Using the correct terminology
The terminology used to describe who does what in the medication delivery system is subtle and often misused. One of the most commonly misused terms I hear used in correctional settings are dispense and administer. Only pharmacists and prescribers (physician, advanced practice nurse, physicians assistant) can dispense medication. To dispense is to remove medication from a stock bottle or container, label and package it for a patient according to a written prescription (the sig). Important steps in this process are to verify that the order is safe (right drug for the problem, correct dosage and route) and to review other medications the patient may be taking to ensure that the new medication does not cause an adverse interaction. Administration of medication is to give medication to a patient as prescribed and then to evaluate or monitor the patient for intended and unintended effects. Medication administration involves correctly carrying out the order as well as assessment of the patient’s response which are fundamental steps of nursing process. Most states allow administration of medication to be delegated by a nurse to unlicensed personnel if they have been trained and are supervised. Sometimes medication is given to inmates in correctional facilities by other types of personnel including clerical staff, medical technicians, paramedics and correctional officers. The proper term for this is distribution of medication because there is no evaluation that the medication is being given as prescribed and no evaluation of the medication’s effect.
An adequate number and variety of medications must be available at any time at a correctional facility to treat inmate/patients in a timely manner. To accomplish this a correctional facility will have an arrangement with a wholesale drug supplier or pharmacy to dispense and deliver patient specific medications that are prescribed and will keep some medication on hand to use in an emergency or to start treatment immediately. Procurement is the term used when ordering or receiving medication at a correctional facility to be available for use, as prescribed, in the treatment of patients. Medication accountability is a similar term, but broader in scope. Both state law and the accreditation standards require that there is a system to track, document and account for all medication from the time it is received at the facility until it is administered or delivered to the patient, returned or destroyed. Nurses may be responsible for procurement and accountability of medication at the facility, especially if no pharmacy staff are on site. This is not a role nurses have in traditional health care settings but is common in corrections.
Knowing how and where patients get medication
There are a handful of terms used in correctional settings to describe how inmates receive medication. When inmates receive medication administered directly by a nurse is referred to as directly observed therapy or DOT. When a package of medication (an envelope, blister card or bottle) is given to an inmate and they are expected to take the medication on their own is referred to as keep on person or KOP medication. Another term is self-administered medication. When inmates receive medication it may be at a “pill call” or “pill line”. Medication may be delivered “cell side”, through the “cuff port”, at the “pill cart” or “pill window”. Sometimes the vernacular used to describe an activity or place within a correctional facility can be unprofessional or demeaning. Nurses should know what local terms are used as well as their meaning, then make a deliberate decision to use the local language or not.
Selection and availability of drugs
As mentioned in last week’s post, correctional facilities should have a formulary which is a list of the medications that providers can order. The formulary can be “open” meaning virtually any brand of drug is available. A correctional facility that uses a local retail pharmacy to supply medications is more likely to have an open formulary. A “closed” formulary narrows the choices of drugs available in each class (antibiotics, analgesics etc.). Accreditation standards require that if a particular medication is not on the formulary that there must be a way to request it for a particular patient if needed-this is a “non-formulary” request. Correctional nurses are often involved in helping to fill out and track responses to non-formulary requests so that the medication is received by the patient in a timely manner. It also pays for nurses to be familiar with what drugs are on the formulary so that they can help providers remember what is available when writing orders.
Having a voice in drug selection
Nurses sometimes have representation on the Pharmacy and Therapeutics Committee (P & T) where decisions about what drugs are on the formulary are made. Nursing input is very important in drug selection especially to avoid decisions that result consume unnecessary time during pill line (such as pill splitting or crushing) or present safety issues in the correctional setting (potential misuse or error). If you have a chance to serve on this committee I hope you will jump on the invitation. Even if you do not have a spot on the committee be sure to voice your opinion about the selection of drugs available for treatment at your facility.
Use of generic vs. brand names
One of the most important decisions and practices in medication delivery is how particular medications are referred to. At your facility is the brand or trade name of the drug used or is the generic or chemical name used? In a comment on last week’s post a nurse said that some nurses organize medications in the cart by using the generic name and other nurses put the medication in by brand name. That means that you have to look in at least two places on the cart for a particular medication! Deciding on and then using one or the other saves a lot of time. It really is preferable to use the generic name since the brand or trade name changes.
How medication is packaged
Various terms are used to describe how medication is packaged. Some nurses came into the profession when most medication was administered out of “bulk stock”. This refers to taking one dose for a particular patient out of a bulk container of the drug. Some correctional systems prefer to use bulk stock for psychotropic drugs because of cost, frequent prescription change and high patient turnover. To improve patient safety most state pharmacy laws prohibit medication administration systems that rely solely on “bulk stock” and have developed “patient specific packaging” that is in “unit dose”. Patient specific packaging is a medication that has been prepared and dispensed by a pharmacist in a container or package that is labeled with the patient’s name, start and stop date, the medication dose, route and frequency, as well as prescriber and pharmacy names. Many correctional systems will provide discharge medication packaged in this way with a child proof cap. When medication is packaged in unit dose each dose of medication is packaged individually. An example of unit dose are the plastic or paper packets or aspirin or acetaminophen. Unit dose packaging may be labeled with the individual patient name as described in patient specific packaging above or it may not be labeled and used like “bulk stock” with single doses provided to multiple patients. An example of the later would be single doses of medication used for immediate treatment such as an antihistamine. Finally some correctional facilities allow inmates or their families to bring in an inmate’s medication that they were taking in the community. This is referred to as patient owned or personal medications. The medication and prescription must be verified before accepting it into the facility and accountability for proper use must be assured. Usually several types of packaging is used in correctional facilities. How many different kinds of packaging and what terms are used at your facility?
Even when we speak the same language communication can be misunderstood. Errors in communication occur in oral and written communication about medications sometimes resulting in adverse consequences for the patient. The Joint Commission, U.S. Food and Drug Administration (FDA) and the Institute for Safe Medication Practices (ISMP) have each promoted practices that reduce errors in medication management. One example is that QD is often misunderstood as QID resulting in four times the intended daily dose. The opposite is also true but the patient would receive a much lower dose than was intended therapeutically. Either can have disastrous consequences. The IMSP and FDA have listed medication abbreviations that are frequently misunderstood and have developed brochures, posters, a slide set and a video about how to avoid these errors. The health care program at your facility should have a list of approved abbreviations and may also have adopted a list of error prone abbreviations to avoid using. If not the IMSP website is a recommended resource.
Have you had a funny or sobering experience with the language used in medication management at your facility? Do you have any terms unique to medication delivery in the correctional setting you would like to contribute to our glossary? Do you favor use of generic or brand names and why? Please comment by responding in the comments section of this post.
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