20.1        ORGANISATIONAL ARRANGEMENT

The administration of medicines and the use of recording sheet in all clinical areas/teams/practices.

This Chapter Review Group are:

Honor MacGregor, Senior Midwife Practice Development

Jane Brown, Senior Nurse

Peter Buckner, Pharmacist

Jennifer Gray, Pharmacist

Alison Lawrence, Practice Development Nurse

Marian Wallace, Staff Nurse

Natalie Beattie, Practice Development Nurse

20.2         DEFINITION OF A MEDICINE

A medicinal product is both:

·      Any substance or combination of substances presented as having properties of preventing or treating disease in human beings

·      Any substance or combination of substances that may be used by or administered to human beings with a view to restoring, correcting or modifying a physiological function by exerting a pharmacological, immunological or metabolic action, or making a medical diagnosis

Legislation that governs medicines are as follows:

·      Medicines Act (1968).  This regulates medicines and medicinal preparations including medicines used in clinical trials, unlicensed medicines, dressings and medical gasses

·      Misuse of Drugs Act (1971).  This regulates controlled drugs

20.3    AIMS OF THIS CHAPTER

·      Ensure safe practices are carried out consistently across NHS Tayside with respect to administration of medicines

·      To minimise the risk of errors with the prescription, administration and supply of medicines

·      To ensure that patients are given adequate information about their medicines including any special instructions for their use

·      The administration of Controlled Drugs is not included in the section

20.4    PREPARATION AND ADMINISTRATION OF MEDICINES

Practitioners authorised to administer medicines

20.4.1     Persons authorised to administer and check medicines must have sufficient knowledge of the medicine being administered and of the patient to whom the medicine is being administered, to be able to intervene in circumstances where administration is not appropriate.  Healthcare professionals that administer medicines must be familiar with the therapeutic uses of the medicine.

20.4.2     The following practitioners are authorised to undertake single practitioner drug administration:

·      Registered Nurse or Midwife who have completed induction and been assessed as competent and who are working within the Future nurse: Standards of proficiency for registered nurses (2018) and Standards of proficiency for midwives (2019)

·      Registered Doctors including Foundation Year Doctors, if assessed as competent

·      Student nurses (across all fields: adult, children, learning disability and mental health) and midwives can participate in the preparation and administration of medicines following the completion of the appropriate theoretical modules and the associated simulated practice under direct supervision of a registered healthcare practitioner. Students should undertake calculations independently from the registered healthcare practitioner. However prior to administration the registered healthcare practitioner must check that it is correct, and both the student and registered healthcare practitioner should sign the prescription record (electronic or paper)

20.4.3     Other suitably qualified and experienced persons may be authorised to administer prescribed medicines in clearly defined circumstances, for example, non-registered nurses, radiology and physiotherapy colleagues.  Relevant Health and Care Professional Council standards of proficiency and conduct and standards set out by professional bodies must be adhered to.  The Senior Charge Nurse/Midwife of the ward/theatre/team is responsible for ensuring that a written guideline/protocol is in place defining the circumstances and persons authorised.  The Senior Charge Nurse/Midwife or manager must ensure that all persons are assessed and deemed competent before undertaking administration of medicines. 

20.4.4     Administration involving one or more of the following elements must be checked by a second person who is authorised to administer the medicine in the hospital setting.  In the community it is not always practical or possible to have a second person witness or check a medicine and local arrangements are in place in these situations:

·      Intravenous therapy, including the rate of an infusion, the only exception is in maternity services

·      Intrathecal infusions

·      Patients under the age of twelve (including neonates)

·      Systemic anti cancer therapy given by any route

·      Medicines administered by medical devices, for example, infusion pumps and syringe drivers

·      Doses requiring complex calculations

In situations where it is not possible for a second person to check, for example, in a patients home, a risk assessment must be undertaken and action undertaken to minimise risk must be documented

20.4.5     Administration of controlled drugs – see Chapter 8 on Controlled Drugs.

20.4.6     Bank and agency nurses and midwives can administer medicines if they have completed appropriate learning and assessment. 

20.4.7     A registrant is responsible for the delegation of any aspects of the administration of medicinal products and they are accountable to ensure that the Health Care Support Worker is competent to carry out the task following appropriate training, education and competency assessment.  This is only applicable where Health Care Support Workers administer medicines within the community. 

20.5    ADMINISTRATION OF MEDICINES IN ANY CLINICAL SETTING

20.5.1     The administration of medicines must be undertaken in a methodical manner and distractions must be minimised while medicines are being selected, prepared and administered.

20.5.2     The following procedure must be undertaken before administering a medicine.  Where a second person is required in the administration process both the administering practitioner and witnessing practitioner must independently undertake the steps below:

·      Read the prescription carefully

·      Check that the medicine is correct for the patient

·      Check for any allergies or contra indications

·      Check that the prescribed dose has not been given already

·      Select the medicine required and check the label and the medicine against the prescription

·      Check the expiry date

·      Take the prescription to the patient and independently confirm the patient’s identity and date of birth verbally where possible with that on the prescription chart.  The patient’s wristband or photograph (if used for identity) must also be checked against the prescription chart including CHI.  Re-check allergy status.  In certain healthcare settings such as paediatrics and learning disability, the verbal element of the check can be undertaken by asking the parent or carer to confirm.

·      Where a second person is required for the administration of the medication one of the nurses, midwives or registered healthcare professionals administers the medication while the other witnesses the administration.  In some circumstances parents and carers may be involved in the administration of medicines to ensure compliance.  This administration must be observed by one responsible healthcare professional, for example parents administering topical/oral medicines.

20.5.3     Complex dose calculations must be carried out independently by two registered practitioners to ensure accuracy.  Simple calculations, for example the number of tablets required for a dose, may be carried out by a single practitioner.  In the case of uncertainty with any medicine a senior nurse, midwife, doctor or pharmacist must be contacted.  In calculations that involve the patient’s weight the date of the weight measurement must be recorded.

20.5.4     The prescribed medicine must be administered as near as possible to the prescribed time, and normally within an hour either side of the prescribed administration time.  If this is not possible and there is any doubt about the implications of administering a medicine outwith the prescribed time, medical advice should be sought and a once-only prescription written.

20.5.5     Medicines must never be left unattended between removal from the storage area and administration to the patient.  Medicines must be transported in a suitable container.  Doses must never be left unattended on patient’s bedside lockers or tables.  The practitioner responsible for the administration of the medicine must supervise the patient until administration is complete.

20.5.6     An oral (purple) syringe must be used to measure doses to be given via enteral feeding tube or for doses that cannot be measured by any other means.  This is to prevent inadvertent injection.  Liquid controlled drugs must always be measured using an oral syringe to ensure accuracy.

20.5.7     In cases were a witness is required; the whole administration period must be witnessed with the exception of slow administration, for example infusions, for which the set up and start of the administration must be witnessed.

20.5.8     In cases where a patient requests a dose that is different from the one prescribed then the request must be reviewed by the patient’s doctor and a new dose prescribed where appropriate.  

20.5.9     If the medicine is refused by the patient this must be recorded, similarly if the medication is not available this should be recorded and steps taken to obtain the medicine at the earliest possible opportunity.  Consider escalation to medical colleague, please consider the impact of these omitted medicines and act accordingly to reduce harm.

20.5.10   Medicine administration must be recorded by signing the appropriate entry on the prescription record (electronic or paper).

20.5.11   In addition to the guidance above, when administering an "as required medicine", the following must be assessed:

·      Check the medicines administration chart for the last record of administration including any supplemental treatment charts, for example, theatre records

·      Check for patient specific guideline for administration of the medicine

·      Check that the maximum dose or frequency with 24 hours is not exceeded.  Check regular administration of the same medication or medication including the same active ingredients.  Ensure that when any as required medicine is no longer required or becomes a regular that the relevant entry is discontinued in the "as required" section of the administration chart. 

20.6    ADMINISTRATION OF DOSES OUTWITH PRESCRIBED TIMES

20.6.1     If the patient has missed regularly prescribed medicines because they were absent from the ward at the time the medicine was prescribed then confirm with colleagues that the medicine has not been administered and that the medicine is required before the next prescribed dose.

20.6.2     The practitioner must use their professional judgement and if appropriate contact a prescriber and advise them of the situation and provide them with information on the medicines that have been missed.  The prescriber will give advice which must be documented in the patient’s record.  If the dose is to be given, the original prescription may be used, but the actual time given must be documented and subsequent doses amended.

20.6.3     The frequency of occurrence of missed administration times for individual patients should be monitored and consideration given to changing the regular administration times.

20.7    ADMINISTRATION OF MEDICINES IN PATIENTS’ OWN HOMES OR HOMELY SETTING

Within independent care homes, the administration of medicines by nurses and/or care workers is legislated by the Care Inspectorate, not NHS Tayside.

20.7.1     Medicines administered in the community setting must be recorded on the agreed medicine administration sheet.

22.7.2     Medicines supplied on prescription remain the property of the individual for whom they have been prescribed.

20.7.3     On occasion there may be a cause for concern regarding the safety of the patient, or the custody of medicines.  In these cases nurses should be aware of their professional responsibilities and should consult the patient’s General Practitioner and/or other relevant authority in order that suitable arrangements can be made. 

20.7.4     Nurses, midwives and other clinical staff have a responsibility for assisting the education of the public regarding the safe custody and administration of medicines.  Patients should be advised that all medicines require careful storage and that prescribed medicines should not be made available to persons other than for whom they were prescribed.  Unused medicines should be returned to the Community Pharmacy for safe disposal by patients or their families.

An individual health professional may chose to involve a second person in circumstances where they may be working outwith their normal area of work or patient group.  This is voluntary.

Registered healthcare professionals who administer medicines, or delegate the administration of medicines are accountable for their actions, non-actions and omissions and must exercise professionalism and professional judgement at all times.  Before administering any medicine the healthcare professional must have an overall understanding of the medicine being administered and seek advice if necessary from a prescriber or pharmacy professional. 

8.    MEDICATION INCIDENTS

Medication incidents must be reported and investigated in order to ensure that the appropriate corrective action is taken, and to agree the appropriate preventative action required to avoid recurrence.  This enables learning and the reduction/prevention of harm in the future.  Patients and their families (where appropriate) must be informed of the incident.

The person who discovers a medication incident is responsible for completing a Datix incident report form.  Prompt investigation by the department manager must be carried out with support from pharmacy where appropriate.  Serious incidents should involve the professional lead/manager, appropriate Pharmacist and/or non-medical prescribing lead for the area.  For incidents involving controlled drugs the Accountable Officer must be informed.  Incidents involving a student should be reported appropriately.

A medication incident occurs when (please note this list is not exhaustive):

·      The wrong medicine is prescribed, administered or dispensed to a patient

·      An unsuitable medicine, for example, expired or incorrectly stored is supplied or administered to a patient

·      A medicine which a patient has an allergy to is prescribed or administered to that patient

·      A medicine is administered to the wrong patient

·      A medicine is administered via a route other than that prescribed

·      A wrong dose or strength of a medicine is prescribed, administered or dispensed to a patient

·      The wrong concentration is prescribed or administered to a patient

·      The wrong frequency (time between doses) of medicine is prescribed or administered

·      The wrong rate of administration of a medicine for infusion is prescribed or set up for administration

·      Failure to record and accurately monitor infusion devices containing medication

·      A dose of medicine is significantly delayed or indeed missed, either because it has not been prescribed, administered or dispensed in a timely manner

·      A medicine dispensed or supplied to a patient is labelled with the wrong medicine name, strength or dosage instructions

·      Any other prescribing or administration error

·      Prescription or administration is not correctly recorded

·      The medicine is found not to be of a quality suitable for administration

·      Medicines have been inappropriately stored, for example not in freezer

·      There is inappropriate disposal or destruction of medicines

A breach of security is also a medication incident and includes any deviation from the procedures that cause actual or potential loss or theft of medicines.  Examples of these are:

·      Medicines left unattended at an insecure location

·      Signatures are not received when a medication changes hands, for example ward transfer forms (Appendix 2 of the ‘Safe and Secure Handling of Medicines Policy’) must be used along with a valid prescription sheet if borrowing medication from another area.  During pharmacy opening times all required medicines should be obtained from pharmacy in the first instance.

·      Medicines are found to be missing

·      A key for a medicine cupboard is discovered to be missing

·      Where controlled drug legislation has been contravened

·      Controlled stationery is missing or in the possession of an unauthorised person.  Non medical prescribers should, in addition follow the Policy for Non medical Prescribing in the event of missing stationery.

20.9    THE ADMINISTRATION OF MEDICINES BY MIDWIVES UNDER THE EXEMPTION LISTED IN THE PRESCRIPTION ONLY MEDICINE (HUMAN USE ORDER) 1997 SI NO 1830

The Prescription Only Medicine (Human Use Order) 1997 SI No 1830 (the ‘POM Order’) the Medicines (Pharmacy and General Sale-Exemption) Order 1980 SI No 1924 and the Medicines (Sale or Supply) (Miscellaneous Provisions) Regulations 1980 SI No 1923 allow midwives to supply and  administer, in the course of their professional practice, medicines which are listed in the exemption order. The list of allowed medicines can be found below.

This allows midwives to record on the TPAR and administer, in the course of their professional duties, the medicines contained on the exemption list.  Midwives do not have to be supplementary or independent prescribers to do this, the above orders are an exemption to allow Midwives to supply and administer these medicines in their practice.

Student Midwives

With the exception of controlled drugs, student midwives can administer any of the parenteral medicines on the midwives’ list under the direct supervision of a registered midwife. Student midwives may administer prescribed drugs including controlled drugs parenterally if prescribed by a doctor or an appropriate practitioner according to their directions for administration. This must be under the direct supervision of a midwife.

20.10   STUDENT PARAMEDICS

• Student paramedics can undertake the pre drug checks for the patient and the post administration checks.

• Student paramedics can prepare medications, although not controlled drugs such as morphine or drugs which fall under a Patient Group Directive. 

• Student paramedics cannot physically administer drugs by any route or hand out any medications to a patient.

• Student paramedics can site a cannula but cannot flush with sodium chloride 0.9%.

• Student paramedics can prepare fluids for administration but cannot connect to an IV.

The Human Medicines Act 2012, only provides exemption for saving life in an emergency and students can administer IM medicines such as naloxone (for opiate overdose), adrenaline 1:1000 (for anaphylaxis), glucagon and hydrocortisone in accordance with Schedule 19 exemption of the Act for this purpose.

20.11   COVERT MEDICINE ADMINISTRATION

Please refer to the Policy on Covert Medication.

20.12   CONTROLLED DRUG ADMINISTRATION

Please refer to Section 8 on the administration of controlled drugs. 

[Section updated 08/08/22]