Long-Term Care

TIP OF THE WEEK: Taking extra precautions with medications

Contemporary Long-Term Care Weekly, September 26, 2006

Source Briefings on Long-Term Care Regulations, September 1999

As resident acuity increases, the average number of medications they take in a week goes up and up. To add to that, the likelihood of drug side effects, interactions, and counter-indications increases as people age. Unfortunately, the chance that a resident will get the wrong medication, at the wrong time, or in the wrong dosage becomes more likely as the number of meds being dispensed rises.

Can you read the doc's orders?

The first thing long-term care facilities need to do, according to Jody Silva, director of adult care at ChemRx, a long-term care pharmacy that fills prescriptions for nursing homes and assisted living residences throughout New York state, is to make sure that a doctor's prescription is legible. "You could write a book about doctors' handwriting," she says. And doctors in a hurry - as they so often are when they visit nursing homes - write even more illegibly.

"Doctors are rushed," Silva explains. "They're usually watching the clock when they visit a facility, but you've got to slow them down."

It's critical that someone on your staff monitors all physicians' visits to residents. Before a doctor leaves the facility, someone on staff should see each prescription that's been written and make sure that the orders are legible and that they make sense.

To avoid prescription errors, a registered nurse (RN) should handle the responsibility for reviewing each prescription with physicians before they leave your facility. The RN must know clearly, at a minimum, what the prescription is for, whom it's for, and what the dosage is. "A doctor may write a prescription for C. Smith," she explains, "but if you have a Clara Smith and a Claire Smith, that's not enough."

Prozac or Proscar?

Some prescription drugs that treat totally different conditions are spelled almost identically. Celexa, a medication prescribed for depression, for instance, is easy to confuse with Celebrex, an arthritis medicine. Proscar, a prostate drug, could look like Prozac if a prescription is scribbled. And there are many other medicines that sound and look alike on prescription pads.

"I have a department here that's on the phone all day clarifying doctors' handwriting, and making sure that the drug prescribed is the prescription we fill," Silva says. However, if you can do some detective work at your facility before the prescription goes to the pharmacy, you'll save time and trouble.

As important as it is to make sure the drug dispensed is the drug prescribed and that it's for the right patient, it's also key that the doctor's prescription includes the name and address of the facility. If a pharmacist receives a prescription for Claire Smith without an address, it could be a long while before Mrs. Smith gets her medicine.

Follow an Rx from start to finish

You need a foolproof system for handling prescription medicines, Silva says. A logbook is central to this system. Don't just use a logbook to record when medicines are dispensed to patients. "Record everything that you do," Silva says, "from the time the prescription is written to the time it's filled and received from the pharmacy."

Whenever a doctor changes a patient's prescription, record the change in your logbook as well as on the patient's chart. "You need a backup to doctors' notes," Silva says. Again, she urges long-term care staff to quiz physicians while they're in the facility.

When it comes to changes in prescribed medicines, the RN needs to find out exactly why the change is being made, when the change is supposed to go into effect, and for how long the new order is to be continued. Does the doctor want someone at the facility to check the patient's progress on the new medication in a day or two and phone his office with a report? Once the RN has found out all the facility needs to know about the new prescription, she should enter the information into the logbook and share the information, as soon as possible, with at least one other staff member. When shifts change, information about any new drugs that any patients are taking should be part of the staff briefing. Then, staff on duty when a patient has a reaction to a new drug later in the day will know what to do.

While doctors write the prescriptions and change them, the long-term care facility and staff is generally responsible for ordering and re-ordering drugs from the pharmacy. Prescription plans change frequently, Silva says, and it's your facility's responsibility to keep on top of these changes so that reimbursements are not delayed.

Deductibles change. Policies are renewable - most often annually - and coverage will be dropped if the forms aren't filled out and sent in to the insurance company. Insurers change their formulary lists (the lists of drugs they cover) with regularity. Medicare and Medicaid coverage have their own set of forms to wade through and reimbursement can be a long time coming. You need to work with a pharmacist who can be patient.

No matter how adept your staff is at keeping on top of reimbursement forms, some will slip through the cracks. Silva recommends that you talk over what will happen if a patient's coverage is disrupted with the pharmacy that fills prescriptions for you.

Family members sometimes let coverage drop and this can be an awkward situation for long-term care facilities, Silva says. Some family members can also be reluctant to pay deductibles out-of-pocket. She urges facilities to think about these problems in advance. "Make it clear when the patient is admitted," she says. "Ask family members to sign a form assuming responsibility for paying bills that aren't covered by insurance."


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