Melissa Dean
Leading Change in Healthcare and Nursing Education
Leading Change
Introduction
If we ask nurses to recite the five rights of medication they will answer the same way.
Right patient, right drug, right dose, right route and right time. Timing can be a significant factor
in the efficacy of medications. Nurses educate patients on the importance of taking medications
as ordered to ensure the patient receives the appropriate effect. S. Ohdo states “the effectiveness
and toxicity of many drugs can vary depending on the time of administration in relation to 24-
hour rhythms of biochemical, physiological and behavioural processes under the control of the
circadian clock” (Ohdo, 2003). In a hospital setting physicians can specify time frames and if
the fail to do so, the responsibility falls to the pharmacy. With hospitals using electronic charting
formats, many times the suggested time listed for the physician is not the best practice for
Levothyroxine and Protonix often get administered at nine a.m. rather than before first
meal and insulin administration can be taking place hours after the morning blood glucose is
collected. Nurses are left administering medications that may not be as effective or based on
results that are no longer valid. Many electronic records have an option to alter administration
times, allowing nurses in some cases to suggest to pharmacy that the time be altered. Suggesting
alternatives does not guarantee a modification and in some cases the administration times remain
unaltered. This contradicts the five rights of medication administration. Dr. Frank Federico,
executive director of the Institute for Healthcare Improvement states “the five rights focus on
individual performance and not on human factors and system defects that may make completing
Description
The proposed leadership change will include an adjustment in overall administration of
time sensitive medications. For the purpose of this project we will focus on three main
medications; levothyroxine, protonix and insulin but this policy can apply to any time sensitive
medication. Current practice with, Levothyroxine and Protonix are being scheduled with the 9
am medication pass. Insulin is a bit more complicated. Meal times are 7 am, noon and 5pm.
Insulin for slides are being scheduled for 9 am, 1 pm and 6 pm. If the patient has a carb count
the dinner insulin isn’t scheduled until 7 pm. It can be seen here that the levothyroxine and
protonix are not currently being given with meals and the insulin is being given in some cases,
Levothyroxine and Protonix will be administered prior to the first meal of the day. If
Protonix is ordered two times per day, the second dose will be administered prior to dinner.
Insulin will be adjusted depending on carbohydrate counts, a slide, or a combination of the two.
If insulin is ordered with a slide only, it will be administered with meals. If insulin is ordered
with a carbohydrate count or with a slide and a carbohydrate count, it will be administered
immediately after meals. Patients who are NPO (nothing by mouth) should have these
Purpose
The purpose of the leadership change project is to reexamine the time frames for
medication and maximize the effects of medications through proper administration. The Centers
for Medicare & Medicaid Services (CMS) outline what they refer to as “basic safe practices for
medications administration” (Centers for Medicare & Medicaid Services [CMS], 2011). CMS
continues to state that “The hospital’s policies and procedures must reflect accepted standards of
practice that require the following be confirmed prior to each administration of medication” and
this includes “the appropriate time, to ensure adherence to the prescribed frequency and time of
Aims
action, or therapeutic goals of some medications” (Centers for Medicare & Medicaid Services
[CMS], 2011).
Objectives
The strategies and interventions targeted towards the leadership project include the
following as outlined by Institute for Safe Medication Practices (ISMP) in their acute care
guidelines:
levels
Guidelines are further developed through a collaborative effort and require feedback from
staff, council and individuals responsible for policy development in the facility.
Review of Current Literature
The ISMP defines “time-critical scheduled medications” as those where early or delayed
administration of maintenance doses of greater than 30 minutes before or after the scheduled
dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect”
("ISMP," 2011). Looking at the three medications listed for this project, the recommended
1. Levothyroxine
a. The American Thyroid Association states it is “is well documented that food and
is clear, it is commonly given after breakfast and with medications that affect its
patients with hypothyroidism taking levothyroxine. It was found that the “amount
(of levothyroxine) adsorbed decreases from 80% in the fasting state to 60% in the
food and herbal remedies” (Rajput, Chatterjee, & Rajput, 2011). Failure to
Adjusting the administration time for levothyroxine to be given before first meal
2. Protonix
a. According to the Food and Drug Administration, protonix should be taken 30
minutes prior to a meal as “food may delay absorption by two hours” (Food and
Drug Administration [FDA]). Care must be taken to avoid giving protonix along
states that “Proton pump inhibitors (PPIs) have also been reported to reduce
3. Insulin
insulin thirty minutes prior to a meal ("ADA," 2015). In this way, the insulin is
most effective and peaks when the food enters the bloodstream Waiting up to two
hours after a meal to administer regular insulin not only provides poor coverage, it
risks an overlap of insulins. Looking back to current practice, the morning blood
insulin at 9 can mean that at noon when it is time to have another meal, the
Theoretical Framework
focused on patient safety with the medication process from ordering to administration as detailed
below:
(Halbesleben, Savage, Wakefield, & Wakefield, 2017)
Stakeholders
Stakeholders for the proposed policy include the following the hospital council and board
of directors adapting current policies. The Institute for Safe Medication Practices (ISMP) has
developed a set of guidelines for medication safety. ISMP includes medications by all routes
including set guidelines for insulin administration ("ISMP," 2011). Hospitals and other facilities
will work in collaboration with ISMP in order to develop a higher standard of medication
The Food and Drug Administration (FDA) is an additional stakeholder whose mission as
a steward to public health by “ensuring the safety, efficacy, and security of human and veterinary
drugs, biological products, and medical devices; and by ensuring the safety of our nation's food
supply, cosmetics, and products that emit radiation” (Food and Drug Administration [FDA]).
The FDA outlines multiple laws and regulations regarding medication that can guide the
The timeline for implementation of this leadership change is 3-6 months. Rationale
behind rapid implementation is so patients may have medications given at the appropriate time as
(IT). Computerized order systems like EPIC can have modifications built into them to suggest
appropriate administration times for medications. Currently these medications are ordered at
these default times by however EPIC has been configured. Barring any complications with the
build, the changes could take place within a very short period of time. Training will be provided
to staff on any EPIC changes. Prior to the change education can be focused on providers and
nurses so that they can be aware of current practice and take steps to modify existing orders.
Main Findings
When medications are properly administered, patients have better outcomes. Giving
medications at inappropriate times decreases their efficacy. Some medications, such as insulin,
can overlap if given too close together or don’t provide adequate coverage if not given at the
appropriate time.
The appropriate time for a medication varies based on therapeutic index. Arbitrarily
assigning a default schedule prevents medications from reaching their maximum potential.
Halbesleben, Savage, Wakefield, & Wakefield state that “right time was the most commonly
noted potential impact” related to medication administration (Halbesleben, Savage, Wakefield, &
Wakefield, 2017). Grossman & Valiga state that as idea(s) take hold among healthcare
providers, word about the positive patient outcomes spreads” (Grossman & Valiga, 2017).
Safe medication practices are a responsibility of all caregivers in every facility. It is of vital
importance to supply the appropriate interventions to reduce hospital stays and promote recovery
References
Centers for Medicare & Medicaid Services . (2011). Interpretive Guidelines for Hospitals (42
CFR 482.23(c)). Retrieved from Centers for Medicare and Medicaid Services:
https://www.cms.gov/
http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdmini
Stration.aspx
https://www.accessdata.fda.gov/drugsatfda_docs/label/2007/022020lbl.pdf
Grossman, S. C., & Valiga, T. M. (2017). The New Leadership Challenge (5th ed.). [Kindle].
Halbesleben, J. R., Savage, G. T., Wakefield, D. S., & Wakefield, B. J. (2017, April-June).
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http://dx.doi.org/10.1097/HMR.0b013e3181d116c2.
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http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insul
in-routines.html?referrer
ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications. (2011).
Retrieved from http://www.ismp.org/tools/guidelines/acutecare/tasm.pdf
https://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and
-therapies/type-2-insulin-rx/types-of-insulin/
Ohdo, S. (2003). Changes in toxicity and effectiveness with timing of drug administration:
implications for drug safety [Journal]. Drug Safety , 26(14), 999-1010. Retrieved
from https://www.ncbi.nlm.nih.gov/pubmed/14583062
When is the best time to take thyroid hormone? (2011). Retrieved from
https://www.thyroid.org/patient-thyroid-information/ct-for-patients/vol-4-issue-5/vol-4-is
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