It can be argued that medication management and handling is one of the single most important areas that any clinic can improve in order to reduce the incidence of medical errors. Development of protocols, staff training, and continuing education for ALL staff involved in medication management and handling is critical for any practice in the world of veterinary medicine. Medication management/handling protocols and trainings should, at the very least, include oral medications, injectable medications, vaccines, and topical preparations. Below is a list of selected topics that should be considered when developing staff training and protocols for medication management/handling. This list is in no way inclusive of all the topics you should consider. There are also excellent videos, podcasts, and distant learning resources available on the internet as you begin to develop your own medication management/handling protocols:
- Medication labels for dispensed medication: Are you including all the information required by law on your labels? Are you including appropriate warning stickers on all medications dispensed? Are the directions clear and concise for a client that has no medical knowledge?
— The following is taken directly from the AVMA website —
Basic Information for Records (R) Prescriptions (P), and Labels (L)
Name, address, and telephone number of veterinarians (RPL)
Name (L), address, and telephone number of clients (RP)
Identification of animal(s) treated, species and numbers of animals treated, when possible (RPL)
Date of treatment, prescribing, or dispensing of drug (RPL)
Name, active ingredient, and quantity of the drug (or drug preparation) to be prescribed or dispensed (RPL)
Drug strength (if more than one strength available) (RPL)
Dosage and duration
Route of administration (RPL)
Number of refills (RPL)
Cautionary statements, as needed (RPL)
Signature or equivalent (P)
The actual container must bear the veterinarian’s name, address, name of the drug (active ingredient), identification of the animal(s) to be treated, adequate directions for proper use, and cautions/precautions including milk and meat withdrawal times. This information may be on the label applied by the manufacturer, or on a label attached to the product by the veterinarian.
If there is inadequate space on the label for any of the other required information, the veterinarian must provide the additional information on a separate sheet that accompanies the drug dispensed or prescribed.
State law and other regulations such as the Pasteurized Milk Ordinance may require more information than is stated in these guidelines. Specific label and record keeping information is required when drugs are prescribed for extralabel use.
When veterinary prescription drugs are dispensed to companion animal owners, the AVMA recommends that such drugs be placed in child-resistant containers. Such containers are mandated by law in certain states.
2. Syringe Labeling: Are you and your staff labeling every syringe that is prepared for administration to a patient? Is everyone within your practice using the same system and abbreviations for syringe labeling? Are you also labeling the concentration of the drug, noting that many drugs have multiple formulations that may differ in concentration?
There are multiple systems available for syringe labeling protocols. The important thing is to be sure that whatever system you adopt, that everyone in your practice is trained on the protocol, and that everyone is using the same protocol all the time. Some options include: writing directly on the syringe with a permanent marker, writing on a piece of tape that is secured to the syringe, or pre-printed labels for commonly used medications.
3. Dispensing Medications/Refilling Medications:
a. What is your hospital’s protocol for filling and dispensing medications?
b. Who inputs the instructions on the labels?
c. Who goes over the instructions with the owner?
d. Is there a written prescription information discharge printed for the client?
e. Is a signed copy of written discharges put into the medical record?
f. Who approves prescription refills?
g. Does your hospital have a protocol for turn around time on prescription refill requests?
h. Does your hospital have a policy of current exam time frames for refill requests?
As with other areas of medication management the most important thing is to have a protocol in place, train your staff on that protocol, and ensure that everyone is following that protocol all the time. It is also critical that your hospital’s protocol be in accordance with all state and federal laws regarding the dispensing of medications and medication refills. One of the most common areas where hospitals fall short in the area is dispensing medications outside of a valid client-patient relationship. The document below was taken directly from the AVMA website regarding the requirements for valid client-patient relationship when dispensing medications.
— The following is taken directly from the AVMA website —
Veterinary Prescription Drugs
Veterinary prescription drugs are those drugs restricted by federal law to use by or on the order of a licensed veterinarian [Section 503(f) Food, Drug, and Cosmetic Act]. The law requires that the drug sponsor label such drugs with the statement: “Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian.”
A VCPR means that all of the following are required:
The veterinarian has assumed the responsibility for making clinical judgments regarding the health of the patient and the client has agreed to follow the veterinarians’ instructions.
The veterinarian has sufficient knowledge of the patient to initiate at least a general or preliminary diagnosis of the medical condition of the patient. This means that the veterinarian is personally acquainted with the keeping and care of the patient by virtue of a timely examination of the patient by the veterinarian or medically appropriate and timely visits by the veterinarian to the operation where the patient is managed.
The veterinarian is readily available for follow-up evaluation or has arranged for the following: veterinary emergency coverage, and continuing care and treatment.
The veterinarian provides oversight of treatment, compliance, and outcome.
Patient records are maintained
4. Communication and Continuing Education for all staff involved in medication management and client communication:
- Is each member of your team trained in medication administration, contraindications, routes of administration, and uses?
- Is each member of your team notified and trained appropriately when a new medication is introduced to your hospital?
- Does your hospital have a patient safety coordinator or committee that can facilitate these communications and track/provide continuing education opportunities for your team?
The importance of regular staff meetings that include inventory updates, staff trainings, and documentation of these communications cannot be overstated. Establishing a patient safety coordinator and/or committee that is in charge of providing this information to the rest of the staff is an important part of ensuring that this happens. For example, if a new concentration of a currently used medication is going to be carried in the hospital, it needs to be communicated to staff and documented that it has been communicated. Additionally, if a new medication is introduced to a hospital the patient safety coordinator can be in charge of insuring that the team is trained on handling, storage, usage, and pricing. As with the other medication management techniques we have discussed, the protocol that you choose is not nearly as important as being sure that the team is trained on the protocol and that the protocol is used and followed through on at all times.
Relevance of Documentation:
Medical records documentation is not only a lawful requirement of our profession, but an extremely important tool in preventing medical errors. Meticulous attention to your medical records to ensure they are thorough, complete, legible, and completed in a timely manner is absolutely critical to the health of your patients, the well being of your practice, and the prevention of medical errors. This meticulous attention to detail should be carried through on EVERY medical record for EVERY case. Whether the case is a routine annual exam, a complicated internal medicine case, or anything in between, the same protocol should be used for each and EVERY medical record. As previously discussed with medication management, medical records techniques and protocols should be a training point, as well as a continuing education point for every team member in your practice. Established protocols should be ingrained in each member of the team so that they are followed through on each and every case… even during times of chaos. Medical records documentation in fact becomes even more important during chaotic times in a veterinary practice. Keeping meticulous records will help every member of your team remember details and follow through on details, even when they are multi-tasking many cases at a very fast pace.
Although there are established lawful requirements for medical records within each state, there are additional protocols that your practice can add to the lawful requirements to ensure meticulous charting. Below the Texas code on maintenance of medical records has been included for your reference. This document was taken directly from the Texas Administrative Code, Rules Pertaining to the Practice of Veterinary Medicine. All veterinarians should be familiar with the requirements for medical records maintenance, and help their team develop protocols and training that include these requirements.
— The following is taken directly from the Texas Administrative Code, Rules Pertaining to the Practice of Veterinary Medicine —
RULE §573.52 VETERINARIAN PATIENT RECORD KEEPING
(a) Individual records shall be maintained at the veterinarian’s place of business, shall be complete, contemporaneous and legible and shall include, but are not limited to:
- name, address, and phone number of the client;
- identification of patient, including name, species, breed, age, sex, and description;
- patient history;
- dates of visits;
- any immunization records;
- weight if required for diagnosis or treatment. Weight may be estimated if actual weight is difficult to obtain;
- temperature if required for diagnosis or treatment except when treating a herd, flock, or a species, or an individual animal that is difficult to obtain a temperature;
- any laboratory analysis;
- any diagnostic images or written summary of results if unable to save image;
- differential diagnosis and/or treatment, if applicable;
- names, dosages, concentration, and routes of administration of each drug prescribed, administered and/or dispensed;
- other details necessary to substantiate or document the examination, diagnosis, and treatment provided, and/or surgical procedure performed;
- any signed acknowledgment required by §§573.14, 573.16, 573.17, and 573.18 of this title (relating to Alternate Therapies—Chiropractic and Other Forms of Musculoskeletal Manipulation, Alternate Therapies-Acupuncture, Alternate Therapies—Holistic Medicine, and Alternate Therapies—Homeopathy);
- the identity of the veterinarian who performed or supervised the procedure recorded;
- any amendment, supplementation, change, or correction in a patient record not made contemporaneously with the act or observation noted by indicating the time and date of the amendment, supplementation, change or correction, and clearly indicating that there has been an amendment, supplementation, change, or correction;
- the date and substance of any referral recommendations, with reference to the response of the client;
- the date and substance of any consultation concerning a case with a specialist or other more qualified veterinarian;
- copies of any official health documents issued for the animal.
(b) Maintenance of Patient Records.
- Patient records shall be current and readily available for a minimum of five years from the anniversary date of the date of last treatment by the veterinarian.
- A veterinarian may destroy medical records that relate to any civil, criminal or administrative proceeding only if the veterinarian knows the proceeding has been finally resolved.
- Veterinarians shall retain patient records for such longer length of time than that imposed herein when mandated by other federal or state statute or regulation.
- Patient records are the responsibility and property of the veterinarian or veterinarians who own the veterinary practice, provided however, the client is entitled to a copy of the patient records pertaining to the client’s animals.
- If the veterinarian discontinues his or her practice, the veterinarian may transfer ownership of records to another licensed veterinarian or group of veterinarians only if the veterinarian provides notice consistent with §573.55 of this title (relating to Transfer and Disposal of Patient Records) and the veterinarian who assumes ownership of the records shall maintain the records consistent with this chapter.
(c) When appropriate, veterinarians may substitute the words “herd”, “flock” or other collective term in place of the word “patient” in subsections (a) and (b) of this section. Records to be maintained on these animals may be kept in a daily log, or the billing records, provided that the treatment information that is entered is adequate to substantiate the identification of these animals and the medical care provided. In no case does this eliminate the requirement to maintain drug records as specified by state and federal law and Board rules.
Source Note: The provisions of this §573.52 adopted to be effective June 14, 2012, 37 TexReg 4229RULE §573.52
Meeting the lawful requirements is absolutely necessary, but more can be done to help prevent medical errors within your practice. For example, what is your hospital’s policy on documenting phone calls? Is every communication with a client documented, even if that communication does not occur with a doctor or technician? Your practice policy should be very clear on this aspect of documentation, and your staff in turn should be trained on this policy and held accountable if they deviate from this policy. Another common example that practices should have a formal protocol for, is the charting of OTC medications and nutraceuticals that owners are giving at home, on their own accord. Every medication, herb, vitamin, essential oil, or other substance that a client reports to your team should be charted in the medical record, no matter how benign the substance may seem. Additionally, every effort should be made to by your team to determine exactly what substance the owner is giving, how much of it they are giving, how often they are giving, and for how long they have been doing so. This charting should include food and treats that the pet receives. What are they feeding? How much? How often? What types of treats are they using? Charting and verifying information that owners provide about previous visits with other veterinarians is also absolutely critical to complete medical records and medical error prevention. Does our practice have a policy on ensuring that previous medical records from other practices have arrived, and are complete? If a previous veterinarian sends only vaccination history, is there a policy for your team to request complete records, or at the very least speak to someone at the previous practice to verify history or medications the pet may be taking? How many times have you had a client advise your staff that their pet is taking an “antihistamine” that their previous veterinarian prescribed only to find out that the antihistamine was actually a steroid? This type of information could lead to a major medical error if the pet is then prescribed an NSAID or additional SAID in your practice. Or, how about the client that reports no major medical history, but their pet has been on enalapril, furosemide, and pimobenden for the past 3 years? It is not uncommon for an owner to omit a chronic medication in the history when a chronic medical condition has been well managed. Developing a thorough protocol for the collection of previous medical records, meticulous charting, and verifying ALL of the information that an owner provides is one of the most important things you can do to decrease medical errors within your practice.