NEW YORK NURSE: September 2011
by Renée Gecsedi, MS, RN, Director, Education, Practice and Research
There was once a time when an RN would pour a patient’s medications from the med cart drawer and compare that to the patient record and medex all the while remembering the five rights -- the right patient, right medication, right dose, right time and right route. The nurse would verify that the patient received the medication and note the actual time the patient received it and a justification when there was a delay.
Now, however, given the use of automated dispensing cabinets, electronic documentation and barcode administration, electronic time stamps that record administration times, have the five rights stood the test of time? There is no argument that nurses should verify the right patient, medication, dose and route, but what is the right window of time for a drug to be administered?
In October 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a new 30-minute rule for medication administration policy. The policy appears in the Conditions of Participation Interpretive Guidelines for Hospitals, State Operations and outlines the indicators for assessing medication administration, which includes: “Are drugs administered within 30 minutes of the scheduled time of administration?”
In an attempt to comply with the policy and avoid a citation for noncompliance with regulations, nurses are taking shortcuts. Cipriano (2011) writes that nurses are removing medications in advance of administration times, removing them for multiple patients at the same time, charting in advance of the administration time and asking nurses on the previous shift to “pull” the medications for the current shift.
This 30-minute rule, as it has become known, has generated serious safety concerns from many in health care, including the American Nurses Association (ANA), the American Pharmacists Association (APhA), and the Institute for Safe Medication Practices (ISMP), which have all begun taking action to remedy the problems they see.
In its July 2010 newsletter, ISMP asked nurses on the frontline to weigh in on this issue and the results were published in the September 2010 newsletter. More than 17,500 nurses responded to this short survey. Of the responders, 70 percent stated that their facility enforces the policy. “Of that, only 5 percent stated they were always able to comply with the policy, while 59 percent were only sometimes or infrequently able to do so.” ISMP shared the survey results with CMS, which took the results under advisement. In addition, ISMP convened an expert advisory panel that came up with suggested guidelines. The guidelines were available for review and public comment in January 2011. This information was also made available by ANA in January. The guidelines may be found at www.ismp.org/Newsletters/acutecare/articles/20110519.asp.
The ANA has raised the same safety concerns to the leader of the CMS Nurse Steering Committee as well as to the National Coordinating Council on Medication Error Reporting and Prevention. In a recent email Carol Bickford, PhD, RN-BC, Senior Policy Fellow at the ANA stated, “Revised guidance is going through CMS’ internal review process, and it’s difficult to predict when that will be completed, but hopefully it will be sooner rather than later.”
Until the CMS changes the rules, however, hospitals remain accountable for the 30-minute rule.
Cipriano, P. (2011). When medication regulations collide with common sense. From www.medscape.com/viewarticle/740643. Retrieved August 31, 2011.
ISMP. Final Acute Care Guidelines for Timely Administration of Scheduled Medications posted on ISMP website. ISMP Medication Safety Alert! 2011; 16(10) 1,3. Downloaded from www.ismp.org/Newsletters/acutecare/articles/20110519.asp. June 2011.
ISMP. Special report; Patient safety at risk. CMS 30-minute rule for drug administration needs revision. ISMP Medication Safety Alert! 2010; 15 (18) 1-6. Downloaded from www.ismp.org/Newsletters/acutecare/articles/20100909.asp. June 2011.