management in a hospital is first and foremost important for patient care and safety. In addition, compliance with government requirements is necessary to prevent penalties. Proper medication management also helps keep costs down.
What are the components of medication management?
This topic includes several elements, each requiring attention from multifunctional resources:
- Day-to-day medication management throughout the facility, including ordering, receipt, storage, disposal and all related administration, documentation, and training.
- Management of special medication circumstances, such as recalls and high-risk medications.
- Medication reconciliation for individual patients considering the patient’s complete medication history and new medications related to current treatment.
- Medication management for follow-up patient care beyond the treating facility upon discharge or transfer.
Who manages medication?
To some extent within a hospital, any staff member could say, “We all do.” Add patients and caregivers to that list too. Many hands touch medications on their way to the patient or at least engage in transactional elements of medication management.
Pharmacy: The pharmacy is responsible for procuring, storing, compounding, and filling orders for prescribed meds. This includes ensuring traceability for every capsule, vial, cream, or suppository. After all, if you can’t identify the name, strength, expiration date, and source of a bit of medication, it is not usable.
Beyond the day-to-day execution of these jobs, the pharmacy leads recommendations or decisions on specific drugs that will be stocked. For example, will the hospital primarily use generics or brand-name products for a specific treatment? If brand-name, which one(s)? These decision focus primarily on safety and efficacy for the patient.
Other purchasing considerations are weighed, including cost and inventory management. In some cases, the hospital will contract with outside purchasing agents to get lower costs through network drug purchasing. These broad medication considerations may be managed by a facility-wide drug and therapeutics committee for administration.
Physician: The patient’s primary physician within the facility and multiple members of a round-the-clock care team are responsible for assessing medication needs, prescribing proper meds (specific drug, dosage, timing), and monitoring patient response.
Nursing and technical staff: In many cases, nurses are the ones who physically deliver pills to patients, give shots, add meds to IVs, or insert suppositories. They monitor that the prescribed amount is used and properly dispose of any extra material.
“Everyone”: Without getting into a situation like multiple baseball outfielders shouting “I’ve got it” and then crashing into each other, all members of the pharmacy/physician/nursing staff must play a role in monitoring patient medication. Physicians make the best choices for medication prescription based on diagnosis, pharmacists manage medication reconciliation to maximize effectiveness and minimize potential drug interactions, and nurses and techs watch patient response as they interact closely throughout the patient’s stay. The entire professional team needs to communicate and make integrated decisions to ensure the best care for the patient.
Others: Transcribers play a role in interpreting physician orders correctly. Hospital non-professional staff may be engaged in stocking and monitoring inventory levels. Patients themselves and their caregivers have the responsibility of making sure drugs are actually taken as prescribed.
To the extent possible within the hospital’s budget, technology can enhance many of these actions. Traceability, transcription, and documentation can all be made faster and more reliable with some electronic enhancement. Patient electronic health records (EHRs) can increase awareness of all drugs a patient is taking for more complete medication reconciliation across multiple healthcare professionals. Automated dispensing and barcode verification can minimize variability and errors. New developments, such as AiCure, which monitors patient medication compliance, can facilitate processes that are prone to human error.
Special situations for medication management
Special situations beyond the day-to day delivery of patient medication occur regularly and require additional management actions. The hospital’s medication management team needs to address these and other questions in devising overall plans:
Discharge and transfer have many elements of medication management, with questions such as:
- How will the patient’s first post-treatment medications be provided? (included in discharge, communicated to a pharmacy, prescription given to patient/caregiver to fill)
- How is medication information communicated to the patient and caregiver? (specific medication, dosage and timing, potential side effects, impact if not taken)
- How is medication documented as part of patient’s records for current drug interactions and future reference?
Drug recalls happen at a rate of 1,000 or more per year, with health hazard rating from likely none (Class III) to probable serious adverse reaction or death (Class I). Recall steps should include staff training, receipt of notification, evaluation of recall, determination of action plan, communication, removal, documentation, follow-up monitoring. Consider these questions:
- What is the hospital’s proactive plan to ensure all recalls are understood and immediately addressed? (including acting on any FDA early notification before classification)
- What is the process for ensuring all recalled material is removed from locations across the hospital and no longer prescribed or administered?
High-risk medications require special care. Nurse Jackie showed enough creative and unethical ways of getting opioid drugs within a hospital to fill seven seasons on HBO. Although most of these dramatized situations are not likely, the hospital needs to address management of narcotics and other high-risk items:
- What is the control procedure for high-risk drugs including secure storage, monitored access, and quantity verifications?
- How will the process be audited to verify there is no misuse?
Disposing of unused medications is required daily for multiple reasons including patient refusal, end of treatment excess, and change in treatment.
- What is the disposal process? (hopefully making the substance irretrievable and minimizing flushing to sewers)
- What is the monitored-disposal process for controlled substances?
- What is the process for calling in hazardous treatment resources, if needed?
Adverse drug events and medication errors will occur despite everyone’s best intentions.
- What is your adverse reaction reporting system?
- How does your culture encourage people to report mistakes rather than try to hide them?
What can you do to improve your current medication management?
Medication management deals with special products that make inventory management somewhat complex. Medications are perishable items with varying shelf lives, they have a relatively large number of producers and recalls, they have high resale value, they can be quite interactive, and they regularly have life-and-death impact for end users (patients). This requires thoughtful planning and excellent execution.
Establish a drug and therapeutics committee, if you don’t already have one, and begin creating and improving processes for the day-to-day operations and special cases related to medication management. Get started by contacting EON and walking through an assessment.