A Pre-Flight Checklist Before Rolling Out of the Med Room

A Pre-Flight Checklist Before Rolling OutMedication administration is a common and frequent nursing task in most settings. There are plenty of opportunities to get things wrong….even when surrounded by fantastic resources like an onsite pharmacy and electronic information sources. Correctional nurses don’t often have these advantages, though, and medication administration can take on some interesting configurations. I’ve been in quite a few jails and prisons in my correctional consulting career and have seen many a method for medication delivery to overcome environmental and security challenges. Here are just a few of the ways medication may be delivered behind bars.

  • A window in the med room. Patients may line up outside the room in a hallway or in an outdoor area
  • A medication cart rolled to the housing unit and stationed in the common area or a small room in the housing unit
  • A cart, room, or even table near the dining hall
  • A larege utility shed in the recreation yard

In most of these cases (except the first one, maybe) the nurse must take all the medications and supplies out away from the medical unit and must be prepared for any situation. There is little opportunity to ‘run back to the unit’ for something forgotten or unexpectedly needed. This made me think of airplane pilots who need to know they have everything checked out and ready to go before they take to the air. As a passenger on these flights, I am glad the captain doesn’t rely on memory to be sure everything is in order. Cruising altitude is not a good place to be finding out the gas tank is low.

Here are my suggestions for a pre-flight checklist before you take-off on your medication flight.

  1. Check that the cart is properly stocked.
  • Patient medications
  • Medication administration record
  • Pen, highlighter, notepad
  • Current drug book
  • Pill crusher
  • Calculator
  • Pill cups
  • Water/drinking cups
  • Waste receptacles
  • Any access keys needed such as access to the narcotics box
  1. Perform the following activities while in the Medication Room.
  • Scan MARs for
    • Any new medication orders since last administration.
    • Any new patients
    • That all patients have drug allergies listed or NKA (no known allergies) identified
  • Check to see that new medications are available or, if being processed, are added to the cart before starting administration
  • Check a drug reference book on any new medications that are unfamiliar
  • Perform any calculations for odd dose orders
  • Perform hand hygiene
  1. Each single episode of medication administration should follow the same path in order to habituate safety principles. Here is an example of a workable medication line episode path that includes the safety mechanisms of checking the medication three times and involving the patient in medication verification.
  • Ask the patient to recite their full name while checking ID band or card.
  • Locate correct MAR page
  • Scan page for medications due at this administration time
  • Locate patient medication group in medication cart drawer
  • Take first card and check against MAR while popping pills into medication cup
  • Take next card and check against Mar while popping pills into medication cup
  • Continue in like manner until all pills for this administration time are in the medication cup
  • Recite medications to the patient while preparing them
  • Recheck cup of pills against MAR before handing to the patient
  • Ask patient if he/she has any questions about their medications while pouring water
  • Watch patient take medication. Perform oral check or confirm officer is doing oral check
  • Observe that cups are deposited in waste receptacle and not taken by the patient
  • Move to the next patient
  1. Additional steps in the process might be needed depending on the patient or situation.
  • Crushing some or all medications.
  • Responding to a patient question or confirming a medication if questioned.
  • Unlocking and signing out any narcotics.
  • Obtaining a double-check on high risk medications and complex calculations.

Do you have a mental checklist you use when preparing for and administering medications? Share your tips in the comments section of this post.

Scope and Standards: Five Tenets of Correctional Nursing

This post is part of an ongoing series discussing key components of the Correctional Nursing Scope and Standard of Practice, 2nd Ed. Review prior posts in this series here. Purchase your own copy of this highly recommended book through Amazon.

Correctional nurses practice in a unique setting with a unique patient population, however, the way we practice is based on tenets common to nursing across all settings. These five tenets of nursing practice are identified in all nursing specialties and here applied to our practice in the criminal justice system.


In the end, correctional nursing is providing care to one patient at a time. Yet, we are careful to understand the demographics of our particular patient population when providing that care. For example, when working in a maximum security setting every patient is considered a high safety concern. However, correctional nurses constantly struggle with the challenge of balancing objectivity with cynicism due to the potential for manipulation of some in the patient population. Actively focusing on the individual needs of the current patient while keeping in mind the patient population characteristics can help maintain individualized care.


Nursing care in all settings requires collaboration with other disciplines, the patient, and family members to reach health goals. In the correctional setting, nurses also coordinate and negotiate with officers and non-healthcare administrative leadership to reach these goals. Correctional nurses, in particular, need skill in communication, collaboration, and persuasion to be successful.


Correctional nurses struggle with the definition and application of caring in a secure setting. Professional boundaries, safety issues, and security rules are ever-present concerns that alter caring practices from those of a traditional care setting. Defining caring in our practice is an important professional goal.


The nursing process is foundational to nursing practice. Correctional nurses use the nursing process to plan, deliver, and evaluate care in such activities as nursing sick call, emergency treatment, and infirmary care. The autonomous nature of nursing practice in jails and prisons requires excellent assessment and critical thinking skills.


Our practice environment affects our practice, no way around it. Although many correctional nurses work in positive environments, the nature of the corrections culture is punishment and control. These twin goals can facilitate an oppressive work environment where care and caring are difficult. Correctional nurses must strive to overcome a negative work culture that can discourage and demoralize our practice.

Do you have a favorite tenet of correctional nursing? Share your thoughts in the comments section of this post.

Keep Your Cool: Heat Injury Alert

keep your coolIt’s that time of year again-Summertime. Time to be hot and bothered at work if you are one of many correctional nurses working in a setting that lacks air conditioning. Jails and prisons were not built for comfort and many older ones are without air conditioning or even good ventilation. Heat injuries such as heat exhaustion and heat stroke should be on our minds when evaluating vague patient symptoms during the summer months; especially when the weather is both hot and humid, like many of our southern states. For example, as identified in a recent lawsuit, most of the Texas state prisons are without air conditioning, although some have climate control in the medical unit. So, what should you do to identify and treat heat injuries?

Vulnerable Conditions

Although anyone can succumb to heat and humidity, the young and old have fewer reserves to overcome heat stress. If possible, move patients with the following conditions to special housing or provide with additional monitoring and fluids during high heat alerts.

  • Elderly
  • Heart disease
  • Pulmonary disease
  • Mental illness

A main reason those with the above conditions are prone to heat-related illness is the medication they are likely prescribed. The following medications or substances increase heat injury risk.

  • Anticholinergics (Atrovent, Chlor-Trimeton, Cogentin, Spiriva)
  • Antihistamines (Allegra, Benadryl, Zyrtec)
  • Benzodiazepines (Klonopin, Librium, Valium, Xanax)
  • Beta blockers (Atenolol, Corgard, Lopressor)
  • Calcium channel blockers (Cardizem, Norvasc, Procardia)
  • Diuretics (Chlorothalidone, Diuril, Lasix)
  • Neuroleptics/Phenothiazines (Haldol, Mellaril, Prolixin)
  • Tricyclic antidepressants (Pamelor, Tofranil, Vivactil)

Rapid Cooling and Hydration for Heat Injury

Heat exhaustion and heat stroke are the two most common heat injuries, although sunburn and heat cramps are also often listed.  In heat exhaustion, the body is decompensating having difficulty maintaining normal body temperature in an extended high heat situation. Heat stroke begins when the body becomes unable to keep internal temperatures in a livable range. Without intervention, heat exhaustion can progress to life-threatening heat stroke. Here is a quick comparison of the presentation and treatment of heat exhaustion and stroke.

Heat Exhaustion Presentation

  • Body temperature under 104 degrees F
  • Heavy sweating
  • Muscle and stomach cramps
  • Headache
  • Nausea or vomiting
  • Tiredness, weakness
  • Dizziness and fainting

Heat Stroke Presentation

  • Body temperature above 104 degrees F
  • Hot, dry skin
  • Confusion, strange behavior, seizures, or unconsciousness
  • Rapid pulse
  • Throbbing headache
  • Nausea

As you can see, many of the symptoms are similar as heat stroke is an intensification of heat exhaustion. A differentiating factor is the change from heavy sweating to hot, dry skin. In both cases, treatment focuses on rapidly cooling and hydrating the body. Heat stoke definitely requires hospitalization while heat exhaustion, if mild, can be treated at the facility and may require infirmary monitoring.

Heat Exhaustion Treatment

  • Move to a cool area (Shade, AC)
  • Remove or loosen restrictive clothing
  • Rehydrate with fluids
  • Use evaporation methods
    • Spraying water on the body and fan the air
    • Sponge body with cool water
  • Rest
  • Monitor until body temperature returns to normal

Heat Stroke Treatment

  • Move to a cool area (shade, AC)
  • Removal of restrictive clothing
  • Use evaporation methods
    • Spraying water on the body and fan the air
    • Sponge body with cool water
    • Covering the patient with cold water–soaked sheets
    • Place ice packs in the axillae and groin
  • Supplemental oxygen, if available
  • Prepare for possible initiation of IV therapy
  • Prepare for transfer to acute care

Patient Education for Prevention

Helping patients to manage heat and humidity can prevent heat injury. These reminders are important for officer staff, as well.

  • Keep hydrated. This can be difficult where bad-tasting water and fruit-flavored Kool-Aid are the only options. Advocate for healthy fluid options for your patients when possible. Ask about fluid intake during your subjective assessments.
  • Reducing physical exertion. Now is not the time for basketball competitions or lifting challenges. Many inmates are on outdoor work duty with many hours in the sun. Be mindful of the work status of inmates coming to sick call with symptoms of dizziness, weakness, headache, and general body tiredness. Instruct patients to take frequent rest breaks and seek out shaded areas at work and recreation sites.
  • Use available cooling methods. Teach patients evaporation heat reduction methods to stay cool such as sponging body areas with cool water and body fanning.

Personal Safety in the Heat

Don’t forget yourself in your summer heat preparations. You are also vulnerable to heat injury. Even if the medical unit is air conditioned, many health care activities take place outdoors or in housing units. Be sure to follow all the instructions provided to patients. Stay hydrated and monitor your mental and physical status regularly. Urine output and characteristics can be a good indication of adequate hydration. If you are basically healthy, pale urine is an indication of appropriate bodily fluid volume and generally good kidney function. Concentrated darker urine or decreased urine output can indicate a need to increased fluids. Double up on the fluids you bring on shift. Water is always a better option than sweet or caffeinated drinks.

Do you work in a high-heat setting? How do you keep your cool and manage your patient’s heat regulation during the summer? Share your thoughts in the comments section of this post.

Photo Credit: © OlegDoroshin

June 2015 Correctional Health Care News Round Up (Podcast Episode 101)


Ep101Lorry is joined by Mari Knight and Catherine Knox to discuss the latest correctional health care news items.

New study examines health factors influence on ex-prisoners’ chances of returning to jail

The first news item is a study out of Australia that links health factors to recidivism. In this exploratory study of prisoners from seven institutions in Queensland, those inmates with a history of risky drug use and mental illness were more likely to return to prison while those who were obese or had a chronic disease were less likely to be incarcerated again.

Prison break casts spotlight on staff-inmate relationships

The New York Prison Break has been prominent in the news and in this last week of June the two escaped inmates from a maximum security prison in upstate New York have been apprehended. As more information emerges about the planning and implementation of the elaborate escape, light is being focused on staff-inmate relationships and how staff can be manipulated. Resource links on the issue of nurse-patient relationships can be found in this recent post.

Top doc blasts California prison health care

A prison psychiatrist at San Quentin State Prison in the California Prison System circulated a memo about constitutionally inadequate mental health treatment in the prison and seems to have suffered retaliation for doing so. Correctional nurses have felt a need to speak out about inadequate care or conditions of their inmate patient population and have also suffered negative consequences.

Caring for the dying, behind bars

Our final story is about caring for dying patient behind bars. This is an opinion piece written by Dr. Jaime Mayer, an infectious disease physician, and published in the Boston Globe. She basically askes the question – is it possible to have a good death in prison? It is a struggle to balance compassion and correction …or, care and custody in many areas of healthcare behind bars. This essay provides a good example.

How about you, do you have some input or experiences to share related to our news items? Share your thoughts in the comments section of this post.

Compassion Fatigue (Podcast Episode 100)


Episode 100Sonya Khilnani, PhD, CCHP, a licensed clinical psychologist and behavioral health manager for Corizon in Brentwood, TN, joins Lorry to talk about compassion fatigue in correctional health care practice. This was the topic of an article she wrote for the Spring 2015 CorrectCare magazine.

Telltale Signs of Compassion Fatigue

We are in a ‘sea of trauma’ in the correctional setting as many in the patient population have past and present traumatic history. This vicarious exposure to trauma results in work stress over time. Unlike other causes of burnout such as long work hours or coworker strife, compassion fatigue is caused by absorbing trauma from our patients and being drained through helping and ‘caring for’ traumatized patients. A nurse who also has a traumatic past will be at an elevated risk of empathizing with patients and, thus, triggering memories that enhances the potential for compassion fatigue.

Signs of compassion fatigue include:

  • Social isolation
  • Sleep difficulty
  • Nightmares
  • Drug or alcohol overuse

Don’t Neglect Yourself!

Intentional self-care is important to prevent compassion fatigue. Being mindful of our own mental and emotional health is a first step. It is vital, then, to regularly reflect on your own practice. Counseling may be helpful and available through the employer.

Self-care activities can include:

  • Openly share about challenges with other staff
  • Education about compassion fatigue
  • Regular physical exercise
  • Meditation or relaxation

Set limits and calendar in ‘me’ time to recenter yourself and replenish your reserves. Hobbies or recreational activities could be helpful.

Episode 100 Celebration!

Fellow nurse podcasters Jamie Davis of The Nursing Show, Rachel Silva of The Nurse Practitioner Show, and Keith Carlson of The Nurse Keith Show, send greetings and congratulations on Correctional Nursing Today’s reaching 100 episodes.

Links Mentioned in the Podcast

Blog Post: Ways Your Patient Can Help You Avoid a Medication Error

Audible Free Trial

Additional Information

Read my post Correctional Nurse Self-Care: Preventing Compassion Fatigue on the Essentials of Correctional Nursing Blog.

How are you dealing with compassion fatigue? Share your tips in the comments section of this post.

Book Review: Guide to the Code of Ethics for Nurses

Book Review: Guide to the Code of Ethics for NursesThis spring marks the second anniversary of the release of the Cleveland captives. The horrendous story of the teenage girls abducted and sexually abused for a decade is hard to think about. My heart goes out to them as they struggle to come to terms with what they have experienced. At about the same time as newspapers were marking the anniversary of the freeing of these captives, I received the latest edition of the Guide to the Code of Ethics for Nurses by Marsha D. M. Fowler, published by the American Nurses Association.  This second edition was developed to match the 2015 revision of the Code of Ethics for Nurses. This combination was a strong reminder that we work in a specialty full of ethical issues requiring us to cling to an Ethical Code to guide our professional practice. For, you see, nurses had to provide health care to Ariel Castro in both a jail and prison setting before he committed suicide in his prison cell. As correctional nurses we must come to terms with providing nursing care to unlovely and unlovable people.

The Guide to the Code of Ethics provides a real-world application of the key principles of the Code of Ethics for Nurses and explains the additions and revisions of the newest code revision. Its stated purpose is to

  • Set the Code within its developmental context
  • Provide resources that further the readers’ understanding of the Code
  • Identify pivotal documents that have and continue to inform nursing ethics
  • Guide nurses in the application of the Code

Application is assisted through illustrative cases and group discussion questions. While not advocating any particular ethical decision-making model, the author looks to the nursing process as a framework for assessing an ethical situation, developing a plan of action, and evaluating the outcome.

Virtue and Obligation

Since the inception of the Code in 1950, the ethical framework of our profession has been virtue (values) based; with a foundation in ethical principlism. The principles of autonomy, monmalefecence, beneficence, and justice underpin the nine provisions of the Code. Our professional obligations, then, are based on the outworking of these principles in practice and in relationship with our patients, our colleagues, and society.  For example, the key themes of the Code are compassion, social justice, care, and human rights; all application of the above ethical principles as they would relate to nursing practice.

Although the foundational principles of ethical nursing practice have not changed, overtime, nursing practice has expanded and gained complexity. Society and social concerns have progressed, as well. The 2015 Code of Ethics for Nurses reflects this progression and the Guide to the Code explains and interprets these changes in light of nursing practice.

Nursing Self-Care

One area of expanded concern in the new Code and, therefore, discussed extensively in the Guide is that of self-care. Provision Five of the Code of Ethics had previously focused on the nurse’s duty to self but the provision was further developed to more fully examine the implications of this duty. Promotion of personal health, safety, and well-being has been added as an interpretive statement to the provision and this is developed in the Guide. Compassion fatigue is a very real correctional nursing issue, as I have discussed elsewhere. Nurses have an ethical obligation to take care of themselves for both their own well-being and as a role model to our patient population.

Civic Professionalism

Also expanded in the Code and, therefore, the Guide is the concept of civic professionalism as an ethical obligation. As the world becomes smaller and nursing practice expands, we have the ability and obligation to seek out social justice in the wider arena of community and political life. “Nurses act to change those aspects of social structures that detract from health and well-being.” Our unique position as the most trusted of health care professionals leads to an obligation to use that position for the good of our patient population. For correctional nurses this may mean engagement in such issues as improving literacy, supporting and advocating for community-based health services for our patients re-entering society, or even challenging the oppressive conditions of confinement in some correctional settings. The Guide provides the background of these values and obligations found in Provision Nine of the Code.

Application to Correctional Nursing

The Guide to the Code of Ethics for Nurses is a book worthy of space on every correctional unit’s bookshelf. A personal copy that can be marked, highlighted, and dog-eared is recommended for every correctional nurse. Here are my suggestions for maximum benefit.

  • Start a unit book club and tackle one of the nine provisions each month. Try to apply the case studies to a situation in your setting.
  • Debrief your next critical incident using the Code as a guide. What are the virtues and obligations inherent in the situation?
  • Post the Code in your breakroom to keep it in active memory. Here is a poster version and a bookmark version.

How are you applying the Code of Ethics for Nurses in your setting? Share your tips in the comments section of this post.

Four Ways Your Patient Can Help You Avoid A Medication Error

Four Ways Your Patient Can Help You Avoid a Medication ErrorA well-informed patient can be a great assistance in reducing medication error. The more patients understand about the medications they are taking, the better they can assist with monitoring treatment practices and questioning when unfamiliar medication is offered. Here are four ways to engage your correctional patient in the medication process to avoid error.

  1. Be Sure Your Patients Know the Important Stuff

Patients are best able to contribute to medication safety by having both general and specific knowledge of their medication program. Low general health literacy contributes to misunderstanding and gaps in patient medication. The level of understanding of the medical process, and specifically the medications ordered for treatment, affects medication adherence, whether provided by direct observation or through a self-administration process.

  • Medication allergy. General knowledge includes an understanding of any medication allergies a patient has and the symptoms they see when taking these medications. Indeed, understanding the difference between side effects and allergies are of particular importance for proper treatment. For example, a patient may state that they are allergic to aspirin when what they have experienced is stomach burning when they have taken aspirin on an empty stomach. Therefore, it is important to obtain descriptive information about medication allergies when documenting a health history.
  • Medication effect and side effect. Even when patients come into the criminal justice system on long-term chronic medications they may have misconceptions about why they are taking the medication, the expected effects of the medication on their condition, and what side effects they should be monitoring. There is even greater need for this information if new medications are added to the regimen.
  • Self-administration practices. Self-administration practices such as dosing and timing of medication self-administration can be an added challenge for patients, especially those with low literacy skills. It may take more than mere labeling instructions to be sure patients are appropriately self-administering medications allowed in the keep-on-person program. Besides basic information about medication effect, side effect, dosing, and timing, patients should be able to identify an interactions with food or other medications as well as any precautions that need to be taken such as avoiding direct sunlight or not stopping the medication abruptly. Because incarceration can restrict movement and meals, health care staff should also be sure self-administration practices are adapted to the particular situation of the patient.
  1. Give Them a Way to Communicate Directly with You

A knowledgeable patient is particularly important in a correctional setting where security barriers can cause medication delay or omission. A direct communication process between the patient and the health care staff assist in allowing patients to speak up when they have concerns about medication administration schedules. Many inmates use the sick call slip process for communication with health care staff, although other systems may need to be initiated if this is burdensome to the sick call process. For example, some settings have electronic communication through a kiosk system and others have a phone message system for inmate/health care communication.

  1. Help Them Understand Their Role

Incarcerated patients may need to be directly told to speak up about their medical condition and to question medication administration that does not fit with their understanding of their medical treatment. The power-over structures within a correctional setting does not encourage proactivity or self-efficacy in the patient population. Health care staff need to encourage and support patient participation in the care plan, including actively addressing unfamiliar medication administration.  Staff administering medications must be willing to explain any changes in the regimen. Here are a few common times when medications may be unfamiliar to a patient.

  • New patients may have medications switched from non-formulary brands to generic equivalents on intake into the facility.
  • Patients may not understand the information provided by a prescriber regarding a dosage change.
  • A new medication formulation including a change in size or color of the pill may be used while patient-specific medication is shipped from the pharmacy.
  1. Create a Solid Medication Self-Administration System

Involving the patient in administering their own medications can improve patient safety and assist with developing independent health habits. As identified earlier, patient education on drug and food interactions is important; so is information about medication effects and side effects. Confirm that the patient understands what situations require medical attention and the process for obtaining more medication when the supply is dwindling. Here are some tips for a safe and effective keep-on-person (KOP) medication program.

  • Establish a system for distributing and reordering KOP medications. Be sure patients understand the system and their responsibilities. Many medical units ask that patients 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, over-the-counter 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.

How do you involve your patients in monitoring their medications? Share your tips in the comments section of this post.

Photo Credit: © Vera Kuttelvaserova

May 2015 Correctional Health Care News Round Up (Podcast Episode 99)


cnt-podcast_cover_art-1400x1400CJ Young, Sue Smith, and Gayle Burrow join Lorry to talk about the latest correctional health care news.

 Mentally ill inmate died of water intoxication in Michigan prison, lawsuit says

In the first story, a mentally ill inmate in a Michigan prison died of water intoxication caused by psychogenic polydipsia. He was a severe schizophrenic. It is only a brief article and there are gaps in available information, but it is a reminder that there can be dangerous physiological ramifications to psychological conditions. In Podcast Episode 94 I talked with Dr. Scott Eliason about this condition. He provides some good information for managing those with this condition.

Nova Institution for Women sees spike in self-injury incidents

Our next story is from the Canadian System. Incidents of self-injury are up in their federal prison for women in Nova Scotia. The Nova Institution for Women has seen increasing self-injury events in the inmate population. Self-injury is defined as hunger strike, overdoes interruption, or self-inflicted injuries. Usually deliberate self-harm does not include suicide attempts but, instead, head banging, opening old wounds, inserting objects into the body, burning….things like that. Often these physical injuries relieve psychological stress.

Navy will not discharge Guantanamo nurse

Next up is the conclusion to a story being following for some time. A military nurse serving in Guantanamo refused an order to force-feed a hunger striking detainee and was brought up on charges. This story was originally discussed in Podcast Episode 86.In this latest news item, we read that the nurse was not discharged for refusing to force-feed. A good outcome to a difficult situation. What can we learn from this nurse for our own practice in the ethically challenging correctional setting?

 Hard Labor: A doula offers a little comfort for a birth behind bars.

The final story is certainly good news for pregnant inmates in the Minnesota prison system. The Minnesota Prison Doula Project provides weekly maternity classes and birthing support for pregnant inmates in the system. DONA International, an organization promoting the doula process, provides a definition:

The word “doula” comes from the ancient Greek meaning “a woman who serves” and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.

Studies have shown that when doulas attend birth, labors are shorter with fewer complications.

That certainly seems the case for these Minnesota inmates. Panelists discuss the many benefits of such a program.

Which news item was the most helpful this month? Share your thoughts in the comments section of this post.

Worth the Risk? Double-Checking High Risk Medication Calculations

Double checkOliver usually worked the pm shift at the prison but was helping out in a staffing pinch over the summer vacation period. He regularly does the evening medication round so volunteering to do morning medications didn’t seem like a bad deal. Everyone is harried as there was a man-down called for one of the housing units and the patient is being settled in the infirmary. Although there is a standing policy to have anticoagulant doses double-checked by another nurse, he decides to do the simple calculation himself. Without a calculator handy, he does the math in his head and documents that he had administered 7.5 mg of warfarin to Inmate Strump. In reality, he just gave double the prescribed dose as the tablets were 10mg rather than 5mg, as he thought he was using.

The need to calculate a dose based on available forms or strengths of medication can lead to mathematical error. If at all possible, medication formulation needs to be in the strength necessary for the prescribed dose. When medication is being titrated, like the warfarin above, the changes come too fast for this pharmacy oversight. Nurses often need to calculate the dose and convert to available pill strength from stock.

Even simple math calculations can be challenging in a noisy housing unit with many distractions. While limiting the variety of strengths of various medications in stock may reduce the error of selecting the wrong strength of medication for a particular patient; relying on only one stock strength of medication increases the need to split scored medications and to make on-the-spot mental mathematical calculations. Both increase error risk.

Calculation Double-Checks

Complicated calculations or high-risk medication calculations call for an added level of safety. We cannot always see our own mistakes and a set of independent ‘fresh eyes’ are needed in high risk situations. However, double-checking medication doses is time consuming and other nurses are not always available to stop and help. So selective use of an independent double-check process before administering certain medications is recommended by the Institute of Safe Medication Practices

What to Double Check

Health care safety organizations such as the Institute for Safe Medication Practices (ISMP) publish lists of high risk medications based on ongoing analyses of life-threatening medication administration errors. Some medications make the list based on look-alike/sound-alike qualities and the dangerous patient outcome if the wrong medication is administered. An example of this might be confusing MetFORMin (Glucophage) with MetroNIDAZOLE (Flagyl). Most, however, are high risk related to the danger of providing an incorrect overdose. This is of particular concern for pediatric, oncology, and geriatric patient populations as they have less reserves to process an inappropriate dose and may have complex medication regimens prone to error. Categories of high risk medications in acute care settings according to the Joint Commission and ISMP include anticoagulants, opiates, insulins, chemotherapeutics, and sedatives.

What high-risk medications should require a double check in the correctional setting? Certainly, if chemotherapeutics are provided, particularly as an IV additive, they should be independently checked by another nurse before administration. But, how about other, more common, categories such as anticoagulants and insulins? Both medications can have a seriously adverse patient outcome if an incorrect dose is administered. Insulin, in particular, has many strengths and formulations; making administration errors even more likely.

Too Much Trouble

A major reason many settings do not enforce a double-check policy (even when it is on the books) is because it is time consuming and often incorrectly performed. Here are some recommendations from ISMP on how to perform an effective medication double-check process:

  • Only use a double check process for the highest risk medications otherwise the process is likely to fall to the wayside due to time and availability issues.
  • Make sure the double check is totally independent. The second nurse should check the order, calculate the dose, and compare to the first calculation without additional information or interpretation. This reduces the chance that the double-check follows the same error path as the first calculation.
  • Don’t let the double-check process become superficial. Make the review an active engagement in the process. Do not assume it is correct because the practitioner is a trusted and high-level colleague. Mistakes happen to everyone!
  • Establish a standardized process (mental or written checklist) for calculation double-checks. Consider these items in the list.
    • Is this the medication ordered?
    • Is this the dose ordered?
    • How is the dose calculated? Redo the calculation independent of the original calculation.
    • Is this the correct patient?
    • Is this the correct time for administration?
    • Is this the correct route for administration?

Although standardized dose calculation double-checks are an important part of reducing medication administration error, they cannot overcome a faulty system and should not be the only safety mechanism in place.

Do you use medication calculation double checks in your setting? Share your experiences in the comments section of this post.

Photo Credit: © raywoo  – fotolia

Crushing Injury: Are You Helping or Harming When You Crush Pills?

Inmate Dexter was found cheeking his psyche meds. The facility has a blanket policy that all narcotics are crushed and, in addition, all pills are crushed for patients found to divert their medications. This morning he is to receive Effexor XR, Ery-Tab, and Kaletra. Now what?

Some correctional systems require that medications be crushed to avoid diversion. There are few studies about this practice and many concerns. Besides the increased time needed to crush medications, some formulations are not absorbed correctly once crushed. In particular, time release capsules and slow-release tablets are based on the medication remaining in the manufactured format for correct absorption. Other medications are caustic to the intestinal system and require enteric coating to avoid adverse effects. Thus, pharmacy experts strongly advise against crushing both time-released and enteric coated preparations. The ISMP provides a detailed listing of medications that should not be crushed.

Little is available on the practice and outcome of crushing medications in the correctional setting but much can be learned from observation of nursing practice in long-term care. One study in Australia found many medications being crushed with communal crushing equipment and multiple medications being crushed at the same time. Both practices can cause adverse effects or expose patients to an allergic reaction according to experts.

Harm to Patient – Harm to Nurse

Other concerns with indiscriminate crushing of medications is the possibility of teeth staining and irritation of the mouth, esophagus, and stomach lining.  Binders or other substances included in the tablet formation may be needed to buffer Ph or other irritating qualities of the medication. The erythromycin (Ery-Tab) that Inmate Dexter is to receive is enteric coated for this purpose.

Opening capsules or crushing medications can be harmful to staff, as well as patients. Exposure to active ingredients may be carcinogenic and harmful to an unborn fetus (teratogenic or fetotoxic). Sensitive individuals may have an allergic response. In the example above, Kaletra should not be crushed and a pregnant staff member should not come in contact with the active ingredients.

Harm to the Treatment Plan

The effectiveness of medication can be altered or eliminated by crushing. For example, medications that are sublingual or effervescent should not be crushed for this reason.

Medication toxicity can result when sustained-release or extended release tablets are crushed or capsules opened. The patient may receive the entire dose immediately rather than over a longer time period, as intended by the formulation. Inmate Dexter’s Effexor XR is such a medication.

Sometimes you can immediately identify these danger medications by their prefix or suffix. Common controlled-delivery indicators are:

      • CC
      • CD
      • CR
      • ER
      • LA
      • Retard
      • SA
      • Slo-
      • SR
      • XL
      • XR
      • XT

Time Pressed

Crushing medication properly is a time-consuming operation that can increase the time-stress of medication administration, thus increasing error risk. So, medication crushing should not be required indiscriminately but used judiciously when necessary for the patient and patient community’s safety. For example, some settings limit crushing to highly abused medications such as psychotropics and narcotics. Other settings require crushing for individual patients who have been identified as diverting their medications like Inmate Dexter.

Avoiding Crushing Injury

Based on the literature (also here, here, and here) the following safety measure should be considered when crushing medications.

  • Establish a list of common medications that should not be crushed.
  • Limit crushing to high risk medications or high risk patients to reduce error potential and increase medication administration efficiency.
  • Require the prescriber to order crushing as the mode of PO administration.
  • Require pharmacist oversight of crushing (through the order) as a double check that medications ordered for crushing are appropriate for this delivery method.
  • Transcribe crushing as the route of administration onto the MAR.
  • Make every attempt to obtain the medication in liquid formation to avoid crushing.
  • Only crush medications with approved devices. Use a fully self-contained device such as this one. Avoid mortar and pestle or twist devices that need cleaning between doses.
  • Use individual packets with communal crushing devices to eliminate the potential for mixing medications.
  • Do not make a slurry of combined medications. Each crushed medication should be administered separately to avoid incompatibilities.
  • Mix crushed medications with water and not food (like applesauce) or other liquids (like juice) that might interact with the medication.

Another good practice is to eliminate highly abused medications from the formulary; replacing them with an appropriate substitute of lesser abuse potential. Quetiapine (Seroquel), gabapentin (Neurontin), and bupropion (Wellbutrin) have been eliminated as options from some jail formularies due to the high level of abuse in the particular inmate population. While this may reduce abuse, it is important to have alternative medications on formulary to use when therapy is needed for an actual patient condition.

What about Inmate Dexter?

Inmate Dexter’s medications were delayed while the med nurse consulted with the pharmacy about options for his daily medications. Although not the most convenient solution; it was the safest and best practice. Later that day she set up a nurse sick call appointment for him to discuss the reason for his medication diversion. The root cause needs investigated. For example: Is it because he doesn’t want to take the med? Is it a medication that someone else is pressuring him for? Is it something he thinks he can sell? Armed with this information, she plans to discuss the situation with the provider to see if there are any alternatives such as medication discontinuation or exchange.

What do you do when pills need crushing in your practice setting? Share your procedure and best practices in the comments section of this post.

Photo Credit: © Rob Byron – Fotolia.com