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31 May 2017
LMM MEDICATION DISTRIBUTION 2
(WWU) RN-to-BSN students for their expertise to enhance the medication distribution process
and reduce errors. The current procedure requires Agape House guests to release their
medications to staff and Mens Ministries guests to release only particular medications to staff
for safekeeping. The guests retrieve 24 hours worth of medications once a day from staff during
a medication distribution period. Through interviews with multiple staff, first-hand experience,
and review of surveys complete by guests and staff (see Appendices A, B, & C), students were
able to identify the specific problems. Among staff, there is a lack of continuity with distribution
discrepancies was a major issuehow can staff best prevent these and what is the best course of
action when the recorded number of medications does not align with the guests reported
number? A goal of LMM staff is to empower guests to regain their independence, but staff need
to maintain a safe environment and discourage poor medication habits. With these factors in
Assessment
distribution system. First, the time of distribution was observed both in the Agape House and the
main mission building where men receive their medications. To be clear, LMM is not licensed
to dispense medications, so staff can only handle medications when counting in during check-
in. When dispensing times were observed, only one staff was present with multiple guests in the
lobby in both facilities. During mens medication distribution time, there was not enough room
LMM MEDICATION DISTRIBUTION 3
for the guests to record medications in the log binder--the staff member had to fill this
out. Guests were required to state what they were taking so the staff member could record them
in the binders. Further, one staff member was unfamiliar with the medication process and had
trouble locating each guests medications. That staff member also did not know everyone by
face and relied on the guest stating their name to find their medications. There was no means of
identification to refer to. The major issue was guests constantly entering and leaving the facility
and milling about in the lobby. Some guests stayed close enough to the dispensing area to
Interviews were conducted with four key informants: three who handle medication and
one who oversees the process. Informants agreed on two major problems: medication times
were busy and only one staff member was available for help, and there was an inconsistent
system that lent itself to things being overlooked. Guests are required to report how many pills
they are taking and display what they have in their hands, but it is an inconsistent practice so
staff were concerned that guests were not taking their medications as prescribed. Further, guests
take out 24 hours-worth of pills, meaning they do not necessarily take those pills in front of
staff. Staff members have been accused of taking or misplacing medications, though most of the
LMM has a document called Procedures Regarding Medications (see Appendix E),
developed by past managers in the Agape House (there is no known document for the Mens
medications available during medication time, accountability, disposal, as well as a copy of the
medication forms to be filled out for each guest. Of note, checking in medications requires only
one staff members presence and should be in front of the camera as much as possible. Checking
LMM MEDICATION DISTRIBUTION 4
in medications is the only time when pills are required to be counted. Under 8.4.7 in Appendix
E, there is a privacy clause stating staff should not ask the guests to say the prescriptionthis is
the purpose of giving the guests section in the medication binder to them and having the guest
show the prescription as well as the number of pills they took. Under 8.4.10, there is short
A literature review was conducted about the best practices of medication distribution in a
community setting with no license to administer medication. There was very little written in
regard to a community setting because most locations that distribute medications are health
facilities licenses. The group utilized knowledge obtained from nursing practice and reviewed
literature about the best practices for nursing medication administration and ways to decrease
errors, which would adapt to be more appropriate in a community setting with a less controlled
environment that has different goals of giving out medications than treating illness. These
practices are well-established, though evolving with technology and extensive research has been
itself to errors and decrease in privacy; some staff were unfamiliar with all guests and not enough
guest information was available to verify identity; staff have limited knowledge on identifying
high-risk medications; safety checks are either nonexistent or followed inconsistently; safety
protocols are also inconsistent; and some staff are unfamiliar with the policy and
The team developed a survey to evaluate how both staff and guests thought about the
Deliverable
A survey of the guests and staff at Agape House and the Main Mission were performed to
learn their thoughts about the current medication distribution process. Results show that guests
are mostly satisfied with the process with the exception of independence with medications. The
results from Agape House revealed that the current process does not facilitate for the guests
independence in managing their own medications and state that they would like to be more self-
sufficient in this area. The staff, however, seemed less satisfied with the medication distribution
process, stating there are inconsistencies among staff, a lack of privacy for guests, and frequent
errors on the log sheet. Results of both surveys can be viewed in Appendix B and C.
The group modified the medication log sheet because, after reviewing, it was determined
that there were categories that could be added which would assist in decreasing the time of
times, a predated column was added so that guests would only have to sign on that line and then
To improve staff-guest relations, more frequent audit checks were suggested so that
inaccurate medication counts could be investigated in a timely manner. The column, Amount
Remaining, was also added to keep a running total of remaining medications on the log
sheet. Additionally, a section was included on the bottom of the log sheet to chart audit dates
and signature line for the guest and staff member. By keeping a running total and performing
more audits with the guest will reduce medication discrepancies and alleviate mistrust between
Interventions
At the time of the initial assessment, it was discovered that the LMMs organization and
structure needed attention, particularly the storage of medications. The Agape House stored
medications in foam pipe insulation that were kept in a locked cabinet organized by the guests
last name. This system worked, but it lacked a professional appearance. At the Main Mission
building, medications were stored in plastic zip-lock bags that were kept in locked drawers. It
was unclear how the zip-lock bags were organized, but it was not organized by last name or
room number. The system of how medications were stored by staff differed from building to
building. One possible solution is to purchase a nice tool storage device with individual
drawers. Each drawer would contain a guests medications, organized by last name or room
guests. This would also involve the use of a point system. Points would be given for good
behavior and deducted for poor behavior. For example, following the rules and taking the
correct amount of medications would constitute as good behavior, resulting in more control for
the guests over their medications. Guests with fewer points would have less control over their
medications.
It was determined that the Agape House and Main Mission building did not follow the
same P&P. In fact, further investigation revealed the main mission building did not have a
formal set of written P&P. The first recommendation is to develop a set of P&P that both
buildings would follow and to place a copy in each medication log binder. Having staff adhere
to P&P would be essential in providing structure for the guests as each staff member would be
following the same set of guidelines. Medication log sheets differed slightly from one building
to the next. The group recreated the medication log sheet and recommended that each building
LMM MEDICATION DISTRIBUTION 7
utilize the same log sheet. Additions that were made to the medication log sheet include quantity
taken, prescribing physician name, a pre-written date, and two medication audit sections with a
place for the guest and staff to sign following the audit. Having a location to document that an
audit or count of medications has taken place would decrease the likelihood of discrepancies and
would strengthen the guest-staff relationship. Along with the log sheet, a very brief and simple
face sheet was created to be placed in front of each guests set of medication sheets. It would
contain a picture of the guest, name, and date of birth. The face sheet would help the staff
members verify that correct medication was given to the correct guest.
recommendation was made to use small storage bins or containers to store medications rather
that plastic zip-lock bags. The small storage containers could easily be organized in alphabetical
order going by last name. This would decrease the amount of time spent looking for medications
Finally, the last issue addressed the constant amount of distractions and interruptions the
staff member would face during medications times. A solution would be to set up a quiet zone, a
simple and effective way to decrease distractions and increase privacy for the guest. To set up a
quiet zone, mark a perimeter with red tape or something similar around the counter or desk
where the medication process takes place. Another intervention to decrease the amount of
interruptions would be to add a staff member or volunteer during the medication time. The
second individual would supervise the door, as guests frequently come and go as they please. He
or she would also be the go-to person for questions or concerns during the medication times. To
assist with cost containment, it is recommended that the second individual working during
Evaluation
In order to evaluate any changes that have been implemented related to the
recommendations, the group suggests repeating a survey inquiring about the effectiveness. The
goal is to see an improvement with staff concerns related to the previous survey and that an
atmosphere of trust has been maintained or increased between the staff and guests. Also, an
Summary
Medication errors have the potential to cause harm. It is important to take necessary
steps and have systems in place to prevent medication errors. LMM staff realized that their
medication distribution process needed to be revamped and reached out to students from the
WWU RN-to-BSN program to utilize their expertise with medication administration. The
current process lacks structure, organization, continuity, and safety. Through our assessment and
research, recommendations include creating a set of P&P for both buildings, using the same
medication log sheet, and adding a face sheet to streamline the distribution process while
enhancing the safety and accountability for all parties. Other recommendations include
recruiting the help from either another staff member or volunteer to watch the door during
mediation times, the implementation of a quiet zone, and improving the organization of stored
medications to cut down on distractions and interruptions during the medication pass
times. With the implementation of these recommendations, the medication process can be safer
Katherine
It was a pleasure working on this project with the Lighthouse Mission Ministries. The
staff and guest were very welcoming and open to any new ideas to assist in improving the
medication distribution process. I believe that the LMM staff has an unwavering desire to
support this particular population of people by offering support through food, shelter and life-
building skills to facilitate their recovery and reentry to an independent living and working
lifestyle. The guests at LMM are there for a variety of reasons such as addiction, homelessness
due to loss of job and income and domestic violence. I believe that anyone can find themselves
under the same circumstances of financial or domestic hardships that lead to the services of
agencies such as this one. LMM exhibits a true dedication and support for the community and
Brittani
All staff at LMM were hospitable in allowing us to invade their space in order to improve
the processes for the guests. It was apparent that all staff put guests needs first. What I learned
from the experience had more to do with the people I met rather than learning about medication
procedures outside of skilled health facilities. I was surprised by the population of gueststhey
were wary of us, but friendly for the most part. Their ages were far more varied than I had
expected. There were many young men and women who were dressed and groomed nicely, not
looking like your stereotypical homeless person. One flaw of mine is being judgmental,
something Im working on. Working with LMM staff and guests especially gave me a better
perspective on the situation homeless are found in, showing me my judgments are more often
Harp
The LMM is a wonderful asset to our community. In the beginning, it was difficult for
myself to entertain the idea that licensed individuals were not involved in the medication
process. As I learned more of the LMM and their processes it became difficult for myself to
nursing facilities handled medications, but that was not the goal for this experience. For this
experience, we needed to focus on what the staff at the LMM could do with their skill
level. Once I could understand this, I was finally able to come up with creative
recommendations the LMM could adapt. I hope the recommendations we came up with can help
References
Hughes, R. G., and Blegen, M. A. (2008) Patient Safety and Quality: An Evidence-Based
Appendix A
Guest Survey
Western Washington University nursing students are assessing the procedures for medication
dispensing at Lighthouse Mission Ministries. We would like your feedback to improve the
current system. Your answers will be kept confidential and will only be used for the
improvement process. You may leave your name for follow-up (see the bottom of the page), but
this will not be shared. Your privacy is important to us. Thank you!
5. Do you feel your medications are safe the way they are stored right now?
YES SOMEWHAT NO (please explain)
6. Is the current medication process helping you become more independent in managing
your own medications?
8. Do you feel you have to wait long times to get your medications?
YES SOMETIMES NO
10. Do you feel more staff need to be available at medication dispensing times?
YES SOMETIMES NO
If you would like to participate in follow-up questions, please leave your name and staff will
arrange a follow-up meeting:
LMM MEDICATION DISTRIBUTION 14
Appendix B
Question Yes Sometimes/somewhat No More IND No Change More Help 615-715am 900-930am 645pm Other Staff Guests
1 5 3 1
2 6 3
3 _ 1 8
4 _
5 7 2
6 2 6 1
7 _ 2 5 1
8 _ 2 7
9 _ 2 2 6
10 3 6
Other questions/comments/concerns:
I would be happier filling my meds for the week with staff and follow up with them during one-on-ones; successes or short comings
I think medications should be poured into a cup then given, I could take as many pills as I wanted
have another line for those usually wait, have 2 medication lines
LMM MEDICATION DISTRIBUTION 15
LMM MEDICATION DISTRIBUTION 16
Appendix C
13. Do you feel the privacy of the guests is protected during the medication pass times?
a. Not completely, because though we request guests to stay away from the counter
where someone is checking out meds, it is still an open space with people coming
and going
b. Mostlydepends on individual staff and their process. If our process is followed,
then I think its private enough. Turning to correct page, not handing them the
binder. Not saying meds; maintain safe distance
c. No. The lobby is an open room where meds are given during med times. Often
guests overhear another guest talking about what med theyre getting/taking
d. No
e. Not really
f. Sometimesbut often not depending who is presentsome guests/staff have
more discretion than others
g. No, no privacy
h. No
i. No, but I do feel we do the best we can under our current situationwe do done
person at a time and have the others wait in the staircase
14. Do you feel the guests are judged about what medications theyre taking?
a. I believe our staff culture is one to not judgethat being said I dont have the
privilege of working with every staff member, let alone observe their execution of
the med time procedures
b. By staffno? Mostly not; not often do we know what everything is for.
Potentially by other guestsDoes this person have 3 sleeves of meds vs 1 sleeve?
c. Yes, sometimes. Not by staff, but by other guests
d. Not by staff
e. By staff? No, absolutely not
f. No
g. At times, or how many they take
h. No
i. No not the least bit
f. No
g. Yes, too many distraction
h. Yes
i. I rarely do it but when I did definitely rushed
16. Do you feel medications are safe the way they are kept right now?
a. I do feel medications are safe when the procedures are followed correctly
b. Mostly. Camera could be adjusted better? Although more than once cabinet left
unlocked. I think meds in office should be disposed of ASAP.
c. Anyone could pick these locks! So, no! also, the camera is NOT fully on the meds
going into the cabinet, so theres no real verification of them going in the cabinet,
its more faith/trust based than anything
d. No
e. Yes
f. Yes
g. Yes, it is hard to monitor what is actually being taken though
h. I think we could do better. Too much room for error.
i. No too many staff w/ access and sometimes they are rushed and forget to lock the
drawers when finished
17. Is the current medication process helping the guests reach their goal of becoming
independent with managing their own medications?
a. No, I believe that when someone takes care of something for you (almost
completely), you start to lose your sense of responsibility in that area in some
cases take on a victim mentality
b. Mostly. I think we still overseemeds skipping, preventing abuse. I dont know
what some guests wouldnt abuse pain meds, for example, if we didnt keep theirs
c. In certain ways, it makes them realize the correct dosages they should take, when
to take them, etc.standing in a long line though does NOT help this, though!
d. I hope so
e. Those who want to manage their meds well, will. I feel our scheduled med time
is more about saving staff time
f. Noit controls too much
g. Yes and noyesthey are responsible for taking the proper amount. Nothey
have to report what they are taking
h. Again, I think we could do better
i. Yes, but only when we are tracking correctly by taking the extra seconds/minutes
to watch and ask questions w/ the guests
18. Would you like to see more independence with guests taking their medications?
a. I think we should at least be giving guests the independence to decide if they are
not going to take a medication or take a lower dose than is prescribed. I dont feel
LMM MEDICATION DISTRIBUTION 19
were equipped/trained to tell someone how much of a med they have to take and
ultimately if it effects their ability to living in the community, that will play out in
their behavior and our accountability system
b. Maybe except narcotics, etc. we could have a list of the exceptions that we
dispense (20%?)
c. YES!
d. No
e. Yes and no. some guests have a habit of leaving pills everywhere. I worry about
theft and the misuse of certain meds, but it is really an honor system. What
actually stops guests from keeping meds on their person anyway?
f. Yes
g. For some, yes.I would have concerns with some guests.
h. Yes
i. No we only currently hold onto narcotics and psychotropic medsNorco can be
easily sold or stolen and we want to make sure they are not overtaking or
undertaking psychotropics
19. Do you feel that medications should by audited or counted more frequently?
a. Yes
b. Yes. Could this prevent the missing meds? I hate it when staff are accused.
We lose respect and credibility.
c. They should be counted in/audited at least 2x monthly for everyone!
d. No
e. Yes. If we maintain our system is designed for accountability then we should be
auditing our system
f. Maybedepending on what consequences would be if we found discrepancies.
would guests move along the accountability process when there are discrepancies
in that case? Would we able them to leave for that?
g. If we are going to hold them, then yes. This will help w/ accountability, but not
independence.
h. Yes, let the guest control their own meds and staff has periodic pill counts
i. Yes, once a week
20. Do you feel more staff need to be available at medication dispensing times?
a. I dont think this is necessary, at least with the current method.
b. In case there are issues? Accountability? Not necessarily. For speed?maybe.
But average wait time10-15 min? I think thats acceptable
c. YES!
d. No
e. No. I feel we trip over each other when two people are in that tiny space.
f. No
g. Yes, one to handle it all is a lot
h. No
LMM MEDICATION DISTRIBUTION 20
i. I believe 2 people should be presentone to hand out meds. The other to help
keep lobby empty for privacy
22. Do you have any other suggestions to improve the medication process?
a. I dont know that this is the right option but it could be good for staff to discuss
what it would look like to only lock up narcotics and opioid medications. Maybe
GAs could still be made aware of what other prescriptions guests are takingnot
positive how we would enforce thisjust a couple of thoughts.
b. Training! And more training! I am baffled when people, for example, give more
meds than whats allowed per dayjust bc a guest says Another staff let me or
something. We should know the rules and feel confident in enforcing them. (no
matter what guests say).
c. *Having guests come one at a time for med time and having set times each day
would be very helpful. *Better documentation of meds/check in/check out/etc
would be good. *Better privacymaybe bring guests to office one at a time
d. More secure lock up
e. Maybe doing away with med system and trusting our guests, as adults, to navigate
their meds on their own and with their Dr. or offering med lock-up as a chosen
recovery path? Optional accountability
f. Allowing guests to keep their own insulin and needles (stored appropriately)
g. For guests with numerous medsrequire a mediset
h.
i. Just to have 2 people present at hand out time/this can be a volunteer as well
Optional: Other questions/comments/concerns:
LMM MEDICATION DISTRIBUTION 21
a. My hope would be that there would be a high-level of consistency among staff in our
procedures, including the dispensing of medications. That being said, I have heard from
multiple guests that there is not always consistency amongst staff, which can bring up
concerns of inaccuracy or a questioning of the rules from both staff and guests
b. In a perfect worldI would love it if Gas could have more influence and the freedom to
address issues of narcotic/prescribed meds abuse. I think its rampant here, and we seem
to turn a blind eye to it
c.
d.
e.
f.
g.
h.
LMM MEDICATION DISTRIBUTION 22
Appendix D
Month: .Year: .
Date Time Amount taken Amount Remaining Guest Initials Staff Initials
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Appendix E
Over-the-Counter Medications.
Guests that have over-the-counter medications can maintain possession of these
medications while on the Mission campus. Staff does not check in over-the-
counter medications. Though, when administering a urinalysis staff should ask if
the guest is taking any over-the-counter medications to cross-check for a false
positive.
Prescription Medications.
Guests that have prescription medications need to check in their prescriptions
when entering Agape, unless given other permission by staff (ex: an inhaler).
Guests can have enough of a prescription on their person while on Mission
campus that they need for one 24 hour period. This check in is done at intake, at
each prescription refill or filling of a new prescription, or when coming back from
overnights. If a guest has prescriptions on them it is suggested that their first
stop back to Agape be the office with the prescriptions.
files inside the downstairs office (for medications that will be placed in the downstairs
office filing cabinet). Please see step #13 for refill prescriptions.
4. As much as possible, all check-in of prescription medication should happen at the front
desk in view of the camera.
5. The staff person needs to then legibly fill out this medication check-in form completely.
Please see the example med sheet following this procedure as well as the below list for
more information.
For name: please write the full name of the guest
Date of Check-In: write the date you are checking in the prescription
Medication: Name of medication (Check spelling)
Mg/ml (or other measurement): Write mg/ml as listed on the label
Number of Pills: please write the number of pills in the bottle after counting
them (please see steps #6-10).
Refill Date: Either none or number of refills and date (Ex: 5x by 10/20/2014)
Directions: please write the directions for taking the prescription (ex: once in
the morning and once at night or as needed for pain or two times per day)
6. After filling out as much as possible on the form, put on laytex gloves and pull out the
plastic pill sorter from the front desk drawer.
7. Open the pill bottle and pour the pills carefully onto the pill counter, being careful not to
spill the pills.
8. Using the plastic pill sorter (this looks like a clear plastic knife attached into the side of
the pill counter) then begin counting the pills into the side compartment of the plastic
pill sorter.
9. Once the pills are counted they can be poured carefully back in the pill bottle.
10. Record the number of pills in the bottle on the medication sheet.
11. Take particular note if the number of pills in the bottle do not match the number listed
on the outside of the bottle. Discuss this discrepancy with the guest and make note for
other staff if the difference has not already been explained upon handing in the
prescription medication.
12. Place the form in the medication binder at the front desk or in the medication binder in
the downstairs office in the respective alphabetized spot for that guest.
13. If the prescription is a refill of the same dosage then find the medication sheet already
written up for that prescription medication.
14. The next step is to count the number of pills in the bottle. Please refer to steps 6-11.
Except at step #9 record the number of pills in the bottle on the next row on the
medication sheet. Please write in the next row:
Date: Date prescription is counted in
Time: Write Refill
Amount: Amount of pills turned in/the refilled amount as on the bottles label
Ex: 120/125 [If the number turned in is significantly different than the number
listed on the pill bottles label, please address this discrepancy with the guest at
the earliest convenience.]
Guest: Leave blank
LMM MEDICATION DISTRIBUTION 25
11. It is the guests responsibility to place the pills in an appropriate container. As available
staff can offer ziplock bags to guests for this purpose.
When necessary for the safety of a guestparticularly with the concern of suicide
staff may ask for the medications to be taken in front of a staff person.
Please refer to the Progressive Discipline Guidelines with regards to consequences for
prescription abuse or misuse. A copy of the Progressive Discipline Guidelines can be found in
Procedure #7 regarding discipline and consequences.
Guest has brought in a doctors note stating that they are discontinuing a
particular prescription.
2. If one of the two situations is identified, then the decision can be made to dispose of the
medication.
3. All medication disposals must be done with two staff persons present and inside the
office.
4. Put used coffee grounds and filter into a plastic ziplock bag.
5. Pour medication to be disposed of inside the bag onto the coffee grounds.
6. Mix pills into the coffee grounds.
7. If there is still space within the coffee grounds you can pour more pills in, though be
careful not to overload the grounds because the pills will not dissolve if the grounds are
oversaturated.
8. Continue mixing the pills with the bag closed by squishing the bag with your hands until
the pills have begun to dissolve.
9. Once you know the pills have begun to dissolve, throw the ziplock bag into the
downstairs office trash can.
10. Note in the daily log that pills were disposed of and by whom.
For labeled pill, liquid or non-pill forms of medication:
1. Situations where staff would be disposing of medication:
Medications are left behind by a past guest for a significant amount of time
(approximately a month). Calls can be made if appropriate and helpful to check
in with the past guest regarding prescription pick-up or disposal.
Guest has brought in a doctors note stating that they are discontinuing a
particular prescription.
2. Once a medication is identified as needing to be disposed of, then the medication is put
in the top drawer of the filing cabinet in the box designated for medication disposal.
3. Once a few medications have accumulated in the box to be disposed of, the Womens
Ministries Manager and one staff person takes a bag with the medications inside to
Hoaglands pharmacy for proper disposal. Always have two staff persons transporting
the medications.
For sharp disposal:
1. Guests that use syringes, needles or laplets to inject medication, dispose of the used
needles and syringes in a designated sharps container provided by staff at the Agape
Home unless the guest desires to provide a personal small sharps container to stay in
the office.
The container can be a 2 liter soda bottle or some other plastic, rigid container
that is unlikely to puncture.
The container must be labeled clearly on the outside as a SHARPS container.
The container should be kept in the downstairs office for ease of access and use.
2. Once the sharps container is three quarters of the way full, staff will seal the container
with the lid, and tape it shut, and then dispose of the container in the regular garbage
bin at Agape.