Safe Opioid Use, IV Medication, Blood and Medication Administration Requirements 2021 Update

Safe Opioid Use, IV Medication, Blood and Medication Administration Requirements: Complying with the CMS’s Hospital COPs

CMS has a requirement that the first time an opioid is given by a nurse, a special assessment must be done.  Do you have a safe opioid policy that specifies what vital signs must be taken, how often you take the vital signs, and if you are going to use pulse ox and/or ETCO2? There are many requirements that must be met when the patient is provided their first opioid.

This program will discuss the revised standards on the CMS hospital CoPs on safe opioid use, IV medication, and blood transfusion. This is the fifth time this section has been amended in the past few years along with an amendment last to nursing section 405 which addresses safe injection practices, compounding, and beyond use date.

The following are also covered: CDC opioid guidelines, Joint Commission final pain management guidelines, federal guidelines for opioid programs, the opioid epidemic, and required hospital policies and training. The CMS standards on the care of the patient receiving opioids also apply to critical access hospitals.

In the survey memo on the care of patients on opioids, CMS states that while this section is in the nursing section, hospitals are expected to meet the related requirements found in the pharmacy and quality assessment and performance improvement sections. This program will also discuss the ISMP IV Push guidelines for adults which hospitals should have. It will discuss the National Action Plan for ADR prevention related to opioid recommendations. The CMS final worksheet on QAPI will be covered regarding the tracking of medication administration errors and adverse drug reactions. The CDC's final opioid guidelines are also discussed.

Hospitals are required to include this in their policy and procedure which must be approved by the Medical Executive Committee. Staff educated is required on the safe opioid use policy. This requires an assessment of the patient to determine who will be at risk for an adverse event from the use of IV opioids including PCA. Staff must be educated on the side effects and how to recognize them. CMS includes documentation requirements, minimum monitoring requirements, and information that must be explained to the patient. This memo amends four tag numbers: 405, 409, and 412 which are located in the nursing section, and PACU tag 957.

• Discuss that CMS has issued a 32-page memo on medication administration and safe opioid use
• Describe that all medications must be administered within three different time frames
• Recall that CMS has required policies and education requirements on medication administration and safe opioid use
• Discuss that CMS has requirements to ensure nurses are competent when giving IV medications or blood transfusions
• Recall that the CDC issued opioid prescribing guidelines

• Introduction into the CMS hospital CoPs
• Where to locate a copy
• CMS deficiency reports and problematic standards for tags in CMS Medication Memo
• How to get apprised of changes
• Changes and safe injection practices
• ISMP 26 pages of guidelines on IV Push medication
• CDC Opioid Guidelines
• Federal guidelines for opioid programs
• TJC pain management guidelines
• Amends tags 405, 409, 412 and 957
• Changes: medication administration, IV, blood, and opioid safe use, and immediate post-op care
• National Action Plan for ADE prevention
  • Anticoagulants, opioids, and diabetic agents
• Stages of the medication process
• Incidence of medication errors and ADEs
• Reminder for nurses to know pharmacy CoPs
• Blue boxes or advisories
• IV Medication and Blood transfusions
  • Guidance on the vascular access route
  • Verification of tubing connections
  • Monitoring patients for fluid and electrolyte imbalance
  • Patient risk assessment
  • Monitoring to prevent over-sedation of opioids
  • Required policy and procedure
  • Required nursing education
  • Equipment, ETCO2, pulse ox, etc,
  • Administration of blood and blood procedures
  • Competence of staff
• Assessment and safe use of opioids
  • Educating patients and families of side effects
  • PCA as a variant of self-administration
  • Monitoring post-op patients
• Orders for drugs and biologicals
  • Must include many things include age and weight of patient and dose calculations when applicable
  • Standing order
  • Consistent with state and federal law
  • Accepted standards of practice
  • Medical staff approved P&Ps
  • Basic safe practices for medication administration
• Flu and Pneumovax
• Nine rights
• Timing of medication
  • 3-time frames
  • Missed or late administration
  • Critical and non-critical scheduled medications
  • P&P required
  • Required education
  • Assessment and monitoring of patients
  • Documentation requirements
  • Audit the nursing documentation

Chief nursing officer, all nurses with direct patient care, nurse managers, nurse supervisors, nurse educator, pharmacists, director of the pharmacy, compliance officer, chief of medical staff, Medical staff coordinator, risk manager, patient safety officer, senior leadership, documentation specialist, hospital legal counsel, PI director, Joint Commission coordinator, regulatory officers, legal counsel, chief operating officer, chief medical officer, physicians, education department staff, board members, director of health information management,  audit staff, and others responsible for compliance with hospital regulations including documentation compliance.