Staying Focused on Medication Administration and Deprescription

More and more often, long-term care facilities are being pressured to provide cost-effective, competent care to residents who are increasingly medically and psychologically complex. But this pressure can contribute to procedure and medication errors as well as less emphasis on quality.

For example, facilities aiming to administer medications within a two-hour window may actually contribute to an increase in medication errors. And how long does it really take for a nurse to administer medications at 9 AM on a particular unit? Does one medication pass flow into the next as an uninterrupted cycle of medications? In passing medications all day, will your nursing staff lose their assessment skills or their empathy towards the residents, staff, and visitors?  Will the mechanics of passing medications take precedence over the practice of geriatric nursing?

In addition to providing interventions to minimize the number of interruptions to nurses administering medications, facility directors should ensure staff focus on deprescribing, since the more medications prescribed, the greater the risk of drug-drug and drug-food interactions. 

A Quality Assurance & Performance Improvement (QAPI) program focusing on deprescribing begins with a recognition from medical providers—the pharmacy provider, pharmacy consultant, and the nursing staff—to set goals using clinical practice guidelines for the management of chronic health issues commonly seen in the long-term care setting. Over-the-counter medications, including vitamin supplements and alternative medicines, should also be considered.

The QAPI team may choose to focus on deprescribing particular classifications of medications, such as antipsychotics, analgesics, statins and proton-pump inhibitors.   Through the use of reference materials such as the Beers criteria, the team may prioritize the classifications of drugs most problematic in the facility. Tracking how new medications are prescribed (eg, via the attending physician, nurse practitioner, or by verbal order of the covering provider at night) and how decisions are made to discontinue chronic medications may be valid starting points to reduce the total number of medications. These may also provide an opportunity to determine if some of the medications ordered once-daily can be administered at times other than 9 AM.

Deprescribing has the potential to enhance not only the health of our residents but also the processes of administering medications, by administering less medications or administering agents more evenly among staff shifts. Thus, nurses may be able to focus on quality nursing care and further improving their skills.

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Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, has been practicing nursing for 33 years, specializing in the care of geriatric patients. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.