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Running Head: POLICY AND PROCEDURE

Policy and Procedure: Medication Management Elizabeth Gutierrez NUR 165_2: Advanced Medical/Surgical Clinical Bernard Miller February 08, 2012

Mount St. Marys College Spring 2012

Medication Management Medication management is one of the most crucial parts of nursing and medication administration. The VAs Nursing Service Policy on medication management pertains to controlled and non-controlled medications. This policy establishes all the adequate steps and actions required to take when handling controlled and con-controlled medication. The policy refers to substance security, drug accountability, day/time of drug administration, drug accessed, patient, and operator. The security of controlled and non-controlled drugs is established by its handling requirements. These include limiting its access to designated code locked areas, and staff/personnel who have a designated code. Security also involves reporting any discrepancies with medication handling, such as an incorrect number of medications removed from the Omnicell, these discrepancies should be reported to a Charge nurse and a green Omnicell sheet should be filed. The main purpose of this policy is to inform its nursing staff of who is responsible and what are the appropriate steps when handling controlled and non-controlled medication. Medication management and handling is part of a nurses everyday routine. Medications are regularly being administered to patients and commonly to more than one patient at a time. As a student nurse and future nurse it is the responsibility to follow and practice every step in medication management thus affecting each clinical practice. During practice, as an operator of non-controlled and controlled medication, my responsibility involves maintaining security of the access code, addressing controlled substance discrepancies and appropriately resolving the discrepancies before the end of the shift, notifying the immediate supervisor or designee by the end of the shift, submitting a copy of the Omnicell discrepancy report, ensuring medication administration records are accurate, returning unused controlled substances to the automated dispensing unit, and wasting/disposing of controlled substances that have not been used.

Medication Management As an administrator of non-controlled and controlled medications, it is duty to abide by all the assigned steps. Access and privileges of medication management involve a security code, this code must be private and secure, if the code is forgotten a nurse manager must notify the Pharmacy Department and request a new code. When handling and removing medications, the operator who removes the medication is responsible for ensuring the accuracy of the medication in the drawer and ensuring the patient receives the medication. Discrepancies should be reported immediately, and report must be filed. Dispensing and wasting of controlled medication is a process that requires two licensed operators as witnesses, one being an RN, physician, or pharmacist. Medication management involves documentation. When administering medications, a nurse is required to document the 6 steps in medication administration safety. These 6 right steps include the right patient, drug, time, dose, route, and most importantly documentation. Documentation represents that all the appropriate steps in medication management were performed. As student nurses and future nurses, documentation represents our work ethic and reliability. Therefore documentation of medications and medication management must always be correct and professional, this includes following all steps involved.

Medication Management Reference VA Greater Los Angeles Healthcare System: Nursing Service Policy (2010). Medication Management (00-10B-118-52)