Medication Pass SOP Template

1.Purpose

To give each resident their medications accurately and on schedule during the medication pass, and to document administration completely and catch errors early.

2.Scope

Applies to routine oral and topical medication passes conducted from the medication cart in assisted living or skilled nursing settings. Injectable and controlled substance handling are covered by separate SOPs.

Definitions

MAR

Medication administration record, used to schedule and document each resident's medications.

Medication pass

The scheduled round during which medications are prepared and given to all residents due at that time.

PRN medication

A medication given as needed rather than on a fixed schedule, based on the resident's symptoms and the physician's order.

3.Responsibilities

Medication Aide / LPN

Prepares, verifies and administers medications during the pass and documents on the MAR.

Registered Nurse (RN)

Oversees the medication pass, handles unclear orders and manages medication errors.

Certified Nursing Assistant (CNA)

Reports resident condition changes that may affect medication timing, such as difficulty swallowing.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →Locked medication cart
• →MAR in the EHR or paper chart
• →Resident identification photo on the MAR or wristband
• →Medication error report form
• →Water and appropriate food or thickener for administration

Personal protective equipment

• →Disposable gloves for topical medications

5.Procedure

1. 5.1

   Wash hands and unlock the cart

   Medication Aide / LPN

   Wash your hands before starting the pass and unlock the medication cart, keeping it within your sight at all times during the round.

   Warning: Never leave the medication cart unlocked or unattended, even briefly.

2. 5.2

   Review the MAR for the current pass

   Medication Aide / LPN

   Review the MAR for medications due at this pass time, noting any hold, new order or recently discontinued medication.

3. 5.3

   Prepare one resident's medications at a time

   Medication Aide / LPN

   Pull and prepare medications for one resident at a time, checking the label against the MAR before moving to the next resident.

   Warning: Never pre-pour medications for multiple residents at once. Prepare one resident's medications immediately before giving them.

4. 5.4

   Verify resident identity

   Medication Aide / LPN

   Confirm the resident's identity using their photo on the MAR or wristband and by asking their name, matching it against the medications prepared.

   Checkpoint: Resident identity is confirmed immediately before administration, at the resident's location.

5. 5.5

   Check for changes affecting administration

   Medication Aide / LPN

   Ask about or observe for any new difficulty swallowing, nausea or condition change that could affect how the medication should be given, and notify the nurse if something has changed.

6. 5.6

   Administer the medication

   Medication Aide / LPN

   Give the medication by the ordered route, in the correct form, with appropriate food, water or thickener as required, and stay with the resident until it is swallowed or applied.

7. 5.7

   Evaluate a PRN request

   Medication Aide / LPN

   For a PRN medication request, assess the resident's symptoms against the physician's order criteria before administering, and document the reason for giving it.

8. 5.8

   Document immediately after administration

   Medication Aide / LPN

   Record the medication, dose, time and your initials on the MAR right after giving it, before moving to the next resident.

   Checkpoint: MAR documentation is completed immediately after each resident's medications are given, not batched at the end of the round.

9. 5.9

   Document a refusal

   Medication Aide / LPN

   If a resident refuses a medication, document the refusal on the MAR and notify the nurse so the physician can be informed if the refusal is repeated.

10. 5.10

    Secure the cart between residents

    Medication Aide / LPN

    Keep the cart locked or within direct line of sight when moving between residents' rooms during the pass.

11. 5.11

    Report and respond to a medication error

    Registered Nurse (RN)

    If an error is discovered, notify the nurse immediately, monitor the resident as directed, and complete the medication error report.

    Warning: Report a medication error right away. Do not wait until the end of the pass or shift.

12. 5.12

    Reconcile and lock the cart at the end of the pass

    Medication Aide / LPN

    Confirm all scheduled medications for the pass have been given or accounted for, then lock the cart and return it to its secured storage location.

6.Quality checks

• →MAR documentation is completed immediately after each resident's medications, not batched later.
• →Resident identity is verified for 100 percent of medication administrations.
• →Medication carts are never left unlocked or unattended during observation audits.
• →Medication errors are reported and reviewed the same day they occur.

7.Records

• →Medication administration record (MAR)
• →Medication error reports
• →PRN administration and effectiveness notes
• →Refusal documentation

8.KPIs

• →Medication error rate per resident days
• →Percentage of medication passes completed within the scheduled window
• →MAR documentation timeliness
• →PRN medication usage trends

9.Common mistakes

• →Pre-pouring several residents' medications onto one tray to save time.
• →Documenting the MAR at the end of the round instead of after each resident.
• →Leaving the medication cart unattended in the hallway.
• →Giving a PRN medication without checking it against the physician's order criteria.

10.Revision history