Medscape Nurses > Nursing Perspectives

Timely Medication Administration Guidelines for Nurses: Fewer Wrong-Time Errors?

Laura A. Stokowski, RN, MS

Oct 16, 2012

New and Improved Guidelines

Between the release of the first CMS guidance establishing the 30-minute rule and the revocation of that guidance, the ISMP was not idle. In fact, the organization has accomplished something we have needed for a very long time in nursing. With an expert clinical advisory group, they created the ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications, ^[10] a comprehensive document that collates best practices for the administration of scheduled medications. Although the issue is complex and detailed, the ISMP maintains that "timely medication administration is a multifaceted issue that cannot be managed appropriately with a single standard."

The ISMP realized that very few scheduled medications are truly time-critical. Scheduled medications are those that are administered according to a standard, repeated cycle of frequency (eg, every 4 hours, twice daily, or daily). Scheduled medications do not include the following:

• STAT and Now doses;
  
• First doses and loading doses;
  
• One-time doses;
  
• Specifically timed doses (eg, antibiotic for a surgical patient 10 minutes before incision, drug desensitization protocols);
  
• On-call doses (eg, preprocedure sedation);
  
• Time-sequenced or concomitant medications (eg, chemotherapy and rescue agents, N-acetylcysteine and iodinated contrast media);
  
• Drugs administered at specific times to ensure accurate peak/trough serum drug levels;
  
• Investigational drugs in clinical trials; or
  
• PRN medications.
  

Time-critical scheduled medications that should be on every hospital's list include:

• Medications with a dosing schedule more frequent than every 4 hours;
  
• Scheduled (not PRN) opioids used for chronic pain or palliative care (fluctuations in the dosing interval may result in unnecessary breakthrough pain);
  
• Immunosuppressive agents used for the prevention of solid-organ transplant rejection or to treat myasthenia gravis;
  
• Medications that must be administered apart from other medications (eg, antacids and fluoroquinolones); and
  
• Medications that require administration within a specified interval before, after, or with meals -- for example, rapid-, short-, or ultra-short-acting insulins, certain oral antidiabetic agents (eg, acarbose, nateglinide, repaglinide, and glimepiride), alendronate, and pancrelipase.
  

I've always said that having a "window" for *routine* medications is stupid. Nobody's going to have an adverse reaction because their zocor was given a few hours early.... The "window" mind set is disastrous in LTC. It makes some nurses slaves to the med cart and the MAR. How many critical symptoms have been missed because nurses are obsessed with being "on time" with the med pass?