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Teaching Adults SAFE Medication Management
One in nine visits to the emergency department is the result of a drug-related adverse event and is possibly preventable (Zed et al., 2008). The rehabilitation nurse has the opportunity to teach adults a comprehensive medication management plan that will help reduce medication errors. Most patients have minimal medication experience or instruction; this article documents the effectiveness of using a S = systematic, A = accurate, F = functional, and E = effective instructional methodology to help patients learn about their medications. The methodology helps rehabilitation nurses teach the average patient about handling, absorbing, and implementing the information. This article presents detailed instruction about the salient points of the SAFE instructional program. Several figures, a checklist, and pictures demonstrate the techniques utilized. Prevention of medication errors is emphasized throughout.
The majority of older adults take an average of 5–10 prescription medications per day. Confusion and error increase exponentially if medications are taken 3–4 times per day and include special instructions (e.g., “take on an empty stomach, 30 minutes before meals, or at bedtime”). The difficulty managing medications can be overwhelming for the person who has had a recent illness, hospitalization, surgery, or exacerbation of a chronic condition (Kaufnam et al., 2002). Some patients are taking over-the-counter (OTC) products, herbs, and supplements along with prescription medications. Therefore, patients are frequently experiencing more side effects and interactions resulting in clinic and emergency department visits and hospitalizations (Budnitz et al., 2006).
For the purposes of this article, we are assuming that a typical patient requiring medication management instruction is able to understand and follow instructions and is anxious to recover and return to his or her normal activity level. Taking medications safely is one sure way of removing hazards and preventing unnecessary problems while the patient recuperates. If medications are not taken properly, side effects or interactions can result and cause the person to develop other serious complications.
Teaching Adults SAFE Medication Management
Using a well-designed instructional program for medication management is critical for rehabilitation nurses providing medication education to their patients. The goal of the S (systematic) A (accurate) F (functional) E (effective; SAFE) instructional program is to prevent and reduce patient medication errors.
Medication management instruction begins when the patient is admitted to the rehabilitation unit and continues throughout hospitalization. When medications are reviewed by the rehabilitation nurse with the patient, it is important to have an additional person present to receive the information. Oftentimes, patients are eager to go home when they are discharged and fail to listen carefully or remember medication instructions. It can be very beneficial for the patient to include someone else in the education about the medications and serve as support. This person can provide the patient with reminders about instructions and the importance of taking medications on time.
It is critical that instruction be provided at a pace that can be absorbed and understood by the patient and his or her designated support person. The nurse should allot time for instruction on medication management during hospitalization. It is best to divide the information into small segments to make it easier to learn and retain. The patient’s and his or her support person’s questions need to be answered during the instruction. Reinforcement of previous information should be provided when necessary.
When personalizing the SAFE medication management program, rehabilitation nurses should consider the patient’s abilities, knowledge, and background; their resources and support systems; and the list of instructions for specific medications (Curry, Walker, Hogstel, & Burns, 2005).
The SAFE medication management program includes information about how to
Make and Carry a Medication List
The medication list is a critical and valuable tool. It includes information about the patient and his or her emergency contact person(s); all prescription medications, as well as OTC products, herbs, teas and supplements; and any allergies, side effects, or interactions (Figure 1).
The rehabilitation nurse instructs the patient on the importance of an updated medication list to ensure the healthcare team is aware of the medications OTC and other products the patient is taking. In case of an emergency department visit, the list provides important information about the patient’s medical conditions as well as medications and allergies. The list must be updated each time there is a change in medications—adding medications, deleting medications, or changing dosage.
A copy of the updated medication list should be carried by the patient; posted on the refrigerator at home so it is accessible for the paramedics; and provided to an emergency contact, the support person, and to each member of the healthcare team.
Understanding and Learning and Talking About Medications with the Healthcare Team
The rehabilitation nurse helps the patient identify the members of the healthcare team, which include doctors, nurse practitioners, pharmacists, nurses, and the patient and his or her designated support person. The patient needs to know that the primary care physician is the coordinator of any medication prescribing, even when other specialists are involved (Bowers, 2002; Lawrence, 2004).
When the patient receives a new prescription or sees his or her doctor at an annual visit, he or she should request a review of their current medications and ask the questions listed in Figure 2.
The rehabilitation nurse should encourage patients to seek answers to their questions from reliable sources of information such as the container label, warning stickers attached to the label, and drug information sheets. Remind patients that the pharmacist and healthcare team are available to discuss medication questions with them. Patients should consider using one pharmacy so that the pharmacist can check for medication duplication and side effects and interactions.
Many patients use the Internet for medication information. Direct patients to reliable Internet sites, which include AARP.org, MayoClinic.org, or WebMD.org. All of these sites include information on uses, warnings, side effects, and interactions of medications. There are other Internet sources that are not as reliable. Some Internet information is not always current, correct, or based on scientific information (Haupt, 2006).
Prescription medications can react differently from person to person. Friends may recommend products that worked for them. Although two people have similar symptoms, they may be caused by different problems. Comparing symptoms with a friend does not provide reliable a diagnosis or basis on which to take medications.
Patients are often bombarded by advertisements about medications and believes this is what they should be taking, but the nurse should make patients understand that advertisements have the singular purpose of selling a product. Discussions about changing medications should be conducted with the healthcare team.
Store, Take, and Dispose of Medications
Rehabilitation nurses should instruct patients to check prescription labels to make sure the name, name of the medication, dosage, when to take the medication, and expiration date are correct when they pick up their medications from the pharmacy. There may be warnings about the medication—take with water or food, may cause dizziness, or do not take with grapefruit or grapefruit juice. Observe these warnings to prevent side effects and interactions. The patient should not hesitate to question the pharmacist if he or she notices a difference in the pill color, size, or shape because it could be the same medication and dose from a different company. Generic medications have become more accepted by most physicians and can be a cost-saving advantage for the consumer. Check the container lid before leaving the pharmacy. If there is a problem with opening the child-proof lid, ask the pharmacist to replace the lid for one that can open easily.
Storing Medications. Explain to the patient that the bathroom medicine cabinet may not be the best place to store medications because of moisture in the bathroom. Medications should be stored in their original containers with the label in a cool, dry place such as a kitchen cabinet or linen closet. Follow the instructions if the medication is to be kept in the refrigerator. Keep medications out of the reach of children and pets.
Taking Medications. Ask patients about the routines they use to remember to take medications on time. Some people use pill boxes marked with the days of the week. Others write the names of their medications on a calendar and cross them off as they take them. It is important for patients to establish schedules and procedures individualized to their needs.
There are six rights for the patient to consider in taking medications safely as listed in Figure 3. If patients are taking medications for high blood pressure, diabetes, or both, ask if they are checking blood pressure or blood sugar levels. They should record the results and take the record to their medical appointments. The healthcare team will establish the normal ranges for them and instruct them when to call a member of the team.
Disposing of Medication. Instruct patients, when they go home, to review all their medications and OTC products for an expiration date; those that have expired should be discarded. Never use outdated medications or products because the medications concentration may change and cause side effects or interactions. Discard old tubes, creams, or liquids that appear cloudy, discolored, or filmy. To protect the environment, do not flush any medications down the toilet or drain (California State Board of Pharmacy, 2006; Food and Drug Administration, 2011; Milloy, 2007). Medications and diabetic needles and syringes can be taken to a hazardous waste collection center to be disposed (Knopper, 2010).
To properly dispose of medications, remove the label or scratch off any identifying information from the container. Tablets or capsules can be mixed with water and a nontoxic substance like sawdust, kitty litter, comet, or spices. Liquids can be mixed with flour. Seal the container lid tightly with packing or duct tape. Patches or multiple packs of pills can be wrapped with tape. Place containers in a box or coffee can and close with several layers of tape. Place the box in trash where children and pets cannot reach them (Figure 4).
Identify and Discuss Allergies, Side Effects, and Interactions
It is important that the nurse discuss the signs and symptoms of allergies, side effects, and potential medication interactions with their patients. Patients should review the information sheets provided with the medications and talk to the pharmacist. If the medication is new to the patient, encourage the patient to ask the pharmacist to provide education about the new medication and answer any questions. The patient can request information sheets in large print or another language.
Patients need to be able to differentiate between allergies, side effects, and interactions. An allergy is a serious hypersensitivity or adverse reaction and can be life threatening; foods, medications, pollen, or bee stings can cause allergic reactions. An allergic reaction to a medication may result in a rash, fever, or swelling. Stress to patients that signs of wheezing, difficulty breathing, or swallowing require emergency evaluation and treatment. Call 911.
Side effects are unwanted or unexpected feelings such as dizziness, nausea, hives, dry mouth, drowsiness or sleeplessness, rapid heartbeat, or ringing in the ears. The patient needs to report these symptoms to the healthcare team who may change the medication to one with fewer side effects. The patient and the healthcare team need to determine if the benefits of the medication outweigh the negative effects. The healthcare team may have some suggestions to minimize and treat negative effects, for example, taking the medication with food to prevent nausea. Side effects may decrease over time as the body adjusts to the medication.
Interactions are negative reactions between
Encourage the patient to discuss any signs of allergies, side effects, or interactions with the healthcare team. Unless symptoms are life threatening, do not stop taking a medication until it has been approved by the healthcare team. Any allergies, side effects, or interactions need to be added to their medication list to update the information.
Documentation of Teaching Medication Management
The purpose of documentation is to record the care and education given the patient and designated support person (i.e., family member, caregiver, friend), with the goal of promoting continuity of patient teaching and preventing duplication. Documentation should include the information presented, the patient’s understanding of the information, his or her ability to meet the measurable objectives, and the information to be reinforced.
Two types of documentation are progress notes and checklists. A progress note is a written description of what was taught and the patient’s understanding of the information. The checklist documents the information taught and is listed as measurable educational objectives.
The rehabilitation nurses and members of the healthcare team develop educational objectives that are stated in behavioral terms based on the agreed-upon content. The content is constant, systematic, accurate, functional, and effective no matter who teaches it. A sample checklist is presented in Figure 5. There is space for the instruction date and the instructor’s initials. The comments section is used to record the patient’s knowledge and ability to meet the objective or which information may need to be reinforced at the next teaching session. The checklist can prevent duplication of information and ensure that important information is covered.
Using a tool with behavioral objectives (Figure 5) can help the rehabilitation nurse present the SAFE medication management methodology to patients and their families and caregivers. Whether on the rehabilitation unit, in the clinic, or during a home visit, the checklist can assess and reinforce the patient’s knowledge and facilitate positive outcomes.
Many hospitals and rehabilitation units provide patient discharge instructions at the time of discharge. These include information about follow-up appointments for primary healthcare providers and specialist physicians; therapy at home or outpatient, if ordered; home health visits; equipment provided for home use; and an updated list of ordered medications. The patient and healthcare providers—home health—can use the updated list of ordered medications to ensure they have received all prescriptions and to understand instructions on the dosages and frequency of the medications. The patient discharge instruction sheet is a valuable tool for the patient, caregiver, and the rehabilitation nurse or teacher.
Implications for Rehabilitation Nurses
It is important for rehabilitation nurses to discuss medication information with their patients and their families and caregivers; this includes the identifying the correct medication name, amount, route, timing, and method for monitoring the medication’s effects. We also need to teach patients about why they should make and carry a medication list. Rehabilitation nurses also need to explain about when and how to talk with the healthcare team about medications; how to safely store, take, and dispose of medications; and how to identify and discuss allergies, side effects, and interactions. Our patients and their support networks need this information to help them take charge of their medications. By teaching our patients SAFE medication management, we have the opportunity to help reduce the number of emergency department visits or hospitalizations due to medication errors.
The scope of this article focused on the average patient who is theoretically capable of comprehending and implementing effective medication management. In a future article, we will look at patients who are limited in their abilities and present ways to deal with these issues, helpful solutions, and tools for difficult situations, and practice tips.
The information in this article expands on the poster “Teaching Medication Safety,” which was presented at ARN’s 34th Annual Educational Conference in October 2009. We wish to thank Mary Shook, BSN NP, for editing the manuscript and Diane Culross and Robin Tucholski, without whose help the poster would not have been possible.
About the Authors
Elizabeth A. Yetzer, MA MSN CRRN, is director of project development and presentations for Rainbow Medical Media Productions in Anaheim, CA. Address correspondence to her at firstname.lastname@example.org.
Nancy Goetsch, MSHN RN (retired), is a volunteer at the Garden Grove Community Center and lives in Orange, CA.
Marilyn St. Paul, BSN RN, is a community nurse educator at Talbert Medical Group in Anaheim, CA.
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