SAFE AND SECURE HANDLING OF MEDICINES

Section 21:
Parenteral Medicines

“Parenteral” in this section refers to medicines administered by the intramuscular, intravenous, subcutaneous, intradermal, intra-articular and epidural routes. The quality of the medicines administered in this way is dependent upon good technique and procedures being used in their preparation. For example, intravenous medicines must be prepared and administered by Registered Nurse or suitably qualified practitioners who have undergone appropriate training, or by the medical practitioner.

Patient Controlled Analgesia (PCA) is a method of delivering parenteral analgesia to the patient as and when it is required and the patient is in control of his/her own analgesic requirements.  A dose is delivered to the patient, within pre-set limits.

For instructions regarding the prescribing, ordering and administration of patient controlled analgesia, reference must be made to the ‘Pain Management Guidelines.’

21.1  Parenteral Medicines: Prescribing

The decision to give medicine by parenteral route must only be taken if:

• The clinical condition of the patient does not allow administration by another route
• The clinical condition of the patient requires the medicine to be administered by injection to achieve immediate effect/the required therapeutic level
• The medicine is unavailable to administer by any other route
• Administration by injection is in the best interest of the patient

In addition to the general requirements applying to prescriptions given in Section 19, particular care is required in prescribing parenteral medicines. The medicine must be prescribed including:

• route of administration and site
• method of administration, i.e. bolus or infusion
• the time over which the medicine is to be given

and if to be given by infusion,

·         the name of the fluid and volume

Where possible and where the clinical outcome is not affected, a medicine must be prescribed that is available in a ready to administer form.

21.1.1  Dosage parameters may include a continuous infusion of medicine, e.g. Heparin 1,500 units per hour, or a variable dose such as that used for post-operative pain control, e.g. Morphine 1 - 5 mg per hour as required for pain control.

21.2  Parenteral Medicines: Use of Prescription Sheets

All medicines prescribed must be stated on the Medicine Prescription sheet THB (MR) 024SS/LS/DS. All dose parameters defining the bolus administration are included. 

Medicines include parenteral sodium chloride 0.9% and water for injection. This is emphasised in the Safe and Secure Handling of Medicines: A Team Approach, March 2005, RPSGB.

Prescribe “Parenteral Infusions and additives as charted” in the regular medicines section on the TPAR (The additional charts box on the front page of the TPAR must be completed also). When parenteral fluids are discontinued both must be cancelled by the prescriber.

Dose parameters of medicines being given by continuous infusion must be given on the “Continuous Infusions/Syringe Driver” section of the TPAR and be signed by the prescriber.

Other infusions, including Total Parenteral Nutrition must be stated on the Fluid Prescription and Balance Sheet, THB (MR) 29, Fluid Balance Chart/Fluid (Additive Medicine) Prescription & Recording Sheet, PMR191, or ITU and Paediatric Prescriptions (for hospital inpatients).

Other sheets are in use for prescribing medicines in specific locations and/or clinical circumstances.

21.3  Parenteral Medicines: Preparation

It is unacceptable to prepare substances for injection of infusion  in advance of their immediate use or to administer medication drawn into a syringe or container by another practitioner when not in their presence.  An exception to this is an already established infusion which has been instigated by another practitioner following the principles set out above, or medication prepared under direction of a pharmacist from a central intravenous additive service and clearly labelled for that patient.

Prior to the preparation of a new medication a risk assessment must be performed to identify the most appropriate location for its preparation.  This must be carried out using the risk assessment tool developed in accordance with the NHS Tayside policy on the “preparation of Injections in Near patient Areas, including Clinical and home Environments”.

21.4  Parenteral Medicines: Labelling

All injections whether bolus or infusions must be clearly identifiable at all stages during preparation and administration.

Medicines prepared for administration by infusion must be labelled at the time of preparation using  ‘Additive labels’ giving the following information:

·         name of medicine additive(s)

·         amount or concentration

·         reconstitution fluid or diluent (if appropriate)

·         time of preparation

·         time of expiry, according to local policy or Intravenous Manual

·         patients name and Community Health Index (CHI) Number

·         initials of the person who made the preparation

·         initials of the person who checked the preparation

21.5  Parenteral Medicines: Administration

Student nurses and midwives can administer parenteral medicine, including Intravenous (IV) medicine administration with a compatible flush and Sodium Chloride 0.9% flush following peripheral venous cannulation (PVC) and completion of the appropriate theoretical modules and simulated practice under the direct supervision of a registered healthcare practitioner who is competent in parental/IV medicine administration.

Sodium Chloride 0.9% flush post PVC insertion must be prescribed on a prescription record (electronic or online) by a recognised prescriber, and signed for by the student and supervising registered healthcare practitioner when student nurses and midwives are inserting a PVC.

Prior to participation in the use of powered infusion devices students must complete online theoretical modules and simulated practice within their HEI as part of their programme.

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 online). 

The point in the students programme when they are able to practice will be stipulated by their individual Higher Education Institution (HEI) and agreed by NHS Tayside. Prior to participation in the preparation and administration of parenteral medication, all students must complete online theoretical modules and simulated practice within the HEI as part of their programme. Students are expected to access the MEDUSA - injectable medicines guide and web-based resource, available on NHS Tayside Staffnet to support their learning and practice. Students are excluded from administering Systemic Anti-Cancer Therapy (SACT) and cytotoxic medicines as this requires specialist training that is not incorporated in their HEI programme.

For information regarding the administration of medicines by midwives under the exemption listed in the prescription only medicine (Human use order) 1997 SI NO 1830 and how this relates to student midwives, see Chapter 20, Section 9.

[Section updated: 27/09/21] 

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