The June 17, 2010 issue of ISMP Medication Safety Alert I received has an interesting article on the unintended negative consequences of the Centers for Medicare & Medicaid Services (CMS) regulation requiring medications to be administered within 30 minutes of their scheduled dosing time. I’m sure that the CMS 30-minute rule was created with good intentions in mind, but in reality it creates a lot of anxiety and bad habits. According to the ISMP article, the CMS 30-minute rule “may be causing unintended consequences that adversely affect medication safety. While following the 30-minute rule may be important to hospitals, many nurses find it difficult to administer medications to all their assigned patients within the 30-minute timeframe. This sometimes causes nurses to drift into … unsafe work habits.” Those unsafe work habits include removing meds from automated dispensing cabinets (ADC) for multiple patients at once, removing meds ahead of time, falsifying documentation to meet the 30-minute rule and preparing doses ahead of time; all dangerous practices.
The problem is more widespread than most realize and often flies under the radar. I knew about the issues, but wasn’t prepared to deal with them until we went live with our bar-code medication administration (BCMA) system. A side effect of the BCMA system is that it tends to catch things like late and/or early medication administration. That means no more mythical med passes with all medications administered at exactly the same time.
One thing to remember here is that the problem does not reside with the nurses, per se. There are many factors involved. Nurses are frequently asked to do too much with too little time and resources, thus forcing them into undesirable situations. The system is the problem. And as much as it pains me to say, this is one problem where a technology-only solution is not the answer.
The solutions are simple, but not always obvious or practical for many health care facilities. For example, the 30-minute rule could be changed to a 60-minute rule, i.e. medications would need to be administered within 60 minutes before or after their schedule administration time. This was recently done by the American Association for Respiratory Care (AARC) in a position statement that basically said that inhaled medications shouldn’t be held to the same CMS 30-minute rule because “Inhaled medication administration incorporates a unique methodology and has a recognized delivery time between 9-20 minutes, depending on the delivery device used for administration.” The AARC statement is supported by CMS. Or perhaps the facility could stagger standardized frequencies to give nurses additional time to admister medications, i.e. not have all morning medications due at 9:00 am. It may be as simple as moving some medications like aspirin, warfarin or HMG-CoA reductase inhibitors, i.e. atorastatin and the like to the evening time. How about this one: hire more nurses. I know, easier said than done, but very practical nonetheless. It’s important to remember that this is first and foremost about safe and effective patient care.
Ultimately there isn’t a one size fits all approach to the problem and it is clear that it will be some time before we have a solution, but it is certainly something that needs to be addressed. Unfortunately this isn’t a problem that immediately available technology can fix. ADCs are not designed to be a time saver for nursing. Neither are Bar-code Point of Care (BPOC), a.k.a. BCMA, systems or Computerized Provider Order Entry (CPOE). All these technologies are designed with the idea of improving patient safety through the reduction of hospital related medication errors. We’re going to have to look somewhere else for a solution. Just a thought.