Posted on: January 5, 2024
The Pass Medications Policy and Pass Medications Procedure have been updated to better support health care professionals who care for patients and residents going out on a
temporary leave of absence from an Island Health hospital or facility. The new Nurse Dispensed Medication for Future Use Guideline supports nurses in meeting their British Columbia College of Nurses & Midwives Medication Practice Standards for dispensing.
Highlights
- The Pass Medications policy and procedure apply Island Health-wide in the following care environments: acute care, ambulatory acute, long-term care, hospice, respite, and mental health rehabilitation.
- The revised policy and procedure documents are now available on the Policies and Procedures web page under Medication Systems / Specialized Programs.
Practice Changes
Scope Clarity
Applies to all health care professionals (HCPs) and respective student populations who are authorized to:
- Order medications in Island Health. This includes:
- Ordering Providers (i.e., physicians, nurse practitioners, and midwives).
- Administer, handle and dispense medications in Island Health. This includes:
- Pharmacists and pharmacy technicians;
- All nurses: registered nurse (RN), licensed practical nurse (LPN), and/or registered psychiatric nurse (RPN);
- Students authorized to perform medication administration as part of their clinical rotation or practicum or as an employed student nurse, with the required regulatory supervision.
Guidance on Current Practice
Currently, after receiving the written order for pass medications by the provider, nurses either request the pass medications from pharmacy or if less than 24hrs notice dispense the pass medications.
- Nurses provide patient/family education about pass medications.
- Nurses document in the patient record:
-
- Each pass medication instance on the medication administration record (MAR).
- The content of the education shared with the patient/family.
- Information about the medications and quantities given to the patient/family.
Guidance on New/Updated Practice
- Island Health requires an order for pass medications, including exact duration of the pass.
- PRN medication orders must stipulate the number of doses.
- Pharmacy requires at least 24-hour’s notice to prepare and dispense pass medications. Some passes require more notice—follow local processes.
- Nurses will prepare and dispense pass medications for less than 24 hours of medication and less than 24-hour’s notice.
- Nurse dispensing includes preparing and giving medication for a client to take later, taking steps to ensure the pharmaceutical and therapeutic suitability of the medication for its intended use, and taking steps to ensure its proper use.
- Island Health supports nursing staff to dispense medications in accordance with their scope of practice for clients who meet the clinical indicators.
- There are parameters for the quantity of medications a nurse may dispense.
- Guidance is provided for nurses dispensing with and without a client specific order.
- Additional information and knowledge is required to dispense medications without the involvement of a Pharmacist.
- CPOE will change provider and clinician workflow for patient pass medications:
- Providers will place an order to support the patient pass workflow as either ‘Patient Pass with Medications’ or ‘Patient Pass with No Medications’.
- Clinicians will use new documentation tools (PowerForms) to capture patient check-out (e.g., education and nurse dispensing), communication while on pass, non-return from pass and pass check-in.
Education and Implementation
Medication Safety and Professional Practice are presenting at CNE/CNL meetings. Slides will be available for distribution.
- Education package with Quick Reference Guides (QRGs) on new/updated practice will be available.
- Suggest CNEs/CNLs present at education rounds, huddles and other education opportunities.
Questions?
Connect with the Medication Safety Team at medicationsafetyconsultants@islandhealth.ca