Two hundred inmates are once again in line for their medications. A harried custody officer, in charge of line security, is tapping his foot in annoyance as you look up an unfamiliar medication recently ordered for the inmate in front of you. The order is a bit confusing because it is written as 2 tabs rather than the dose amount, requiring you to make a mental conversion. In addition, the inmate has ‘forgotten’ to bring his required ID card and you hesitate to send him back as that is likely to bring a frustrated remark from the officer. Welcome to DOT (direct observation therapy) med line duty in correctional nursing.

Directly administering prescribed medications to patients is the primary method of medication administration in correctional facilities. This process may be termed direct observation therapy (DOT), Watch-Take, medication (med) line or pill line. Medications are administered from a medication cart that goes to the unit or from a central medication room where patients come to the window. General population inmates come to or are escorted to this location and present themselves to the nurse one-by-one to receive a single dose of prescribed medication. The patient is identified, medications poured and delivered, and the patient is viewed ingesting the medication. A mouth check is performed, usually by a corrections officer, to affirm the medication was swallowed. Healthcare staff are concerned that the prescribed medication regimen is maintained, while, custody staff are concerned that medication is not being diverted for other purposes such as black market commerce or self-harm.

DOT medication administration has much potential for error and patient safety concerns. The pressure to work quickly and finish the line on time is intense, yet correctional nurses are accountable to follow all the safety practices in this situation.

Patient Safety Tips

• Use two forms of identification. Having the patient state their name and show an ID number is a common practice. ID cards should have a picture, if possible. Incarcerated persons may exchange cards and use the name of another to obtain what they perceive as valuable medications.
• Be sure someone, preferably a custody officer, is checking that the medication is swallowed. Jeff Keller, over at the JailMedicine.com blog has a great piece on ways inmates ‘cheek’ medication for use for other purposes.
• Set up an efficient system for finding the patient in the MAR (medication administration record). Many facilities keep the MAR in last name order. Some also divide MAR’s by housing unit. For example, one cart may go to Pods A & B and another to Pods C & D. Many have an electronic medication administration record, either a stand-alone program or one integrated into their electronic health record. Nurses can then scan the card/wrist bracelet of the patient and the medication administration is automatically entered. If a patient refuses one or all of their medication, the nurse can easily document that in the e-MAR. Sometimes the refusal form is generated right then and there for easy signature.
• Keep the patient medication cards organized. All medication cards should have the patient name and ID affixed. Keep all the patient’s medication together, and preferably in alphabetical order by medication. It helps if someone is responsible for keeping order, such as a pharmacy tech or the nurse primarily on that cart.
• Discard patient-specific discontinued medication to avoid confusion and error. Keep discontinued medications off the cart or out of the administration area.
• If a calculation is needed to administer the correct dose, write a double-checked calculation on the MAR. For example, 1.5 tabs = 75mg.
• A variety of strengths of a single medication in stock can lead to dose errors in administration. Keep choices to a minimum.
• Drugs that look alike or sound alike should be separated and clearly labeled with the name. Some units underline the differences in the name to emphasize the differences for staff when selecting medication for administration.

Nursing practice safety Tips

In a resource-scarce environment like a correctional facility, nurses may be tempted to overstep bounds in order to provide needed medications to patients. DO NOT give medications ordered for one patient to another patient, even if it is exactly the same medication and dose (NEVER, NEVER!). This is a deviation from accepted nursing practice and can even be considered illegal, as your actions have now gone from medication administration to medication dispensing.

Safe medication administration practice at the DOT med line may not win you the nickname “Speedy”, but it will increase patient safety and protect your license. What tips do you have for medication administration in corrections? Share them in the comments section of this post.