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 for 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 in a common area such as from a medication cart or medication room. 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 swallowing 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 hoarded for other purposes such as black market commerce or self-harm.

DOT medication administration has lots of 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 inmate state their name and show an ID number is a common practice. ID cards should have a picture, if possible. Inmates may exchange cards and use the name of another to obtain valuable medications. Some facilities require birth dates.
• 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.
• 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 (if you have that luxury).
• Get rid of 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.

Final Tip to Save Your Nursing License

In a resource-scarce environment like a correctional facility, nurses may be tempted to overstep bounds in order to provided needed medications to patients. DO NOT give medications ordered for one patient to another patient, even if it is the same medication. This is faulty nursing practice and can even be considered illegal, taking this action moves the function 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 corrections pill pass? Share them in the comments section of this post.

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An inmate arrives at the medication window one morning with an empty blister pack of Atripla. It is only 10 days since he received a month’s supply. He is sheepish about why they are already gone. After some questioning the nurse discovers that HIV medications bring a high price on the prison black market as a ‘prevention’ for AIDs.

Keep on Person (KOP) medication administration is a common practice in many jails and prisons. This process allows inmates to keep a quantity of medications (usually 30 days) with them and self-administer according to the directions provided. Since most adults in the community self-administer prescription and over-the-counter medication, this seems a prudent practice. There are, however, several concerns that need to be addressed to successfully manage a KOP process.

Medications, like any material item, can be a commodity on the prison black market. Pills can be used for both intended and unintended purposes. In an environment of scarcity, community members will creatively use whatever is available to barter or gain status in the group.

Each facility determines which medications are safe for inmates to carry with them based on the population characteristics and past experience. The need for consistent administration may also be taken into account when determining self-administration medication classes. For example, tuberculosis medication administration is rarely left to the discretion of the patient as consistent dosing over a long period of time is necessary for maximum effect. Another class of medications often eliminated from KOP lists is psychotropic medications. Patient adherence to daily psychotropic medication dosing can be a challenge even in the general community. In addition, many psyche medications can be abused. Vulnerable inmates with desirable medications on their person can become prey to stronger and more powerful inmates and gangs.

Here are some tips for a safe and effective KOP medication program:

• Establish a system for distributing and reordering KOP medications. Be sure inmates understand the system and their responsibilities. Many medical units ask that inmates show up at a treatment or pill line to reorder medications when there are about 10 doses left. This allows time for order filling.
• Incorporate KOP medication into the Medication Administration Record (MAR) process. All medications provided to the patient should be documented in a single place to assist in communication among care providers and decrease confusion in the treatment plan.
• Be sure every medication card has the patient’s name and ID, as well as medication and prescription information. During cell sweeps, medications will be confiscated if not in the possession of the person whose name is on the card.
• If providers give out medications during medical sick call, sometimes called ‘Provider Packs’, the medication cards should have the inmate’s name and ID written on them by the provider along with date and signature.
• In like fashion, OTC medication distributed by nurses during sick call should be labeled for the individual inmate with date and nurse signature.
• Security staff should be able to confirm the rightful owner of any medication found in the general prison population.
• A regular spot-check process for patient compliance with KOP medications is helpful. Randomly check KOP cards in mid-cycle to determine proper use. For example, twice a week, a number of inmates with KOP medications could be called to report to the medical unit with all KOP cards. Nurses can use this time to validate proper use and reinforce patient teaching.

Involving the patient in administering their own medications can improve patient safety and assist with developing independent health habits. Patient education on drug and food interactions is important, as is information about medication effects and side effects. Confirm that the patient understand conditions with require medical attention and the process for obtaining more medication when the supply is dwindling.

How do you handle KOP medication at your facility? Share your tips in the comment section of this post.

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The prison is on lock-down due to a suspicious inmate death. Cell searches are underway. The lock-down is expected to last several days and inmate movement is extremely limited. Medications need to be delivered cell-side. This might have been manageable, if not time consuming, if the prison was new enough to have elevators to the upper levels. However, in this case, only narrow stairwells are available and medication carts cannot be pushed up stairs. What’s a responsible nurse to do?

Medication administration is one of the riskiest nursing tasks in any clinical situation due to the many opportunities for error. Medication administration in a jail or prison has added layers of risk. Correctional nurses must daily administer thousands of doses of medication to inmate-patients in general population, segregated units, and specialty housing areas. Even medication that don’t require a prescription may need administered by healthcare staff to reduce opportunity for abuse in the prison black market.

The three main ways medications are administered in correctional settings are: Med Line (Watch Take), Keep on Person (KOP), and Pre-Pour. This post focuses on key elements for safe pre-pour administration.

Administering medication prepared in advance is risky and should only take place in unavoidable situations where medication cannot be administered directly from the labeled supply. Medications prepared prior to administration are usually placed in small labeled and sealed envelopes for direct transport by the nurse who will administer them. During a pre-pour situation, the following safeguards should be in place:

• Medications are prepared immediately before they are transported to the patient.
• The same nurse prepares, transports and administer the medication.
• Medication envelops have at least 2 patient identifiers (name and ID#) and include the date and time of the doses.
• All medication rights are checked at the time of medication preparation.
• Patient identification processes happen again at the time of administration. For example, confirming the patient’s name and ID#.
• When possible, the patient confirms that these are the medications they were expecting to take. Although inmates may not be aware of their specific medications based on how they look, nurses should double check any medication an inmate questions.
• Documentation of administration should take place at the time of administration or directly after returning to the unit – not before administration. Medication may be refused or delayed for a variety of reasons. Documenting administration at the time of preparation is inappropriate.

What other safeguards do correctional nurses use when pre-pouring medications? Provide your additional tips in the comments section of this post.

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Food allergies can be a real challenge for correctional nurses. It is important to document these allergies during intake screenings and put safeguards in place to avoid allergic reactions behind bars. However, inmates can report food allergies that are really preferences (I’m allergic to bologna sandwiches) or food intolerances (I’m allergic to onions). How can true allergies be sorted out from among the many reported?

I recently interviewed Dr. Jeff Keller, correctional physician from Idaho Falls, ID, about the issue on the Correctional Nursing Today Radio Show. This episode is full of interesting and important information for correctional nurses. I highly recommend you download or livestream the 30 minute program. Here are some important points from my notes of the session.

• There are IgE mediated and non-IgE mediated allergic reactions. The medical concern is with IgE mediated allergies, which involve immune system mast cells that respond violently to contact with the allergen. Check out this animation to remind you of the IgE allergic reaction process.
• Peanuts make up 85% of food allergies. The remaining 15% are from tree nuts and shellfish. Other food allergies such as fin fish or strawberries are rare.
• Almost all food allergy deaths happen to teenagers and those in their early 20’s.
• Allergic reactions include hives, angioedema and asthma/wheezing.
• Ways to test for true allergy include a food confrontation test and skin prick testing. There is also a fairly inexpensive blood test for IgE circulating levels.
• Epinephrine is the main treatment for a life-threatening food allergic reaction.

Managing Food Allergies Behind Bars

If an inmate is determined to have a peanut allergy, a peanut-free diet is needed. However, precautions do not end here. Cellmate assignment and work detail must also be considered. This inmate may not be able to be housed with other inmates who have peanut products in their possession. For example, peanut butter and peanut butter products such as sandwich crackers may be available in the commissary. A peanut-allergic inmate may not be able to be assigned kitchen duty if peanut products are present. Shellfish and tree nuts are fairly easy to deal with as pecan-crusted shrimp are rarely on the menu. However, peanut butter is an inexpensive protein source in frequent use in corrections.

Preparing for an Allergic Reaction

A coordinated response to food allergies is needed in every facility. Dr. Keller recommended a protocol be developed addressing actions custody and medical staff will take to respond to true food allergies. Besides diet, housing and work detail issues, a coordinated emergency response to a reaction is needed. Epi pens are the standard mechanism for emergency treatment of an allergic reaction. Inmates are not able to carry needles on their person so the location and accountability for epi pens should be considered. Housing officers may need to have pens available and know how to use them. Correctional nurses may need to provide information and demonstration of epi-pen use. Officers are also likely to be the first responders in an allergy emergency. They need to know the signs of allergic reaction so that they can act quickly to summon assistance and administer epinephrine.

How has your facility dealt with food allergies? Tell us your experiences using the comments section.

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This post originally appeared on CorrectionsOne.com

Another year is about to roll up and we can look back on plenty of correctional healthcare news from 2011. What top stories from the past year are most memorable to you? Here are my top picks for 2011 game changers along with suggested action to reduce their impact.

#1 Legal eagles rule the roost
Healthcare is now the most common legal issue raised by inmates according to a Harvard Civil Liberties Law Review article. The legal system has led the way in correctional healthcare reform even before the landmark Estelle v. Gamble Supreme Court case of 1976. In that case, the Supremes ruled that healthcare was a prisoner’s Eighth Amendment right. Continued case law has further delineated that right. Lack of healthcare, inadequate healthcare, faulty or denied healthcare are frequent claims of inmate defendants. Not only are the costs of healthcare skyrocketing, so are the costs of medical liability insurance. The financial burden of defending against spurious and serious claims is high.

Game changer actions: Do everything you can to strengthen the healthcare delivery system to reduce serious medical claims. This means solid communication and tracking of outside services and diagnostics. In addition, monitor medication delivery and formulary practices. Medication administration is a high risk and problem-prone area of correctional healthcare.

Consider implementing basic customer service principles to reduce spurious legal claims. Closely monitor inmate grievances in this sector. Early intervention can stem later legal cases. Remember, even if a claim is invalidated, legal costs can still be incurred in developing a defense.

#2 Cost shifting along the corrections pipeline
Although California is the state prison system most in the news about overcrowding, other states are looking for ways to reduce incarceration costs by shifting custody responsibilities to local jurisdictions or mental health services. From a medical perspective, there are renewed calls for improved compassionate release processes.

Game changer actions: Appropriate early release of severely ill and dying prisoners can reduce prison health care costs but burden other systems such as long term care and indigent care services. A practical review of current compassionate release policies and procedures is warrented.

Read the rest of this list on correctionsone.com

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Reason #1: We lose our focus

The last month of the year is busy with many things. You and your colleagues are taking that final stretch of vacation time. Kids have holiday and end-of-year school activities. Work sites have holiday parties and extra treats in the break room. It is easy to lose focus on personal safety or to be working short-staffed. Those who might do you harm take advantage of opportunity. In addition, your own emotions might be swinging between elation and despair as the holidays approach. Emotional turmoil is a magnet for  inmate psychopaths or sociopaths. Therefore, this is a time of year with increased vulnerability to inappropriate relationship. Check out my prior posts on dealing with psychopaths and signs of unhealthy relationships.

Reason #2: Our patients are not merry

For inmates, the lack of family support and distance from children or spouse is accentuated during the holidays. Guilt over not being able to provide gifts for children and family estrangement can be acute. The holidays can lead to deeper depression, anger and aggressive behavior. Be particularly alert for increased evidence of suicide potential during the holiday season.

Reason #3: Our co-workers and managers are with their families

On occasion I review medical charts in cases involving inmate plaintiffs. A common scenario involves lack of treatment or inaction during a weekend or holiday. Reduced staffing and vacant management offices leave staff with few resources to deal with emergent issues. Be sure to know all administrative contacts when working weekends and holidays. Policy manuals and treatment guides should also be accessible to staff. It is not unusual to find these important materials locked in a manager’s office; unavailable to those who need their guidance in an urgent situation.

Do you have some other reasons to add? Have you had some dangerous Christmas Week experiences in your setting? Share your thoughts in the comment section below.

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1. Correctional Nurse Interview Prep Guide: Part I

Many nurses visit the blog to find out about this specialty and prepare for a job interview. This post is a popular first stop. I’m hoping to develop the newbie material on the blog in the coming months. I’m delighted that more nurses are considering working behind bars.

2.  Failure to Rescue

This concept strikes a chord in many nursing specialties and has some particular twists for nurses in jails and prisons. We can easily become jaded about patient complaints and fail to act in a medical situation. Correctional nurses must be ever vigilant to guard against cynicism.

3.  Unhealthy Inmate relationships: 5 Danger Signs

Working with manipulative patients can be psychologically dangerous. Those working in corrections can be drawn into unhealthy relationships. This post is from my CorrectionsOne column and got good play over there, as well.

4.  Eight Medication Rights – Not 5?

This guest column by nurse buddy, Lisa Bonsall, originally appeared on the NursingCenter’s in the Round blog. Medication administration is the riskiest process in nursing. The eight rights are good reminders of best practices.

5. Alcohol Withdrawal: Jail Nurse Alert

Although this post is almost 2 years old, it still gets plenty of play and reached the number 5 spot in 2011. Alcohol withdrawal can be dangerous and a missed diagnosis can be deadly.

So, what’s on tap for 2012? A blog renovation project is in the works – so the site will soon have a new look. I’ll also be adding some embedded video and slide presentations, so, stay tuned and visit often.

What would you like to read about in the coming year? Make your topic suggestions in the comment section of this post. Help me decide the publication calendar for the months ahead!

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The current medication regimen for LTBI treatment is onerous, especially in secure settings. Treatments can last for 9 months and require daily doses of one or more mediations. The serious nature of tuberculosis makes this treatment most often given by direct observation, requiring the patient to be transported to the medical unit daily and observed taking the medication. The new guidelines still require DOT administration, but now the medication is only needed once weekly for 12 weeks for most patients with LTBI. This is a much more efficient regimen for the correctional setting.

New CDC Recommended Treatment for LTBI

• Isoniazid (INH) and rifapentine (RPT) – a long acting rifamycin-class antibiotic
• Once weekly in direct-observation dosing for 12 weeks
• Monthly clinical appointments for side effects and physical assessment

Patients Inappropriate for this Regimen

• HIV-infected patients receiving antiretroviral treatment
•  Pregnant women
• Patient with LTBI and presumed INH or RIF resistant
• Children under 2 years

The CDC is currently collaborating with the Infectious Diseases Society of America and the American Thoracic Society to update their guidelines to include these recommendations. In addition, it is likely that the Federal Bureau of Prisons (FBOP) will include these significant changes in the next update of their January, 2010 Clinical Practice Guidelines.

2012 will be a good year to re-evaluate and revamp your TB clinical processes. How will these new guidelines change your practice as a correctional nurse?

Photo credit: George Kubica/CDC

A nurse stands at a small window in a small room with shelves around the interior. Lined up at the window, much like a bank teller’s queue, are inmates waiting for their morning pills. An MAR (Medication Administration Record) is in front of the nurse on her side of the window, with pages organized in alphabetical order by patient last name. The nurse must positively identify the patient by photo ID card, organize the medication to be delivered for this patient on this date and time, and collect the pills from various single dose bubble-packs into a paper soufflé cup. She hands the medication to the patient with a paper cup of water. Fortunately for this correctional nurse, the custody officer in charge of the pill line does the oral cavity check to be sure the patient does not ‘cheek’ the medication for sale on the prison black-market. All this happens in less than a minute. This nurse must administer medication to almost 200 inmates in the course of 2 hours.

The daunting daily task, performed by hundreds of correctional nurses every day, is complicated by distracting noise and frequent interruption. This medication room in a county jail also doubles as a nurse’s station. The medication nurse is working where other nurses are sharing report and physicians are stopping by to change orders and ask about patient status.

A recent study published in the Archives of Internal Medicine tracked the toll of interruptions on medication errors by viewing nurses administering medications in 2 hospital settings. Each interruption was associated with a 12.7% increase in clinical error. When three interruptions occurred in the administration of a single medication there was a 38.9% rate of error. Nursing experience played no part in the error rate. It was consistent for new nurses and those with years of experience. This is astounding objective data to support efforts to reduce interruptions in the medication administration process.

Here are some ideas for reducing interruptions in medication administration that might be applicable in the correctional setting:

• Establish Quiet Times when medications are being administered in a public area. Ask staff members to commit to evacuate the area while pill line is in effect.
• Place posters indicating Quiet Time is in session as a visual alert. (No, you can’t keep them up all the time!).
• Have the medication nurse where an item of clothing, such as a brightly colored vest or apron, when administering medications. No staff member can approach a nurse when wearing this vest.
• Educate all staff members to the patient safety basis of uninterrupted medication delivery.
• Educate custody staff and patients of the need to decrease nurse interruptions during medication administration processes.

What do you think? Can we reduce interruptions in medication administration in corrections?

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It is that time of year! I love starting the holiday season with a day of thanks for all our blessings. No matter how dire the circumstances, we can find something to be grateful for. Here is my correctionalnurse.net list of thanks:

• Correctional Nurses: Of course correctional nurses top the list for a blog like this! Nursing is hard work in any setting. Nurses working in jails and prison do amazing things with little resources and challenging spaces. Our patients do not always appreciate the effort and sometimes work against us. The rewards are not always thank-yous from our patient’s families and many wonder why we do it. But, correctional nursing is as much a calling as a career and so many would not do anything else. Thank you!
• Correctional Physicians: I have worked in a variety of specialties in my 25+ years as a nurse. I have been employed by teaching hospitals and community hospitals, by corporations and by colleges. Hands down, correctional physicians are the best medical colleagues I have ever worked alongside. There is something very earthy about working behind bars. Most medical professionals don’t have attitude and don’t expect preferences. It is refreshing to see collegiality and collaboration work in health care.
• Custody Officers: Yeah, some officers don’t understand us or  ’get’ the therapeutic relationship ‘thing’ that correctional nurses need with their inmate-patients. But, so many do and these professionals keep us safe in our work everyday. Hats off to our officer partners.
• The Internet: Without the wonders of the WWW, you and I would probably never have met and never had an opportunity to network around our very specialized field of nursing. I am grateful for that connection and for every one of you who read this blog and leave comments. I look forward to another great year together.
• Advocacy Groups: I know they can make our lives crazy and living under a court order or consent decree is no picnic. But, advocacy groups have made improvements in correctional healthcare by making visible some of the situations we, as nurses, know need improved. I am grateful that there are people in the free world that care about our patients, too.
• Being with Family: Thanksgiving is often a time to gather with loved ones. Many of our patients are alone and lonely. Connection and relationship are major elements of a healthy life. I hope you give your family members an extra hug this holiday and remember our patients who won’t be able to do that.

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