Methodist College

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

administering the medication.

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results that are no longer valid.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

the tasks difficult or impossible” (Federico, 2017).

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,

hours after the meal has been consumed.

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

medications adjusted based on need and hospital policy.

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

administration” (Centers for Medicare & Medicaid Services [CMS], 2011).

Aims

The outcomes of the leadership change proposal include:

1. Medications will be administered within a therapeutic window as determined by

the mechanism of action

2. Improved patient outcomes through proper administration of medication.

Avoiding complications can be achieved by timely administration of treatments. The

CMS offers details medication administration based on “chemical properties, mechanism of

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:

1. “Identify a hospital-specific list of time-critical scheduled medications

2. Drugs will be administered at specific times to ensure accurate peak/trough/serum drug

levels

3. Establish guidelines for time-critical medications

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

administration times are listed below for each medication.

1. Levothyroxine

a. The American Thyroid Association states it is “is well documented that food and

a number of medications can decrease the absorption of levothyroxine”

("Thyroid," 2011). Although best practices for administering thyroid medication

is clear, it is commonly given after breakfast and with medications that affect its

absorption, such as iron. Rajput, Chatterjee, & Rajput conducted a study of

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

fed state. [Furthermore] interference with Levothyroxine has been documented

with cholestyramine resin, sucralphate, iron sulphate, calcium preparations,

aluminum antacids, raloxifene, activated charcoal, various soya products, and

food and herbal remedies” (Rajput, Chatterjee, & Rajput, 2011). Failure to

comply with these recommendations results in malabsorption of the medication.

Adjusting the administration time for levothyroxine to be given before first meal

will maximize therapeutic effect.

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

with levothyroxine. Dr Horn of University of Washington School of Pharmacy

states that “Proton pump inhibitors (PPIs) have also been reported to reduce

levothyroxine absorption, presumably, through an increase in gastric pH, thus

reducing dissolution of the levothyroxine tablets” (Horn, 2016). With the

recommendation that both levothyroxine and protonix be taken before a meal,

timing will need to be adjusted accordingly.

3. Insulin

a. Diabetes is a high risk disease. Timing can be critical in obtaining adequate

glucose control. The American Diabetes Association recommends taking regular

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

sugar is checked prior to breakfast which is served at 7 am. Scheduling regular

insulin at 9 can mean that at noon when it is time to have another meal, the

breakfast dose is peaking.

 b.

c. (Nolte Kennedy, 2017).

Theoretical Framework

Halbesleben, Savage, Wakefield, & Wakefield offer a theoretical framework that is

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

administration to improve patient outcomes.

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

development of medication administration policies.

Timeframe and Implementation strategy

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

quickly as possible. Implementation would require the involvement of Information Technology

(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.

Summary and Conclusion

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

for the safety of all patients.

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/

Federico, F. (2017). The Five Rights of Medication Administration. Retrieved , from

http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdmini

Stration.aspx

Food and Drug Administration. PROTONIX®. Retrieved from

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].

Retrieved from Amazon.com

Halbesleben, J. R., Savage, G. T., Wakefield, D. S., & Wakefield, B. J. (2017, April-June).

Rework and workarounds in nurse medication administration process: implications for

work processes and patient safety. [Journal]. Health Care Manage Rev, 35(2), 124-133.

http://dx.doi.org/10.1097/HMR.0b013e3181d116c2.

Horn, J. R. (2016, January 18th). Drugs Affecting Levothyroxine Absorption [Journal].

Pharmacy Times. Retrieved from

http://www.pharmacytimes.com/publications/issue/2016/january2016/drugs-affecting-lev

othyroxine-absorption

Insulin Routines. (2015). Retrieved from

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

Nolte Kennedy, M. (2017). Types of Insulin. Retrieved from

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

sue-5-p-7/