And now I would like to reintroduce our speaker to get us started with part three today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director, Western Region, Patient Safety and Risk Management for The Daughters Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. And she is licensed to practice law in Colorado and in California. We thank you so much for being back here with us this morning, Laura, to get us started with part three. Okay, thank you, Lindsay, and welcome, everyone. Part three has only two topics, but they're huge topics within the manual. They're not as long as restraint and seclusion, granted, but still, they're such an important part because that's why people go to the hospital. So they can have nursing care and have the medications they need to recover. And I wanted to combine these two because there's so much overlap in what those duties and responsibilities are in taking care of patients under CMS. I always include in my webinars my disclaimer that my program is informational only. It is not meant to serve as providing legal advice or establishing the attorney-client relationship. You'll have to reach out to your own in-house counsel, legal representative, whoever that happens to be, for advice, especially as it relates to your particular situation. Well, I always just do a quick introduction on why are we here? Why is Georgia Hospital Association putting on these programs for you? And that's so you don't get one of these, that with the information that you can take away from here, you don't get the statement of deficiencies and where you have to do that plan of correction. And, of course, no provider, whether it's a physician, radiologist, or a hospital, wants to get noticed they have been involuntarily terminated from a Medicare and Medicaid agreement. That is such a huge financial impact for those providers. Well, what we're talking about today is strictly Appendix A, and that's you, your acute hospitals, anything that's over 25 beds. And the areas that we're touching, again, will be nursing and pharmacy. Now, before we do get started, I know there has been some questions regarding the new rule on maternal health care. Those topics are going to be covered over the next two weeks in Sessions 4 and 5. So, yes, they will be touched upon on what the new requirements are for you as a hospital. Well, I do just want to go through some of the deficiencies on the two topics we're referencing. Here's some of the nursing deficiencies. One, we didn't make sure there was an RN who was supervising care, because what was happening in this situation, staff wasn't following physician orders, and that's what the nurse has to make sure is occurring. They didn't follow their own policy and procedures on insulin, and insulin is a high-risk medication. We didn't make sure patients who were in restraint and or seclusion were monitored, not only according to their orders, but, again, their policy and procedures. Here's one where the nursing didn't follow up on an allegation of abuse. We have one where we didn't make sure interdisciplinary care plan was developed in response to what the patient actually needed. Other basic ones, we didn't secure the medication cards. There wasn't adequate and proper supervision of a medical assistant. This individual happened to be practicing way outside of what they should have been doing. They didn't make sure an RN supervised and evaluated care for the patient. Here's what happened, is that the bed alarms for a patient who was at risk for falling hadn't been put on, and they weren't making sure that staff were reinstituting those alarms. It wasn't just a one-off. In this situation, it was a couple of situations where that did not occur. And then they didn't just finally make sure their nursing care plan was updated, especially when a new issue cropped up with that patient. Pharmacy deficiency, they were included. They didn't review policy and procedure on just giving their own services. They didn't make sure that services were prepared and dispensed medications in a safe way. They didn't make sure medication was stored to make sure it was secured. They didn't make sure outdated medications had been taken away and no longer available for patient use. On the medication storage area, they didn't make sure it was maintained according to professional principles. Allergy information hadn't been transferred appropriately within the record from the inpatient to a swing bed. That was the pharmacy's responsibility to do that. They didn't make sure medication profiles were reviewed and orders reviewed before they dispensed medication to inpatients. And just one more, they didn't make sure that they filed actions that were taken for recalled medications in a way to get these controlled substances, especially the expired controlled medications and controlled substances, getting them away from access so they could not be dispensed. Some of the more common deficiencies that I found in review. All right. I'm going to start now with nursing. Multiple tag numbers. I'm going to start with the very basic. We have to have an organized nursing service that provides 24-hour care. That means at least one RN has to be on duty, either supervising or actually providing care. There is an exception. If you are a small rural hospital and you have a waiver, in effect, and the state, they provide that waiver. CMS gives you the waiver, by the way. The surveyor is going to make sure that services are integrated into QAPI, that there is enough staff, you have enough bodies to take care of the patient, and they're also going to look at the job description for the director of nursing because what they're looking at, and I'm just going to go ahead and write into that director. First off, it has to be an RN, and what you call it is up to you, whether it's director, chief nursing officer, manager of nurses, however you want to term it. This individual, they have to make sure and determine what type of staff they need, what type of nursing personnel, and how many, and they're also responsible for the operation of the service. Now, the surveyor may, again, they're going to look at that job description because they want to make sure it provides those two responsibilities at a minimum, and that the individual, the CNO, will approve any patient care policies that have been developed or revised. On nurse staffing, we have to have enough nurses and other people to care for our patients. That's everything from answering a call light to responding to an alarm or a code blue. Do you have enough bodies to go in and safely provide that care? You do also have to have a nursing supervisor, and this is usually the person that's there shift to shift monitoring and making sure care is still provided and appropriately. Every department or unit, however you separate it, has to have one RN present. If they're responsible or working on two units at the same time, that's not available. That's going to be a citation because they need to be focused on that particular unit. The surveyor will look at your staffing schedules, and then they're going to look at the acuity of your patients. When you have a step-down ICU or critical care unit, those acuities tend to be higher than in maybe some of the med-surg areas or the rehab area. That's the acuity of the patient, where you may have to have a nurse for one to two patients or three patients, but then maybe there's support staff. That's what they're looking at to make sure enough bodies and qualified bodies are there to take care of them because there are some studies out there, three of them actually, that show having enough staffing will result in better outcomes. It said patients, if you want to survive your hospital visit, look to the low nurse-patient ratio. The lower the number, the better the outcome. That happened to be an AHRQ evidence study. I have the link there if you wanted to download it. An Institute of Medicine study, they also found adequate staffing levels to better outcomes. This study went so far as to say, we need to limit the number of hours worked to prevent fatigue and no mandatory overtime for nurses. Never work a nurse more than 12 hours at a time or 60 in one week because, again, this IOM study showed you're going to have three times your error rate if that does occur. We recognized during COVID, some of our staff were putting in just monstrous overtime because there weren't bodies around to take care of the patients. And hopefully that never occurs again, but there are some hospitals that have had to shut down or at least units because they didn't have the staff to take care of the patients. And I know California has that mandatory staffing. I think there's one or two other states and maybe New York might have the mandatory staffing numbers that a hospital has to have in order to continue business. We also know that medication error rate goes up, falls go up, other issues go up that lead to maybe unnecessary readmissions when we have low staffing. And this is really important with our value-based purchasing now and getting that reimbursement. So the name of that article that just referenced this was Keeping Patients Safe. And there happens to be the link. You will have to copy paste these links to your surf engine, by the way. AHRQ, they actually put out a resource back in 2008. I have not found an update on this particular resource yet, but it's a good one to have maybe put it in the Director of Nursing or even in the library for nurses. And it talked about staffing and quality patient care and safety. Next back to the manual. So you have to have 24-hour nursing care. And that means, again, it's either provided or supervised by an RN. But you have to have at least an LPN or RN on duty at all times. And here, again, the exception is your small rural hospital where you have that waiver in effect. The surveyor, again, they look at the schedules. They're going to go back at least one week, maybe two. And they'll verify you have at least one RN for every unit 24-7. I want to talk briefly about that waiver, just in case you happen to be listening. 50 beds or fewer. And the deficiencies in staffing in particular, they don't affect the patient's safety. You have to meet everything else, all other statutory requirements of the manual. And to do this, you ask for this waiver in good faith so that you can comply with that 24-hour requirement. If you don't comply because you have a temporary shortage in that area, they do understand that. But otherwise, you do have to have an RN present 24-7. Otherwise, you can have an LPN. Again, this is that waiver for the smaller hospitals. Coming to our staff, we have to have a way to make sure that our nurses and the nursing personnel have a valid and current license. They look in their personnel folders. They want to make sure a copy of it's there. You can do it through usually your state nursing board. That is considered a primary source verification for you. And you may want to think about printing it out and just putting it in the file if the nurse hasn't remembered to bring you a copy of their license. You can verify it independently. Don't forget some of your advanced practice nurses. There is the Office of Inspector General list of included individuals. Those are the folks who, again, these are advanced practice ones, those who can write orders, et cetera. OIG keeps an eye on them. And if there is an issue with perhaps their care in the past, and it's primarily, again, what the Office of Inspector General would look like, fraud and abuse, they put them on that list of excluded individuals. Don't forget that list if you're doing your online search for primary source verification. Otherwise, we have to have an RN for every patient. Doesn't mean they take care of them. They're not doing the care. But they have to at least be there to supervise and evaluate care that is being provided. They must do that admission assessment, though. And then anything ongoing, depending on what your policy says, or if there's a change in that patient's condition. An evaluation would include what are their needs? What does this patient need while they're here in the hospital? How are they responding to interventions? Is there anything else in their health that we need to take into account and help them with? You know, whether it's turning every two hours because perhaps they can't get up because of their illness. Making sure we keep their skin integrity intact. And then here's the one that I know some of us who've done nursing, we always thought the nursing care plan was somewhat the bane of our existence because we kept having to do it. But it's so critical. And that's why CMS says we have to make sure that we develop and keep a current nursing care plan on every patient. Because what that's to do is reflect what does this patient want by coming into the hospital? What do they expect? And then in response to that, what care can we provide as nurses? If nursing participates and you have an interdisciplinary team, that's great. But you still have to have a nursing care plan. Because the idea is we are assessing what is the patient's treatment goals and can we meet them? That care plan starts on admission once they come in the door. And that is not just, okay, here's what they're coming in with and how we can achieve and meet that treatment. But it's discharge planning, taking into account not only physiological but psychosocial factors. And it's part of the record initiated soon or at admission. And then we revise it and make sure it's put into place, put into action. So just an example. We have a ski accident. And the idea is this patient wants to go back to skiing. Now, this was a pretty bad accident. And so they kind of shattered their femur. And the idea was you're not going to go back in two days. Even though we rod it and put it into place, you're not going to go back. And so we need to make sure that we work with them, get them maybe into a rehab facility for a week or two so they can have intensive physical therapy. This place is close to where their family lives. And then the idea is, okay, I'm done with that intensive. I'm not ready to go back. So I'm going to continue PT at home but stay at my mom's house. So that's an idea about what that care plan, how it's developed, and then how it progresses as our patient progresses. An RN has to assign nursing care to each patient. And that's according to what the patient needs and any special qualifications. Are they ACLS? Do they have special training in maybe behavioral health? Do they have special competency that we have to take into account that perhaps that patient needs? The DNO and hospital have to make sure personnel are appropriate based upon education, experience, competency, licensure, special qualifications, and that they're assigned to provide that care according to what does that patient need. This includes agency nurses. And when they put them into the requirements, all nurses must adhere to policy and procedure. That means every nurse, employed, contract, volunteer, based upon what they are doing. Again, the CNO has to make sure enough supervision so we can also evaluate the clinical activities of our agency nurses. Now, if they're there on a repeated basis, don't forget to do it annually, if that's how long they are there. But otherwise, we still have to review those clinical activities. Orientation, we have to, for the agency nurse, the hospital, their unit they're working on, emergency procedures, policy and procedures, safety policy and procedures. They have, say, they're in the middle of an emergency preparedness drill. What are they supposed to do? Or if there's a clinical emergency, what are their responsibilities to do? Is it there to take care of other patients? Or are they to step in and help with the resuscitation? That's what your policies, they have to be aware of what the expectations are for them. Briefly on outpatients, and this is where they're not inpatients, of course, they're outpatients. Maybe they're on an infusion unit or a dialysis unit, something that's outpatient. Have to have still policy and procedures that spell out which of those departments do have to have an RN. You look at that review every three years, and the CNO approves it because this CNO then has to decide what alternative staffing plans are going to be needed. This could be outpatient radiology where the patient's having contrast and you want an RN present in the event that there's a patient event. So that's what the CNO has to do. They have to have criteria in those departments to meet the needs and what is required in that patient care, the type of service, the acuity of that patient or standards of practice. Again, I've just mentioned here a chemo infusion department. Usually it's all RNs that are there taking care of the patient. I mentioned the radiology. If you happen to want the RN present for somebody, maybe those longer term procedures that are being done and it helps to have the RN there as far as monitoring the patient and resuscitation if it's needed. Still in nursing, I'm going to talk now about preparation administration of medications or drugs, and included in here will be safe opioid juice, compounding, and then the ever-present injection practices, safe injection. Well, we know that drugs have to be prepared and administered according to state and federal law. Who can administer? What are the limitations on that? But it all starts with that practitioner's order or someone who is responsible for their care using accepted standards of practice. It used to be only physicians could write the orders. Well, now that CMS has recognized there's other resources that can do this and maybe really be on top of what is the new medication that's out there. For example, a PharmD. If your state allows it and your hospital bylaws, rules and regulation allow it, perhaps you want that PharmD to order those long-term medicines. Maybe it happens to be TPN or working with the dietician and pharmacy to order that TPN. Also, when you have a very critical patient, it is a medication that's fairly new to the market or the process in which you're trying to treat. You want that pharmacist involved, that PharmD, to be able to order it, including maybe lab tests that need to be done or what medication, the strength, etc. On administration, that has to be administered either by or under the supervision of nursing or other personnel. This is where you look to your state and federal laws. Some states will allow PAs to supervise nurses, especially in a critical access hospital. But you also want to look at regulations like licensure requirements. Are there any requirements that say only RNs can administer this classification of medication? Always following approved medical staff policy and procedures because they determine, okay, what are the meds we're going to bring in and using and treating certain diseases? Now, the guidelines also talk about medication errors. By the way, this is the most common error right now. Harming about 1.5 million people per year are medication errors for various reasons, dosage, administration, etc. On the federal and state laws, the interpretive guidelines give some explanation. Like, for example, federal, they're going to regulate and approve the classifications of drugs and biologicals. That's great. They say, is this class one, class five? What is it? The states, on the other hand, they put out the laws and regulation on scope of practice for administering, for prescribing. So they work hand in hand, but different responsibilities. But, of course, we always follow accepted standards of practice and that's based on either guidelines or recommendations from those professional societies. And those who have expertise, again, in preparation and administration. They do include in the interpretive guidelines a list of organizations to establish these standards of practice. I have that in the appendix for you because CMS won't do that. They won't establish the standard. But just the basic, you have to have an order for working off a standing order. Both must be compliant with state, federal laws, and standards of practice. So what must our order include? Well, who are we giving it to, of course? Age and weight, if you need to do that to facilitate dose calculation. Time and date of the order. Dose, frequency, and route. And, again, dose calculation, exact strength when it is applicable. How long are you going to run this quantity and duration? And then if there's any specific instructions for use. And finally, who's ordering it? The prescriber's name. So that's at least what that order must include. The medical staff policy and procedures have to be approved for medication administration. CMS does recommend that medical staff consult with others in doing these policy and procedures. Pharmacists, of course, because they know the most recent classifications. But nurses, how does this work on your floor? Does it work well? How's the response to these meds? And then QAPI. Are they seeing any trends or events that they're running through on medication administration overall? There's multiple policy and procedures that we have to have for medication administration. This is still in nursing, by the way. Policy on who can administer medications. The basic safe practice for administration, the five rights we're very familiar with. Or if your hospital is going to do seven or nine rights. Policy on timing of medications. What do you do if it's a Mr. Late administration? Evaluation of those policies in and of itself. How often is that going to occur and who is going to be in there? Monitoring of patients. This is really a huge nursing function right there to assess them and monitor how they react. And then, of course, documentation. What is the required documentation for medication administration? Policies also have to identify what persons in that licensed personnel can administer those medication. Do they have to have special training and education to administer? Usually you do this during orientation or continuing ed. And that includes handling and preparation of the meds. Indications, side effects, interactions, compatibility, dose limits, how high can I go on that? And then the equipment. Do you have to have any special device, an eye med or an eye pump? Any procedures that have to occur before and after, like they don't eat or we give this med within a certain amount of time after or before they have a meal. Now, here in this section, they do cover the five rights, which we know. It's the patient, med, dose, strength, route. We know those. But they also talk in the blue box. And I'll show you that in the next slide here. The process and nine rights. So as far as the process itself, that's not just administration, it's the process. Transcribing, in other words, doc writes the order and now it's sent down. It is verified by pharmacy and then pharmacy dispense it and sends it up to the nursing floor to get it administered. Then the nurse administers it and then we watch the patient, how they respond to that. Now, with antibiotics, we know that can be tough, but if it's their initial dose, yes, we're watching for any untoward reaction, an allergic reaction. Again, the blue box talks about nine rights. What you do, that's up to your hospital, but at a minimum, the five rights to do so. And this section also talks about the culture of safety, that we are encouraged to promote it, that staff feel safe if they have a concern about an order and to have it resolved promptly. That if I have a concern on how much of a medication that the physician has ordered on a patient or that doesn't look right on that medication, I feel safe picking up the phone and calling that doctor without the fear of literally getting my head bit off because I bothered them. That this is something we need to do, be able to ask that question because sometimes the physicians may forget because they are busy too. There's some other issues. Of course, we want to adhere to standards so we don't have any healthcare associated infections while we're preparing the medication. This is like your compounded meds when the nurses have to dilute the medication in order for administration on the floor. In this area, you're assessed not only under nursing but our infection prevention also. So there's two areas where you might get cited if they have a concern in that area. Expiration dates, those are set by the manufacturer. Beyond use date, that's where you can use it before that date but never after it. And definitely never after the expiration date. After the expiration date, don't care what the beyond use date does, just throw it away. The beyond use date takes into consideration, okay, what are the factors associated with this med after it's opened or reconstituted? Is that going to go bad in 24 hours, 48 hours? What happens to that? What temperature do we need to keep it at? And that's why the policies really have to spell it out clearly for staff so they can determine beyond use date. You may want your pharmacy to do that. That's totally your decision. But the policies have to spell out who does determine that beyond use date. Timing, this was another component of that medication administration. The interpretive guidelines do talk about the timing of medication because we want to meet the best goal, therapeutic response to that medication. And in response to several studies, I got to hand it to CMS, they did recognize this was a need. There really needs to be more give or more laxity. I don't want to say laxity but more understanding when we have medications that are given and that perhaps there's three or four blocks of time. It used to be that if you were past that 30 minutes of when it was to be given, like 9 a.m., you were 945, you were out of compliance, you had to write an incident report and do everything. Well, they were like, that's not necessarily true. These medications still can have that effect after that 30 minutes. And this is also CMS worked with and agreed with ISMP, Institute of Safe Medication Practices. Yeah, we can actually do this. And I'm going to talk about that timing here in just a minute. But here, looking also at the standard of care, national organizations do recognize that we have to have policy and procedures for care and those are consistent with the standard of care. Now, on some of these, those medications in particular, they can be set by your state pharmacy board or other national organizations that CMS does mention. They include a whole list of them. I have, I think I put the links or email, website links for you in the appendix. That's just a list of what CMS identifies. CMS isn't the expert here. These societies, they are the experts. So on timing, your policy has to include the timing based upon the nature of the medication and why are we using it? What's the purpose behind it? They took that then and separated it into meds you can put into this timing schedule and ones you cannot, those that are ineligible. Which ones are ineligible? That's the ones where you got to have it at that time to meet the goal. Your stat meds, one time, your pre-op, one time loading dose. Maybe PRN, you can't establish a time for that. Investigational drugs, they have a host of requirements under the IRB that you have to do for investigational, but again, that's one we needed at this time. Could also be those for the loading dose, your stat drugs. Again, all of those where timing cannot be played into that factor. And then there's everything else. The all, everything else can be an eligible medication. These are ones usually on a repeated cycle, whether it's daily, three times a day, whatever it is. But your policy needs to spell out what your hospital has determined is the standardized time. So then the doctor orders a QID, pharmacy will know when to get it to the unit. Or when do I have to assess my patient? When do I have to look at blood work? So I'm on genomicin, BID. And then I need to know, okay, it's ordered at nine. We draw our trough at 830. And then I make sure that the lab's up there by 10 or whenever it is to do the peak. Or I'm looking at their kidney panel. How is that kidney panel holding up? How's the patient's hearing? Are they losing the hearing? Is there an issue with that genomicin being administered? They also have to address first dose of the medication. And when staff can use their judgment to time out the second or next dose. Also, retiming if needed, if there is a missed or omitted dose. I missed the 10 o'clock. Now I got to redo my timing, because I can give it at noon, and I've got to restart my timing factor. And just simply those meds that you can give outside that time schedule for administration. You also need to evaluate that timing policy and watch your adherence rate. Is there an area you need to work on? And that's a good QAPI if you're looking for one. Are you having an issue with any QA, timing of medications and administration? Track the errors too, because that could give you an indication on what gap do we need to tighten up? So we talked about these timings. These are the eligible ones. Time critical, one hour before and after, and two hours before and after. Starting with your time critical. These are the ones where if you give it outside that one hour window of time. In other words, these are the ones where you give 30 minutes before or after. If you do it outside of there, it could impact that therapeutic effect. And so that's why your policies spell out if these are always time critical. Antibiotics, anticonvulsants, insulin, all of those where we really need to have that therapeutic effect, if need be. Then there's the rest of it, the non-time critical. These are the ones where, okay, if it's shorter or longer between the doses, it's not really going to impact that therapeutic effect. Usually these are the ones daily, weekly, or monthly. Think your DIG if you're giving that just in the morning. Okay, the patient, maybe they decide to go out, take a walk outside, or they're walking around and you can't get it to them in that one hour or whatever window of time. You have some leeway in there. Here, you can give two hours before and after, not to exceed four. And these are ones that are usually more frequent than daily, but less than four hours. So you have an hour before and an hour after to meet it. Then you have your policy on, okay, I missed it or it's late. What do we do in that time? Maybe they're out, they're nauseated, whatever it is. Have parameters when nursing can use their own judgment to reschedule that timing dose, but still we have to report it to the attending. They need to be aware of it because they may decide, yeah, forget it, just go back to your regular timing. That one dose missed isn't going to make a big difference, but that's the physician's determination at that point. And then we periodically, we look at our timing policies, again, staff adherence, because we want to make sure we're doing the right thing for the patient. Errors, track them, analyze them for their cause, however you do that. Is it going to be an RCA, RCA squared, whatever it is, just make sure QAPI is aware of these events. And also looking at the timing policies, make sure medical staff is involved. They may need to revise those policy and procedures if it's a consistent problem. Now, Lindsay mentioned we have a couple of questions and here's our first one, Lindsay. Okay, let's get that one up here on your screen. I'm actually going to read this first part of the question, then I will post your potential responses here. This is patient B, an 85-year-old, is admitted for, and excuse me, Laura, is it just ORIF? Yes, that's open reduction internal fixation. Perfect. So left femur following a fall at home. He has a long-standing history of ETOH abuse and smoking. Post-op pain control includes an MSPCA and vital signs per routine. Two hours after admission to the floor, patient B is found unresponsive and apneic. Will the hospital be cited here? And then I'll give you your options up here on the screen. Yes, high risk due to age and overall status. No, he had substance use in his history or possibly. I did mention when we first opened that if you have questions for Laura as we go throughout the presentation today, we'll utilize the time of the polling questions to also address any of those questions. It looks like we do have a couple here, Laura. Okay. And this first question asks regarding the nursing supervisor, can this be the charge nurse or are they looking for a supervisor that actually supervises the entire hospital or all nursing units? No, you're correct. It can be the charge nurse, just somebody to supervise the care provider, especially on that unit. That's what they wanted is somebody supervising it. And then you have usually your DNO or CNO above that person, that chain of command to report. Okay. And then this is referencing, I think the slides themselves here, but does the number in the upper right-hand corner reflect a tag number? Yes. Yes, it is. And I'm sorry, I forgot to mention that. Yes. And that for hospitals, it's an A and it's a four digit. So if it's not four digits, there's a zero in front of it. Perfect. Okay. I think those were the only two questions I see at this time. And here are the results. Yes. Okay. So that's a very good. I'm glad that you've identified. Yeah, this could be an event. Yes, he has a longstanding history of alcohol and substance use, alcohol abuse, but we're giving him morphine. That's a little bit different and smoking. And so his respiratory component might have been compromised in that situation. So yeah, I think they're going to be, they would have been cited in that situation, given this patient, his age, and we've given him some really good stuff here in that morphine. So we have to monitor our patients. And that's unfortunately one thing that didn't happen with this individual. We monitor them on the opioids in particular. You may need some clinical lab value to evaluate how just an overall medicine responding to them, but definitely with opioids, we got to watch their respiratory, their pulse ox, their pressure, and you may want to go to entitled CO2. And one of the slides in here, there is a recommendation from the patient safety movement foundation where the patient is getting supplemental oxygen, like nasal cannula, and they're on IV opioids, put them on an entitled CO2. They'll react much faster. That one reacts faster than the pulse ox. And with the oxygen, the supplemental oxygen, we may be knocking down some of their respiratory drive unintentionally. Unintentionally. So we look at their other clinical signs too. How's their behavior? They seem a little off the gate, unsteady, and maybe just some confusion. That's why they say we need to know our high risk meds policy and what are the safe practices associated with it. Of course, we have to know and be on the lookout for any adverse events, whether based upon their clinical presentation of kidney or liver failure, smoking, sleep apnea, and obesity. Maybe there's a drug to drug interaction, or you have an opioid naive patient. So ISMP has this alert for those high alert medications. It's not just opioids. You'll see on here, insulin. Insulin is the last one, whether it's on that list here that I've been able to copy paste, but that can be sub-Q too, not necessarily IV. So that's why we have to monitor our folks. Regular assessments, keep an eye on their sedation levels, especially if they've got a PCA running. There are several types that you can use. I don't endorse one of them. CMS doesn't endorse, they just list them out here for you. Whether it's Richmond, Passero, Innova, Aldrete, whichever one works for your hospital, I would urge you to make sure they are used consistently. So if it's used in ICU or PACU, it's used on the floor. That way, if nurses have to float, it is a consistent. Same thing if you're looking at the record, you'll know this is where they scored an Aldrete in ICU, and now they've improved, and here's where they score an Aldrete on the floor. And that's why staff, we also have to make sure we tell the patient, tell me if you've ever taken this med. Do you ever have any problems with it in the past? And tell the patients that you need to let me know if something's not right after you have this medicine. Don't forget the family. And the family may be sitting there, or the visitors, and it's usually a consistent visitor. If you just see so-and-so acting a little off, would you let me know, please? That's my job. I need to know this. But your policies have to address how and how often you are monitoring them. And what are you going to communicate at shift change? What are their risk factors for this patient on these medicines? Now, documentation is talked about in the medical record section. They do talk about specific content for medication administration, and they even know we document after we administer it, right? Pre-documentation is not appropriate and could result in errors. Surveyor will verify you have an effective method for administration of drugs, and they'll take a look at your policy. Are these policies approved by medical staff and the governing body? Who can authorize meds? That's got to be in the policy. Is nursing and the nursing personnel acting within their scope of practice? And likewise, if others are administering, are they following state scope practices, federal laws, bylaws, rules, and regulations? Now, when they're doing a medication focus, they are asking for a lot of documentation. It's not just the patient's record. They will verify your policies address timing of meds, which are eligible and which are not eligible for those dosing times, and the total time for administration. Is it one hour, two hours, four hours? They're going to look at medical records because they want to see orders first off, and then they're going to see is there documentation based upon that medication, the patient's status, vital signs, for example. They will watch the nursing staff prepare and administer medications. They're making sure they do the five rights, or at least the five rights. They're assessing the patients. They're monitoring them where indicated, and then they'll ask the staff, do you know what to do if that patient responds to, say, that antibiotic? What are you going to do? They will interview staff. They want to know, do you understand the policies on timing of administration? Can they identify what is time critical and what's not? Can they identify meds that aren't included in these dosing times? In other words, your PRN drugs, and then what's the requirement to time the time critical and non-time critical? Do they understand that policy? Now, CMS does require, of course, we follow standards of care, but they specifically mention ISMP or IV push medications because we have to make sure overall we're following standards of practice so we don't contaminate that medication and or the patient. This includes those compounded sterile preparations. Again, you are assessed not only here but under infection control. Compounded sterile preps, they can cause infections if we're not following proper precautions because your nurses may do that on the floor when they meet that drug like right now. So they'll watch to see, are they washing their hands? Are they using gloves? Have they cleaned off the stopper in doing so? Have they used a sterile needle? Syringe? Has that only been used once? Those are some of the things they're going to observe while this is occurring. On compounding, we have to label the medication unless you draw it up and give it right away. It doesn't really leave your hands. The label has to include patient information, what's in there, the name and amount, who prepared it, either name or initials depending on how big it is, and the one hour beyond due date. So that has to all be on that little label there. Expiration, we know that it's outdated after its expiration or it's beyond due date. So let's say your expiration date is December this year, 2025. It's a multi-dose file and it expires in 28 days once you open it. Unless of course the manufacturer says sooner. Well, the expiration date is December. Even though let's say you are on December 30th of this year, if the expiration date from the manufacturer says December 31st, you have to toss it at that point. That's why policies have to give clear directions to the staff to determine that if it doesn't come from the manufacturer. And likewise, who does that is up to you. Do you have the nurses establish it or do you have pharmacies establish it? I mentioned that we have to have a physician order for all drugs and biologicals and how you do it, that's up to you. Are you going to use order sets, protocols, pre-printed sets? If you're using those, okay, they have to meet the standards in the medical records section under tag 457. The only exceptions are flu and pneumovax. Where you can follow protocols. You don't have to have that order because these are protocols that are approved by the medical staff. Of course, you assess your patient for any contraindications or allergies. You would do that for any medication that you would administer. Otherwise, they are documented and signed by that person, that practitioner who one, is authorized to write the order and is taking care of the patient. That could be someone on call. You're following the policies, you're following the state laws. Now, you can have someone else sign them off if they're acting within their scope and the state law and the policy and procedure. This is usually like a PA or advanced practice nurse, that if that's what you want them to do, that's fine. Here's just some suggestions. These are not in the manual. Again, have that culture so the staff feel real comfortable in asking questions. Make sure that you have written protocols for standing orders that have been approved, something the staff can implement if absolutely need be. And again, usually you see this, the protocol say it's a protocol for a code blue. Your rapid response team may have those protocols where they can initiate them and they don't have to track down a physician in order to implement them. It just, the provider, if you do have those protocol orders, make sure the provider has signed off on it. Standing orders that other personnel can administer these according to these pre-printed sets. CMS does recognize that having that phrase standing order can really cause a lot of confusion because they could be order sets. They could be protocols. These are things, again, that under well-defined scenarios for medication administration, staff can do it. And those orders are right there and they can do it without having to stop, go get the physician on the phone and get the order. Like chest pain, asthma, they're having an allergic reaction, ACLS, and an arrest. All of those are examples of standing orders or protocols. And the requirement for development of these standing orders is in the medical staff section and under medical records. Usually it's a medical records. Who can do it? Who has to review them? Pre-printed order sets, very similar. You date and time them when they are. These are sets where it may be more than one page. You just have to have the total number at the bottom of each page. Page one of three, two of three, three of three. If there's something in there, this order set that that particular physician does not want, they have to strike it and they have to initial each place that they do so. And standing orders, they, again, well-defined clinical scenarios. They do actually in here also refer to 457 and 450 on more information for standing orders. Verbal orders are a little different. If you're going to use it, use it infrequently. It used to be, they said, no verbal orders. Everything has to be written out. Well, now they do recognize that may not be, may not be the best choice of care when it comes time to taking care of a patient. They do know verbal orders that is a patient safety issue, increased risk of miscommunication leading to an error. These are only used where you have to meet the needs of the patient. And it's either impossible or impractical to find that physician to write the order. They're in surgery, they're on their way in, they're tied up in another room. It's never for the convenience of that practitioner. So if they're standing there, hand them the keyboard, hand them the chart, whatever happens to be. Of course, we have to have policy and procedures. They talk about what are the requirements in this verbal order policy? When can they be used? And when can they not be used? Like for chemotherapy, how do you identify the author? And making sure that yes, indeed, that's so-and-so that's calling it in. Now the regulation does broaden this to include your advanced practice providers. It's up to the state and your bylaws if that's what you want to allow. What are the elements of a complete verbal order such as name, drug, dose, et cetera, et cetera. But that also has to include in there who gave it and the person taking it. For example, verbal orders, give one gram of NSAP pre-op, one hour pre-op by physician. And then who took that order? They have to include their name. Protocols for that clear and effective communication of those orders, read back. Okay, doctor, this is what you want me to provide. You also have to include who can accept that order. Only those that the policy says consistent with federal and state laws. Your state law may not allow an LPN to take a verbal order or they may say, sure, not a problem. Also, if there's any federal law on certain medications that they say only an RN can take those. The person takes it, we know documents it, write it down, repeat it back, and then get it signed off. That practice has to be within your hospital policy and procedures. On signing off, any state law for that period of time, like 24 to 48 hours. If you don't have a state law, then you can write in your policy how soon that has to be done. But no more, definitely less than 30 days. Go for as soon as possible. 24 hours after, and again, if that's on a Friday and their on-call partner is coming on, fine, they can sign off. But it still has to have a name, date, and time for that order. And signing off, they have to be documented by a practitioner acting within their scope and hospital policies and the medical staff bylaws, rules and regulations. So everybody needs to still conform to this with the exception of flu and pneumovax. Blood transfusion, let's go over to that, and IV medications. These, we do have to follow state law and our policy and procedures as with any med, but especially blood. Previously with blood, there was a host of required training that CMS had listed very, very long that nurses had to be trained on. Well, they took it off because CMS finally realized this comes in our basic nursing training. We know what to do with blood and blood products and IV meds, they teach us that. And so since that's already standard practice, fine, they took it out. But we still have to be competent in those areas. Training has to follow any state law requirements. Some states say LPNs cannot hang blood. Others are coming around to realize, yeah, RPNs are just as qualified, they know what to look for. Or maybe they can't push certain IV meds. If allowed, you just have to make sure they are competent. In other words, have them demonstrate to you, have them talk to you about what are the side effects, what can I look for, and what do they do in that event? That has to be in their personnel folder. And again, following your medical staff approved policy and procedures, staff have to follow those. Remember, some of these, we weren't following our policy and procedures on our deficiencies. Our policies also have to address, okay, how are we gonna administer that patient? What vascular route are we going to use? Are we going to allow a central line? Not. What meds can't be given IV? Through what kind of access? Some of you may remember, we had a very tragic case here in the Colorado area. We had a baby born to a mom who was, she had strep B. And the baby was born at that time and started to, they wanted to prevent this child from contracting strep B. And so the idea was they were gonna have to give him a huge dose of penicillin. I think it was Pen-V-K. And I mean, it was a big size dose for a newborn. And the nursing staff was very concerned because it was gonna hurt a lot. So they worked with pharmacy. They also worked with the resident. They worked with the attending and saying, can we give this IV? Everybody signed off on it and said, yes, it can be given IV. It cannot be given IV. The child died once that was administered. And so again, this is one of those meds. Make sure it's very clear that it is not to be given IV under any circumstances. Basic practices for administration, raise the line, make sure you have it going in the right line and the right medicine if that's what it is. That there's programming of your devices. And anytime you have to force a connection, it's not the right one. That's we call our forcing function, that this isn't gonna work. So that's your sign. Don't connect it there. We monitor our patients and we have to know what monitoring for that particular med, if it's applicable. Policies to address the appropriate IV meds requirements for monitoring and assessing our patients for risk factors. Watch our fluid and electrolyte balance too. And of course, anybody getting those high alert IV meds and IV opioids. Watch your post-op patients because we do have to watch these folks very closely for serial assessments. You know, those every 15, every 30, every hour, every four hours. And how are we going to do that? What's the process? What are we looking for in that assessment? And what are you gonna monitor? How are you gonna monitor it? Who's gonna do those vitals? Because we have risk factors. I mentioned a few of them like snoring, sleep apnea, those opioid naive. But don't forget those surgical patients. If they have a thoracic incision and especially a chest tube, those things hurt. And so we have to be very careful and they don't wanna take deep breath. If they have pre-existing cardiac disease, maybe they're under anesthesia much longer where that could be that holdover of the anesthetic and now we're giving them the IV medication. And any other meds like antihistamines or benzodiazepines. ISMP, Institute of Safe Medication Practices and Anesthesia Patient Safety Foundation, they have recommendations on handling patients on post-op. Both are in the blue boxes. You can see here that ISMP, they pretty much monitor everything. And I like that the anesthesia patient safety, these folks have really done a lot of work on IV meds and especially pain medications post-op on what we have to do. And here's where that recommendation came that if they're on supplemental oxygen, really watch that patient for hypoventilation. That if you are using that supplemental oxygen, maybe you wanna look at entitled CO2 for that monitoring. Otherwise, they did add that recommendation that patients on IV opioids need continual pulse ox if they're on oxygen, you see an entitled CO2. But they also suggested linking the monitoring system to a notification so that, oh, by the way, this patient's vitals are starting to tank, somebody needs to go check them. And an escalation. So if nobody's responded to that, that it goes to the next level. Does it go to another RN? Does it go to the charge nurse? They say 60 seconds in that recommendation. I believe that's a little too long perhaps. You might wanna shorten that, but no longer than 60 seconds. That second person is notified. Over to blood. Of course, we confirm our patient and the product that we're using. CMS requires two qualified persons to do this patient check. And one of those has to be the one administering it. Joint Commission, on the other hand, says you can use one person as long as you are using barcoding. But be aware CMS is still, they're staying with that two-person standard. Policies, how frequent do you monitor them and what are you monitoring? And of course, documenting that, monitoring. We have to train our staff in blood transfusion, that we have the right venipuncture and that they're competent in doing that venipuncture, watching that site. Trained in detecting, of course, over sedation and make sure nursing education, by the way, is aware of this, that staff are educated on your policies. Staff competency not only includes the right route and the right needle, but watching their balance, their fluid electrolyte balance and watch for any transfusion reaction. How do they identify them and who do they report it to? Staff competency, there has to be evidence that they know about blood components. What is your administration policy? Are they familiar with the standards of practice? How do they monitor the patient and how often? How do they document it? And how are they confirming it's the right patient, right product? They will interview your nursing staff not just blood, but IV meds. Same thing, venipuncture techniques, safe medication practices, watching their electrolyte balance, assessing the patient and monitoring them, state blood administration. And then what they're gonna do is they're gonna look at your policy and they'll compare it to what they observe in the patient care. And then we have to have a way to report reactions and errors, not just blood, but meds also. And the surveyor, first off, they wanna see a copy of what is your procedure to report these errors? They may look at incident reports. They may look at maybe your QAPI program. Is there any information in there that you are doing this? You have to have a policy to report transfusion reactions that may be your incident reporting. And I've included, just there's a reference in here in tag 508, we get to that when we hit pharmacy. But how do we report these incident reports internally? Make sure all errors, adverse reactions are reported, whether it's blood or IV meds, how they talk in there about the symptoms of a transfusion reaction. What is your policy on reporting internally transfusion reactions? Because they can be life-threatening and immediately report to the practitioner. I don't care what time of day or night it is, they reacted, we need to notify them. So here's question number two. I think we're okay on time. Lindsay. We are, and I'll go ahead and get this. So on your screen, I'm gonna again read that first part to you. It says Baker Hospital recently instituted a policy allowing patients to bring in their established routine medications from home for self-administration. The admitting nurse is to look at the medicine to determine its classification and if it is on the established list for self-administration. So patient C brings in one bottle of all the medication taken routinely at home. Name and classification can be determined. Would you recommend that Baker allow the patient self-administration? And here are your options, yes or no. And I don't know how many of you have run into this. There's someone in my household who combines all of their medicines into one bottle when we go on a trip. And that makes me very, very nervous because those over-the-counter ones, you cannot tell what they are. That's not listed on there, on some of them. So that, again, we've probably seen this happen all the time. They bring them in here. Here, this is what I'm taking. Yep, absolutely. And I see lots of no response here and I'll share those results here in just a second. There are a couple of questions that have come in as well, Laura. And this first one asks if medical assistants are allowed to enter verbal and or telephone orders into the hospital EMR? That's up to your state. If the state permits it and your hospital policies permit it. There are certain meds you probably don't want them entering like chemotherapy. Really, that needs to be a clinical person just because of the impact that that chemotherapy can have. But again, that's up to your state and your hospital bylaws, rules and regs, if they are allowed. I can't answer that for every state. In my state, no, they're not allowed to take verbal or telephone orders. Mm-hmm. Okay. There's a couple more here. This first one says, for clarification, so CMS requires a two-person verification prior to blood administration and then the Joint Commission allows for a barcode to the second check. Right. And just one, that's correct. That's how it's written, yes. Now, whether CMS- And there's a follow-up comment from, yeah, somebody else here that says, always go with the most stringent requirement. Uh-huh, I would agree with that. It'd be better to be on the safe side. Okay. Yeah, and this is a follow-up comment here. It's a polling question that says, regardless of what the policy may say and meds are being verified, I'm so uncomfortable with patients self-administering their meds. Okay. Yes. Mm-hmm. Mm-hmm. Yeah. And there's those also. Oh, right, okay. Here's your self-administration. Now, there's two of them that really are closely tied together. Why they didn't combine them, I don't know, but here we go. Okay. You can allow a patient, Okay. You can allow a patient or their caregiver to administer both hospital-issued meds or once they bring in from home, but it must be specified in your policy and procedures. By the way, a PCA is still considered self-administered, even though we allow them to do that. We know that has the shutoff, so they can't over-administer. And that's why it's so important for nursing and pharmacy staff to be aware of this, that, yeah, they're gonna administer it. To do that, you have to have a policy, you have to have, of course, policy and procedure that spells out you must have an order. That's the patient on their capacity. Are they with it enough that, yeah, I'm feeling good they can do it. Educate the patient, their caregiver on administration. Now, they've probably done this forever and a day, but it helps to watch them because they may have been doing it wrong forever and a day, too. What about security of that med? Is it going to be left out on their bedside table or does it have to be locked up? Document whenever they do it, when they self-administer. And of course, look at the medication for its integrity. And this may be where you want pharmacy, if you're going to allow it. For example, you may want them to have that albuterol bedside if they have so much problems with asthma or if there's a COPD inhaler that can help them for that initial blast. Some as simple as hemorrhoid cream, that's still a medication. It's a biological. Is it better to have it bedside so they can right then and there apply some for them? So look at your meds, determine are you going to allow it? Just make sure you're following those steps from assessing the patient's capacity to documenting the med. So that's really 412 and 413 for those meds. Now we're moving over to pharmacy. Likewise, and I want to start with the antibiotic stewardship program. Here you have to have an antibiotic stewardship program. So we improve prescribing of antibiotics because what they want to do, the goal here is to reduce that C. diff or MDRO. So it's multidrug resistant organisms. It has to be active. It has to be hospital wide. So we're optimizing the use of antibiotics. You have to be able to show that you are adhering to nationally recognized standards to decrease our antibiotic resistance. And of course, best practices, the manual does specifically mention SHEA, IDSA, CDC guidelines, APEC, that's all important. All of these are those professional societies that make that determination. Now, CDC has core elements for this program. There are leadership commitments. It highlights the priority interventions and process manures and the key role of pharmacists and nurses. That's why I wanted to include it here at the beginning that we need to use our staff that we have because nurses administer it. They know how long it's been going on and pharmacy will know perhaps what's the most recent generation. Now, 85% of hospitals did have compliance with the seven core elements. I'll show you where you can find those. Much improvement, double improvement within a four year span. So that's how you would access the core elements of your program and even an assessment tool if you're looking for one. There's one for smaller hospitals. They worked with CDC, American Hospital Association, the Pew Charitable Trusts, practical strategies to implement this ASP. That includes leadership's commitment. A pharmacist can lead it, those who have drug expertise, evidence-based action tracking. How long are they on this therapy? And that use to the CDC net, reporting, education, et cetera. And there's even surveyor training. They had to train their surveyors when it comes time to compounding meds, which is what pharmacy does, because they recognize without that, they were all over the place as far as what the surveyors for CMS were doing in their evaluation. And so that's why when you're using compounded sterile preparation, they are now, CMS says, surveyors, you have to be trained in this on what you're going to look for. Okay, let's go to pharmacy now. So with pharmacy, they do likewise reference professional societies when looking at standards of care. And back in, I guess it was 2019, USP had multiple changes. And at that time, anytime the USP, that's the United States Pharmacist, the formulary, anytime they made a recommendation or change, CMS had to go back and change all their conditions of participation. And it was quite a nightmare for them. So now they no longer will do that. They will now say, follow what USP says. And so now we of course have to follow them, but also federal and state law and standards of practice. This again, avoided them having to go back and change the manual every time USP made a change. So with the pharmacological and pharmaceutical standards, again, this is section A and the four tag numbers. You have to have a service to meet our patient needs and at the same time, promote safe medication use. And it has to be directed by a registered pharmacist or a drug storage under competent supervision. The medical staff, they develop policy and procedures to minimize errors, but they can delegate that to the pharmacy service if they so choose to. So you still have to have a registered pharmacist or a storage area that's under supervision, competent supervision. Our service has to meet the needs of our patients. And that includes those giving information to the staff on this particular medication. The scope and complexity, that depends on what type of patients you have. How big is your hospital? Are you 200 beds or 800 beds? Are you doing research? If there are reports or frequent delays, the surveyor may wanna talk to your director on why is that happening? What's going on within your department? And they will ask, how did you determine you're meeting the needs of those patients? That's not a one quick answer, by the way. Your policy and procedures and drug storage, the medical staff, they develop the policy and procedures to reduce those errors again. They can delegate that to the pharmacist. There are multiple policy and procedures that are required in that event. Pharmacy or your drug storage has to be following those accepted standards of professional practice. And for management, you have to ensure that there is safe and appropriate procurement of the meds. How are we gonna storm? How are they going to be prepared? How are they going to be sent up? In other words, dispensed and then used and tracking. And finally, control of them. And then in the event you do have to dispose of medication, your policies have to show how are you going to safely and properly dispose of these medications? And that includes devices, your pumps. If you do happen to have a particular, say it's an implanted pump, how are you going to safely dispose of that? But the pharmacy management has to make sure that is somehow, somewhere addressed. Now on controlled substances, and this came up in a separate program, what about the patient who comes in through ED and they're carrying some of those environmental supplements with them? What do we do with them? How do we dispose of them? Any other way you would do. Now, pharmacy probably won't take back those illicit drugs like cocaine, heroin. They're not gonna touch them in that respect. What you can do, work with your in-house counsel. There may be, they may have a policy. Sometimes the ERs run into that, where they'll be, a patient is abundant. They can't respond. They have to go through to take the clothes off. They find the heroin in there. What do we do with this stuff? You just make sure you set aside, secure it, and then let law enforcement do it. Sometimes that's usually the best way to take care of that. Work with your in-house counsel on those illicit drugs disposal properly. Otherwise, principles have to be compliant with state laws, your pharmacy laws, any federal regulations such as DEA. They even talk about hazardous drugs and how it approaches. And these are hazardous drugs that could affect your staff and nationally recognized organizations. On drug storage, how you do it is up to you. Whether you're using a unit dose, a floor stock, individual, combination, whatever works for you. If you are using a drug storage, you can only use prepackaged meds that there's no further preparation. In other words, it's a closet, a cabinet that is secured, and it's always right there. The medical staff, they're responsible for those policy and procedures. Again, they can delegate that down to pharmacy. Sometimes that's better because pharmacy has a better handle on what those meds are and what's the best way to store them. But you do have to look at those policy and procedures periodically, revise them as necessary. What sources did you use in development of these policy and procedures? And the date, when did you last review them? CMS always recommends at least two years to review your policy and procedures. You may want to do it sooner, that's your choice. Of course, you train your staff on those policies. That's generally the director of pharmacy that would be doing that. Monitor to make sure they're being followed and a way to minimize errors. How do you prevent, identify and minimize these errors? That there is a process that conforms with the standards of practice. How do we identify and look at those adverse events? Was it the wrong drug? Were there two drugs that look alike, sound alike, that just somehow got cross-referenced? And look at external events. Maybe there's something that you need to be aware of externally that MERP has those, the National Coordinated Council on Medication Error Reporting. That's a really good resource to find out what are the other errors that are coming out. How do we reduce our errors? Usually if you're using Sentinel events, alerts, joint commission, they have good alerts that come out. I did mention the NCC MERP. That's a nice one because those are really up to date. They were heavily involved in tracking some of the COVID vaccine issues that they had identified. If you have a medication management committee, great. Assign it to one of the people on that committee. Watch these to keep an eye out for them. They even have a list of the policies that you are expected to address. Again, that list of policies is massive within that manual. High alert, well, we've already talked about that in nursing, but now we're gonna go look at the others, like look alike, sound alike. Those with a very narrow therapeutic range. Heparin, your psychotherapeutic meds. And then how are you going to minimize those errors? Are you gonna have just dosing limits, guidelines, they help. Labeling and storage. ISMP, USP, they all have lists of some of these high alert meds. I put in here the Institute for Healthcare Improvement. That test, Preventing Harm on High Alert, that how-to guide, these are free, by the way, if you wanted to download them. But some of the policy and procedures. You have to follow standards of practice. Everything from when you get it, you compound it, you dispense it, you dispose of it. The American Society of Hospital Pharmacists, they have a sterile compounding resource center that you can access. I have the link in the appendix. Policies to make sure investigational meds are controlled and administered. You really have to have a written process on investigational drugs, from approval, to review, to monitoring, all of these. IS, your IRB is really, needs to be tightly controlled for those meds. And they have to control, the storage, dispensing, and labeling of any of those controls. Other policies, standardized equipment and medication devices. They recommend limiting what type, how many pumps you're gonna use, that maybe one or two. Helps with a couple things, staff know how to run it, staff know how to troubleshoot. And your biomed can keep up with the updates to them or any fixing. Policy on up-to-date medication information. Policy that if the pharmacist isn't there 24 seven, or if the pharmacy isn't open 24 seven, that the pharmacist is on call. Policy that resume previous orders is prohibited. Policy on specific patient information that should be readily available. Joint commission has in theirs that specification. I don't get into joint commission. If you are accredited, you might want to look at that on what they require. Also, how you avoid standard dangerous abbreviations. All elements of that order from dose to frequency. An alert system for look-alike, sound-alike. There is a USP website that you can check for look-alike, sound-alike. And of course, that you, any pre-approved, pre-printed order sets. If those are available, great. Because they've been reviewed, they've been re-reviewed and been approved, usually by the medical staff. So that is the FDA and the ISMP look-alike, sound-alike drugs that are out. This is quite a few pages long, by the way. And you'd be surprised how many meds really look-alike and sound-alike. And then the ISMP, these are confused drug names where we could totally hurt a person because it sounds so close and it's a totally different classification. Of course, we have to run any errors or issues through QAPI. That's an integrated, as with everything. Look at the new types of mistake. See, why is this all of a sudden coming up? We want to make sure our policies and procedures that we address, not only the policies, but we look at our errors. RCA's one, pheromones effects analysis is another way to, before an event occurs. Voluntary, non-punitive reporting system. That most errors are a system problem. It's not because you had a bad actor. Balance, though, that with just culture. That, yeah, if you have somebody who's overstepping their bounds, not following your policy and procedures, and especially if they know it's wrong and don't care, then yes, follow that with just culture. And joint commission, the same standard. For alert and recalls, monitor and keep an eye on what's out there. An alert could just be, oh, by the way, we've noticed this. You might want to keep an eye on it. Incorporate external alerts and recommendations as much as possible. You may need to look at your policies again and revise them. CMS does say consider those that I mentioned, ISMP, FDA, MedWatch, and then the NCC Merck. FDA, they have a list of all drug recalls. You can sign up to get those alerts. When I was doing some risk management on site, that was wonderful, because then we got alerts right away on what we needed to take a look at. Are we prescribing this med? And if so, then we need to maybe reevaluate it. Society of Hospital Pharmacists, they have resources even on shortages and guidelines on what to do. They include in pharmacy, a section about weight-based dosing, especially with your peeps. But don't forget you may have other patients you want to look at. Your elderly who are very, very frail or cascadic. Maybe those who have underlying comorbidities like renal failure. We have to be careful with some of our dosing on those. They say babies you weigh in grams, children kilos, but not pounds or both. It's usually those you would weigh them in. And that's how we can help reduce our errors with those weight-based. So that's just an example of what that would look like. Back to our manual, we have to have a pharmacist, the pharmacy directed by a registered pharmacist, or again, in a storage under supervision. If you have drug storage area instead of a pharmacy, you still have to have the actual storage under the direction of a pharmacist. Because that pharmacist has to develop, supervise and coordinate those activities. How long they're there is up to you. It can be part-time, full-time, consulting, whatever you need. Some hospitals, they will, that drug storage with prepackaged medicines. But again, that storage has to be under the direction of that pharmacist. The pharmacy director, there you have to have written criteria for those qualifications, according to their scope of service. They're responsible to supervise and coordinate all pharmacy services. You can do it by telecommunications, if that helps. And include leadership committees responsible for medication policy and procedures. They need to be involved in those committees. Have documented training expertise in the practice management of that pharmacist. So that's what the director needs to do. Then, otherwise the pharmacy itself, under the direction and supervision of a pharmacist, or someone who is qualified to ensure compliance with those requirements. Those qualifications have to be in writing and make sure that they have secure, ensure security access to the locked area. Doesn't matter if you have even a satellite. They just have to make sure that the person who's over that is qualified to do so. The surveyor will make sure the pharmacist has been appointed as a director. So they'll look in their HR folder to make sure they're qualified. And then they'll talk to them. How to develop your policy and procedures. How are they reviewed? How are they implemented? They're also asking how often and how are they being reviewed? So that's the director. On the staff, you just have to have enough folks to do your job. And that includes, are they going to respond to any emergencies? Are you going to respond to emergencies to make sure you have enough meds and they can be appropriately distributed? So let's say you've had a mass trauma in your area. You have to make sure that you have enough staff to accommodate getting medications to the floor of the ER wherever that's going to be occurring. You have to have enough staff based upon the complexity of your services. And they must, pharmacy staff must participate in the QAPI program, which is question number three. Lindsey. Okay, let's get that one up here on your screen. So you should now see this question that says, our pharmacy tracks all medications, including controlled and scheduled medications. Yes, no, or prefer not answer here. I know we're getting closer to the end, Laura. So if anybody has any questions that maybe you have not submitted yet, if you would go ahead and be typing those in. So make sure we have time to address those today, but I do not see any other pending questions at this time. Okay, and as we get closer, as Lindsey mentioned, if we do run out of time, we just have one more polling question and we can probably pass on that one just because I do want to get through the rest of the information. Yep, absolutely. And I see a pretty resounding response here. Okay, good. Pharmacy does that, okay. So let's talk about records. We have to keep accurate records from the minute we get them until they're gone, whether they're administered or disposed of. And this is scheduled drugs, our goody stuff, the narcotics. They have to be current and accurate records. They have to be able to trace the movement throughout the service. The pharmacist has to make sure these are reconciled and you have to have a policy to minimize drug diversion. On delivery, drugs, biologicals, they must be controlled, distributed according to what our laws are. So we prevent not only unauthorized use, but distribution too. You have to have a way to account for the receipt and distribution of drugs. These are especially drugs subject to that Comprehensive Drug Abuse and Control Act. That law requires physical security of meds and strict record keeping for controlled substances, whether you do a two-person count at the end of each shift or day, however that is. There's also other guidelines they specifically mentioned on tracking them. I've got them listed here in slide 136. ISMP, of course, is one of the major ones. You have to have a way for dispensing of medications that they're done timely and safely because they dispense them, nurses administer them and safe dispensing following, of course, standards of practice. That means that you have to have a system for dose limits, special labeling, double checks. So we minimize errors if that's the case. High alert meds, staff know what those high alert meds are. You have to have a way to resolve questions with that prescribing person before they're given. Again, just like the nurses, pharmacists have to be comfortable in calling the physician to get this issue resolved. Outcomes, we know we document those in the record. That can be nursing or the pharmacist, whoever that happens to be. The first dose rule, that's the one that all meds have to be reviewed by a pharmacist before that first dose is dispensed because what they're looking for is that therapeutic appropriateness. Is it being duplicated? Do we have the two meds doing the same thing? Is that appropriate drug and dose, frequency, route, method, are there any medication, either med to med, med to food, any med disease interactions that they need to be aware of? Allergy sensitivities, how are they going to monitor those also? So the pharmacy has a lot to do on that first dose rule. Also meds are dispensed and retrieved when they're recalled or discontinued. We all remember, some of us may remember Vioxx and Darboset being pulled off the market. How do you address medications that are brought in with the patient or from the outside? The policy, how are you going to do the count? If you're going to allow it, the patient signs a release, they're locked. And how do you reconcile meds that aren't administered? So I'm discharged and there's a lot of meds still left in my drawer. Why is that? Is it because I sent them up, they came up at the 6 a.m. run, but I went home at 8.30. That's why all the meds are in there. Or what if they're refused or they're given an error? So again, how do we reconcile these meds? And of course we monitor the effects of our meds for any adverse reactions like anticoagulants, antibiotics. The provider may ask the pharmacist to dose, do the dose order. And that's fine, as long as that's permitted by state law. Monitoring is clinical lab, signs and symptoms, they're vital signs. Also watch the patient. Can they, what's their perception of side effects? Oh yeah, I take that codeine and it makes me so nauseated after each and every time, I just can't stand it. Those type of side effects. They talk in the interpretive guidelines, again, the nursing standards on monitoring patients. Well, compounding drugs, this is what pharmacy does a lot. They compound, they package and they dispose drugs. But that has to be under the supervision of a pharmacist. You have to have policies to make sure drugs are prepared by authorized staff. And those that need to be reconstituted or mixed, that is still considered a compounded preparation. So there are a couple of ways to do this. One, buy your own pharmacy, the manufacturer can do it, a registered outsourced facility or an outside compounding pharmacy. All of these, they still have to meet the standards for safe compounding to prevent contamination. The Drug Quality Security Act, there are sections on compounding because they can provide oversight for these medicines. The best one is, if you're not doing it internal, is the registered outsourcing facility. These are under, that Quality Act is called Section 503B. They can become an outsourcing facility. This is at one location or address, and that's all they do. They compound human drugs. They have to register as one, they are inspected by the FDA, meet stringent requirements, and they also have to provide any adverse event information. So to do so, they comply with those good, current good manufacturing practice, and there's minimum requirements for that to occur, everything from manufacturer to packaging. And really that's what the FDA would prefer you use. Use this registered outsourced facility, because again, they really have a high standard. And then there's others, a compounding pharmacy. These are non-registered. They're called 503A. Here, the State Pharmacy Board has oversight over these pharmacies. So if you get your meds from one of those pharmacies, not the manufacturer, not the compounding registered pharmacy, make sure that you approve they have, that they can demonstrate compounded meds are prepared according to the standards of care. So if you're using them, make sure you have access to their quality data. Usually you can have your pharmacist do this, your director of pharmacy. Document that you also did that, you reviewed their standards. In the contract, again, if you're using these compounding pharmacies, require them that they meet the requires of 503A. There is a toolkit that the American Society of Hospital Pharmacists, they have a toolkit so you can assess them. Otherwise, if you're compounding meds, they say really only pharmacy should be doing this unless it's an emergency or you have to have immediate administration. They're done consistent with standards of safe practice like sterile or non-sterile. And we know they can result in contamination or variations in strength. Microbial contamination, bacterial endotoxins, that can be fatal to patients. CMS used to have a host of information on this regarding compounding. But again, that's what they would like you to do. They don't mention USP, but really you need to follow standards of care and that's USP. On packaging and labeling, make sure it's done properly so we reduce our errors. Each floor stock or unit dose has some requirements on what has to be on that package. Name, strength, Latin control number, expiration date. Maybe have a beyond-use date if that's applicable. Multi-dose vials, 28 days, or if it's sooner by manufacture. Once it's open, you toss it in 28 days. Have that expiration date on the vial, not the date you opened it, the expiration date. On dispensing, a pharmacy has to make sure it's done in a safe manner and it's timely. So that's why you have to have a system where orders get down there quickly and that they're then filled and brought back up. Use unit dose if you can. The most readily available to administer. Dose, saves the same dose packaging system. Quantities, this way you can minimize them so we avoid diversion. Any concerns you have on dispensing, that's done beforehand. Any recall, excuse me, recall discontinuements, get them as quick as you can, get them back as soon as you can. They also, we know, if pharmacy is closed, how are you going to get access to that medication? That means you have to have a policy on who can access it, the night cabinet, if that's what it's called. Automated dispensing cabinets outside the pharmacy, great, but have contracted services, so you do have that on-call pharmacist available for resource. We keep our meds secured in a secure and locked area. Schedule two through five must be in a locked secure area. Now that means that if a staff member is actively there providing care, that's considered secure. Otherwise, only authorized person have access to the locked area. So like housekeeping shouldn't have just open access to that locked area. Someone needs to be there when they're there. Policies on self-administration of drugs, and I already mentioned that in the nursing section. If you want to use medication carts, great, but if they're unlocked, someone with legal access has to be close by. They have to be watching that cart. Like a nurse passing the meds, that's okay, as long as they're there, and they don't leave the drawer open, please, when they walk in the room. Just a policy on safeguarding, transferring availability of keys. Now on carts, they do expect you to have a way to secure them and monitor them. Patient care areas, we just have to make sure it's a safe storage and patient safety, so that's why we want to keep them safe. And again, policies to prevent tampering and diversion, for sure. If you have a locked storage area, you have a room, only authorized personnel can have access to that. Make sure for critical care, labor and delivery, if your area is staffed, actively providing care, that is considered secure. If you're setting up the patient for OR, that's considered secure, like the anesthesia carts, because somebody's there with the patient. When OR is closed, you have to lock the cart. Outdated, mislabeled meds, unusable, you get rid of them. You cannot make them available for patient use. Have a system to prevent that from happening, and that includes if it's subject to a recall. They become unusable prior to expiration, and if so, these are usually under conditions when it's been outside what the manufacturer recommended. Outdated, it's after the beyond-use date, and that could be, again, before expiration, but it is never later. It considers the conditions and potential for deterioration and growth. That's during or after the container is opened, and during the compounding process. So the beyond-use date really can encompass a host of timeframes. The beyond-use date, that's based upon what the manufacturer recommends, and it's usually on your compounded preparations. Generally, it's in hours or days. The expiration, that's given in years because that's your commercial products, but the beyond-use date and time, that's when you can no longer use that preparation. I have a couple resources on determining beyond-use date and how you can access that. Then your policies have to give clear direction, not only to pharmacy staff, but perhaps nursing. How do they determine that beyond-use date? If the manufacturer did not provide it. We know those are based upon accepted principles. Okay, what if you don't have a pharmacist on duty? Some don't. They have to have a way that drugs can be removed for administration by only personnel designated in your policies, and according to federal and state laws, like nursing. The nursing supervisor can go down and get the meds. We wanna make sure that we have minimized access, routine access by non-pharmacist, and that you have a process so we still get patients the meds, and especially if it's urgent or emergent need. If you have no pharmacist on duty, you have access limited to a certain set of meds that the hospital has approved, only by those who are trained for permitted access, nurses, prescribers. Quality control is in place. In other words, you're doing a double-check. Secondary verification can include barcoding, but then the pharmacist at some point has to review all of those meds that were taken out and correlate it with the order first thing in the morning. Then automatic stop orders. If you've got beds that aren't specifically prescribed as to time and number, then they're automatically stopped after a reasonable time. That's the automatic stop orders. For those requirements, they have to follow standards of practice. The medical staff and pharmacy services determine those automatic stop orders. And as a hospital, you wanna monitor that and make sure it is still enforced. Your electronic health record may have those parameters built in to their computerized ordering system. I'm gonna skip this question in the interest of time, Lindsay, so I'm gonna keep moving on. Errors, reactions, and incompatibilities, report it right away to the attending. You may wanna also send that to your QAPI. Good way to find out why is this happening. You are required to make sure that the attending immediately knows any errors or medication or drug errors, any adverse reactions, or incompatibilities. Now, what if the attending isn't available? Well, who's covering for them? When the covering physician is notified, you still have to let the attending know. By the way, did you know this happened? Have policies on reporting to the attending and to the QAPI. That could be your incident reporting system. That's fine. CMS has a definition for all three types and error that we know that's preventable. It can lead to the wrong medication or harm. And that's while it's under our control. The regulations, it's limited to those errors in administration that actually reach the patient. Wrong dose, wrong route, wrong patient, not timely. So that's an error. An adverse drug reaction, well, we know that that's not what we wanted to have happen. That's not the outcome. It could mean we discontinue it. It could be involved in changing their entire therapy, maybe a longer stay. Support treatment because they had a terrible reaction that could complicate the diagnosis or negatively impact that diagnosis and could result in anything from temporary harm to death. That's in a reaction. And then we have our incompatibility. This is when they don't get along, where they interfere chemically or physiologically. And there are some that we know don't. They're just simply incompatible. They shouldn't be administered mixed together or they're administered in that timeframe that they interfere with each other. IV meds, if there is a known incompatibility, that rises to the level of an error and we have to report it. Unexpected reaction, maybe we just didn't know that. Still report it. We did not know that reaction was going to occur. Hospital, you can minimize it by having resources like your incompatibility chart online, if that's what you want. Just make sure it's available for staff. They have to be able to go down that list and look to see if it is so. And if there are any updates, make sure those are posted promptly. Hospital staff, we want them to report these events. Use your best judgment whether immediate is required based upon their reaction and their assessment. Follow your policy and procedures. QAPI, you have to track and report these errors and near misses any suspected adverse reactions. Or is it a system error? So we can prevent it in the future. Immediate reporting to the attending, if it's an error that is harmed or has the potential to harm the patient. If you simply don't know, tell the physician, let them know that. Do your incident report. Document in the incident report, in the medical record also, that you notified the attending. In other words, patient was ordered medication A. Patient immediate reported hives and blister noted patient became unresponsive. And then physician notified. You don't say incident report completed, just physician notified. But in the incident report, yes, you put in there physician was notified. Your policies have to establish reporting of medication errors and events and make sure staff know what those requirements are. Include an orientation, revisit it throughout the time that we know this is hard to do, but we have to do it. Immediately, make sure it's done within your timeframes and your policy based upon what is the response or the effect to that patient. Encourage staff to do this, that non-punitive approach. Patient, people make mistakes, we know that. But again, try and get away from the person. Why did that happen? Now, again, you balance that with just culture. If they don't result in harm or it's insignificant harm, we document it. These may not require immediate reporting, like forget to give an analgesic dose during the night shift. Or it was, I gave him Tylenol instead of aspirin for this headache. You can do it first thing in the morning, but just look at the harm and the patient. Is that necessary? Maybe you can wait until the morning to wake them up. But don't, we know we can't solely rely on incident reports to keep an eye on these events. Take and encourage reporting, maybe on a broad definition of an error, but that these do need to be reported. Incident reports do fail to identify most errors. So a proactive identification, maybe watch your nurses as they're passing meds. Do a concurrent and respective retroactive review of records. Did we miss something? Maybe you're going to have an adverse drug reaction surveillance team to keep an eye on it. Use medication usage evaluation for high alert drugs and any indicator drugs. Trigger drugs, IHI has three tools to identify triggers. And they even have a pediatric one. So there are triggers that we can keep an eye on. Have a way to measure your system. Is it effective? And how do you use standardized benchmarks? That's going to be the big one, those standardized benchmarks for size and scope of what you're providing. They do encourage you to report them, whether it's an event, an error or incompatibility. We know reporting is not limited to just the FDA MedWatch and the ISMP. There may be a state law requirement that you have on reporting errors. The surveyor is going to pull your policy. They want to see those definitions. Honestly, just take them right out of the manual and put it into your policy. Ensure all errors and suspected events are documented. The surveyor is going to talk to your staff. What do you do when you become aware of that error? What tools have you used to try and risk incompatibilities? And what is your reporting policy and your documentation policy? On abuses and losses, this is controlled substances. We need to report those to the pharmacist and CEO according to what your state law says. Usually you have to report that to DEA also. The surveyor will determine that the pharmacist knows their understanding of what the policies are in controlled substances and how they discover discrepancy. Just don't forget your state board has rules on abuses and losses. Then we have to have information to our staff. We don't know every medication that comes across or what the issues are, whether it's an interaction or the doses. Is this an appropriate dose for this medication? Because pharmacy would be a great resource on that information. They can help staff with those functions, like maybe collect information on allergies, height and weight, so that they can help with that dosing. They can help identify problems and interactions. They can help monitor and adjust the dose based on labs. Monitor the plan as needed. They can help with that. The practitioner, they may even say pharmacy, you dose it, calculate it, whatever it happens to be. And that's why you may have in your electronic system a function for dosing and interaction. Pharmacy is responsible to make sure that information is accurate and up to date. So have those resources current for your staff, pharmacist readily available by phone and the surveyor will talk to the staff. What do you do if you need a reference material and how do you get it? And then they'll ask nursing also, how do you monitor patients for these therapies? Formulary, that's what medications are going to be in your hospital system. Medical staff determines that. They have to have a list of drugs available and a process to monitor patients on newly added meds. They approve and how you get the medications, not on the list. How do you address shortages and outages? And that includes communication with staff, substituting medications. And what do you do in the event of a disaster? How are you going to get those meds? On shortages, the FDA, they have websites for you. And they also, I mentioned the list of drugs to be discontinued. You can sign up and get those notifications. Now, as we're coming closer, I do want to just kind of show there are hazardous drugs that staff has to handle. And these are hazardous or potentially hazard according to NIOSH. This is those done to protect our healthcare workers. So FDA has some FAQs on it. On these hazardous drugs, NIOSH looked at 180 of them. And there were special warnings that they added, usually black box warnings. They found 26 that they added, but they did take 15 off because they're no longer available in the emergency department. 2020, there were some proposed changes. They added seven medications and they're scheduled for publication in 23. I still haven't seen it come out yet. And so here's our final case that we have. We have a hospital that utilizes CPOE for all meds. They send automatic alerts to the providers and the pharmacists if something's outside of those parameters, outside of those protocols. We have a physician who ordered, somehow, 250 milligrams of Digitalis daily. Well, of course, our system kicked out an alert, but both the physician and pharmacist ignored that alert. Patient got one dose before we recognized the error. And what happened is they went into severe rate of cardio where we had to put in a temporary pacemaker. I think Valley's gonna be cited on this, and if so, which ones? Now, while you're thinking about that, I just wanna show, I do have, in the appendix, a lot of the resources and links. Some of the information I didn't cover, it was just general information on the manual itself. And that's just FYI. There are approximately 28 pages, so I'm not going through all of them in the interest of time. So I'll open it up to Lindsey if there's any questions or if anybody wants to see what's gonna happen with Valley Hospital. Perfect. And if you have any comments here that you'd like to put into the chat regarding this discussion, we, of course, welcome you to do so. And if you have any final questions for Laura, go ahead and be typing those in to either that Q&A option down there at the bottom of your Zoom window, or if you don't see that option for any reason, you can, of course, type that into the chat as well. I don't see any pending questions at this time, Laura, so maybe if you want to go through this final discussion, and then we'll just get some closing comments. Okay. Now, when you're looking at this, you think 250 and a nurse didn't raise her ears up and go, what? Yeah, there were several levels. One, the nurse didn't look at the medication order closely and just administered it. Number two, we have two components, well, actually three, that ignored it, that alert. The pharmacist, the physician, and even nursing. That should have been a red flag. We didn't follow our own policy and procedures on medication administration under nursing. We didn't follow our own policy and procedures on pharmacy. The physician didn't follow standards of practice, and we just administered it. Now, I have never seen 250 milligrams of digitalis ever. I have never seen it even available. So we don't know how that patient got that many pills, whether it was several pills that they took, but somehow it happened. And what happened, they used a decimal point. He was 25.0, and that never should have been there because the decimal point came off automatically, and it was just 250 milligrams of digitalis. How this patient did not die is beyond me, but all of a sudden they noticed he was getting lightheaded, they checked his vitals, and that's when they found the error was after the patient did have a bad reaction. Yes, it did require a longer stay in the hospital. It did require ICU care. So there were several citations that they did receive in this respect. Fortunately, no long-term effects. Patient did recover, but it was a horrible wake-up call for that hospital. Those alerts are there for a reason. Don't ignore them, and don't assume another person is going to take care of it. That's on us individually as healthcare providers. So that's what happened with Poor Valley. Thank you, Lindsay. That will conclude it, and I'll wait to see if there's any questions. Perfect. I don't see any pending questions. There was just a comment saying that, of course, they would absolutely be cited for ignoring that alert and not reviewing the order, so absolutely. Okay, I did just post some final comments there for you in the chat. If you have joined us for the previous two sessions, I hope that you have seen this process play out. So you should get an email tomorrow morning. Just note that it will come from educationnoreplyatzoom.us, and that email will include a link to the full recording of today's session, and then again, a link to the slides that Laura presented for us today. That link to the slides is there for you now in the chat as well. Just note that when you click on the link to access that recording, that it will prompt you to enter your information, and that will send an email to us to approve that recording access request. We do typically approve those requests very quickly, but we ask that you give us one business day to grant those approvals. And again, just remember that the recording link is available for 60 days from today's date, and if for some reason you don't see that email come through to you tomorrow and you'd just like to access the recording, you can just again use that same Zoom link that you used to join the live presentation today to also access that recording. You see Laura's contact information here on the screen, but we do encourage you to reach out to us at education at gha.org with any of your questions that you may have not been able to ask in today's presentation. We welcome you to send those over, and we just thank you all so much for joining us today. Thank you, Laura, as always, for your time and your information that you've shared with us, and we look forward to having you all back with us next week for part four. Thank you, Laura. I hope you all have a wonderful afternoon. Thank you, Lindsay. Thank you, everyone. Bye-bye.

nursing responsibilities

pharmacy responsibilities

patient safety

medication management

24-hour care

care plans

medication safety

drug preparation

antibiotic stewardship

controlled substance management

ISMP guidelines

USP standards

medication errors

quality improvement

patient outcomes