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Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 1 of 32
Overview
Content This document details the policies and accepted practices relating to
the administration of medications by Auckland District Health Board
(ADHB) Staff.
Topic See Page
Overview ..................................................................................... 1
Introduction ................................................................................. 2 Associated Documents ................................................................ 3
Supervision & Delegation ........................................................... 4 Competence Assessment ............................................................. 5 Immunisations ............................................................................. 6 Medicines Requiring Extra Precautions ...................................... 7
Accountability ............................................................................. 8 Independent Double Checking Medications ............................... 9
Controlled Drugs Definition ..................................................... 11 Ward Controlled Drug Register ................................................ 12 Controlled Drug Infusion .......................................................... 14
Operating Rooms ...................................................................... 15 Controlled Drug Keys ............................................................... 16
Administration .......................................................................... 17 Parenteral Medications Given via Non-Parenteral Routes........ 23 Emergencies & Verbal Phone Orders ....................................... 25 Patient Consent & Refusal ........................................................ 26 Medication Omission Codes ..................................................... 28 Assessment of Competence to Administer ............................... 30
Managing Medication Administration Problems ...................... 31
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 2 of 32
Introduction
Purpose The purpose of this policy is to ensure safe and consistent practice in
the administration of medications, intravenous fluids, infusions and
use of medical gases.
Scope Applies to all medical staff, registered nurses and midwives in all
clinical settings across the board.
This policy also applies to:
ADHB nursing bureau staff
Agency nursing personnel and students who practice under
supervision in the administration of medications in our clinical
settings
Technicians who have completed the relevant training and
competence assessment to administer specific medications and
intravenous infusions.
Research staff who have completed relevant training and
competence assessment to administer medications related to
clinical trials only.
An ADHB credentialed staff member is a Registered Medical
Practitioner, Nurse/Midwife or Pharmacist who has passed the
medication competency assessment. They are able to double check
medications and check out controlled drugs with another competent
person, e.g. Enrolled nurse/Nurse Assistant, private bureau staff,
student nurse or technician.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 3 of 32
Associated Documents
Associated
Documents
The table below indicates other documents associated with this
policy.
Type Document Titles
ADHB Policies
& Guidelines Medications - Cytotoxic & Hazardous -
Administration
Enrolled Nurse - Scope of Practice
Entonox® / Nitrous Oxide for an Adult (Non-
Maternity)
Epidural Analgesia for an Adult
Informed Consent
Intravenous Fluid Prescription - Adult
Medications - Management & Safekeeping
Nicotine Withdrawal Management
Opioids Intravenous in Adults
Patient Controlled Intravenous Analgesia
(PCIA) - Adult
Intravenous Catheters - Peripheral
Private Agency Personnel - Inpatient Settings
Reportable Events
Standing Orders
Standing Orders - Pharmacy Website
Starship
Children’s
Clinical
Morphine Administration - Paed
Oral/Enteral Medication - Administration by
Syringe
Pain Management - Paediatric Board Index
Prescribing Guidelines - Paed
Sedation in Children
Education
Programme IV therapy
Legislation Health Practitioners Competency Assurance
Act 2003
Medicines (Standing Order) Regulations 2002.
Mental Health Compulsory Assessment and
Treatment) Act 1992
Misuse of Drugs Act 1975
Hospitals Act 1957
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 4 of 32
Supervision & Delegation
Supervision &
Delegation
ADHB credentialed registered nurse/midwife employees are
responsible for the supervision of and delegation to private agency
personnel who have successfully completed an intravenous
administration competency assessment that is approved by the
ADHB. An agency nurse/midwife must carry notification of his/her
IV Certification.
For the purposes of this policy, appropriately qualified volunteers in
extraordinary circumstances (e.g. Major disaster/civil emergency)
and authorised by the appropriate nursing/midwifery leader, will
have the same obligations and be treated the same as private agency
personnel.
ADHB credentialed registered nurse/midwife employees are
responsible for the direction and supervision of enrolled nurses/nurse
assistants who may administer oral medications or monitor
intravenous infusions. Health care assistants may not undertake
these duties.
ADHB registered nurse/midwife employees are responsible for the
direction and supervision of nursing/midwifery students who may
administer oral medications and monitor intravenous infusions.
Student nurses may administer intravenous medications only under
direct supervision of a registered nurse or midwife. Student
doctors must be directly supervised by a Registered Medical
Practitioner.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 5 of 32
Competence Assessment
Competence
Assessment
All medical staff and nurses/midwifes who are involved in direct care
delivery, and research staff and technicians when it is part of their
role to administer medications, must have:
Received orientation to ADHB policies and practice relation to
the administration of medications.
Received training about the standards of practice in relation to
administration of medications and intravenous infusions
appropriate to their category of registration or scope of practice.
Their competence in skilled administration assessment within six
weeks of employment by an approved assessor if a registered
nurse/midwife is required to administer IV medications.
Note: The assessment does not extend to supervision and
administration of patients with PCA, epidural, entonox and
regional anaesthetic techniques; the additional competencies
to be achieved are detailed within separate policies.
Entonox® / Nitrous Oxide for an Adult (Non-Maternity)
Epidural Analgesia for an Adult
Pain Management - Paediatric Board Index
Patient Controlled Intravenous Analgesia (PCIA) - Adult
Intravenous Catheters - Peripheral
Their competence in skilled administration of oral/topical
medications assessment commenced within six weeks of
employment by an approved assessor if an enrolled nurse/nurse
assistant.
Their competence in skilled administration assessment
commenced within six weeks of employment by an ADHB
assessor (e.g. Nurse Educator) if giving oral medications, IV
medications/infusions as a technician.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 6 of 32
Immunisations
Immunisations Immunisations, which are prescription medicines, can be
administered by Registered Nurses/Midwives in two ways: 1) under
the direction of a Medical Practitioner, such as where an individual
prescription has been issued. 2) for the purposes of the National
Immunisation Programme, immunizations may be administered
without a prescription but they should only be given only by
Registered Nurses/Midwives that have been approved by the Medical
Officer of Health following additional training and met the
competencies for immunization (see "Standards for Vaccinators,
Immunisation Handbook - Ministry of Health, 2006 (page 401 - 407).
Influenza vaccinations may be administered by Registered Nurses
who have undergone specific training and have met associated
competencies.
Note: Immunisations which are prescribed for individual patients
may only be administered by a Registered Nurses/Midwife who fully
understands the safe administration of vaccines and associated risks
of anaphylaxis as indicated above.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 7 of 32
Medicines Requiring Extra Precautions
Medicines
Requiring Extra
Precautions
Precautions during dispensing and administration must be taken
when administering certain medicines as they may have cytotoxic,
immunosuppressive or teratogenic properties.
This list is not exhaustive.
Nurses must check with a pharmacist in regards to what precautions
may be required for medicine administration and whether there may
be a more suitable formulation available for administration,
particularly for enteral/feeding (NG, NJ, ND or PEG) tubes.
For further information, refer to the Medications - Cytotoxic &
Hazardous - Administration ADHB policy.
Medicines*
* list not exhaustive Medicine form
or route of
administration
Required
Staff
Precautions
Disposal/Waste*
*refer to cytotoxic policy
for full details
Acitretin
Antithymocyte globulin
- equine (ATGAM)
Arsenic
Azathioprine
Cyclophosphamide
Cyclosporin
Ganciclovir
Hydroxyurea
Isotretinoin
Methotrexate
Muromonab CD3
(OKT-3)
Mycophenolate mofetil
Pentamidine
Ribavirin
Sirolimus
Tacrolimus
Thalidomide
Tretinoin (ATRA)
Valganciclovir
Oral solid
dosage form e.g.
tablet or capsule
and patient can
swallow
Gloves Dispose of equipment
used to administer
above medicines in
cytotoxic waste
containers. Purple
plastic bags and sharps
bins can be ordered
from supply and
distribution.
Wash non-disposable
items (e.g. mortar &
pestle) with hot water
and detergent then dry
with disposable paper
towels, which must be
discarded as cytotoxic
waste.
Fully flush toilets
when disposing of
excreta.
Oral liquids
already prepared
Gloves
Oral liquids
requiring
reconstitution
Gloves
Mask
Gown
Oral
preparations
that need to be
crushed for
administration
via a feeding
tube
Gloves
Mask
Gown
IV and/or
Nebulised
administration
Gloves
Mask
Gown
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 8 of 32
Accountability
Accountability All registered medical practitioners, nurses/midwives, and where
appropriate research staff and technicians, are accountable for:
Their actions
Their omissions
Failing to take appropriate actions in the safe administration of
medications
Failing to adequately supervise the administration of medications
by others for whom they are responsible
Failing to question or seek clarification where prescription is not
clear or appropriate to local policy
Failure to question or seek clarification where medications are
not available
Ensuring that their practice is based on the best available
evidence
Compliance with the law as outlined in legislation and
regulations pertaining to medicines
Reporting error in line with the Reportable Events policy
Ensuring that the patient fully understands the information given
to them
All registered medical practitioners, nurses/midwives, research staff
and technicians are expected to follow safe and accepted practices in
the process of:
Checking the documented prescription
Preparing the medication or fluids for administration
Ensuring that the right patient receives the right medication in the
right dose, at the right time, using the right route
Assessing the patient and their response to the treatment
Documenting carefully what has been administered and when
Ensuring safe destruction of surplus or unused controlled drugs.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 9 of 32
Independent Double Checking Medications
Independent
Double-Checking
Medications
Medications being administered by a registered nurse/midwife to
adults do not have to be independently double-checked unless they
are unfamiliar medications, it is required by legislation (e.g.
Controlled drugs) or by specific written local policy.
All intravenous, subcutaneous, and intramuscular medications
(including infusions), controlled and restricted medications, oral
sedatives, oral chemotherapy, oral medications which are unfamiliar
to the nurse administering them, in particular, anticoagulants,
antiarrhythmics, vasoactive and anticonvulsant medications
administered to children must be independently double-checked; one
person must be a credentialed Registered Nurse/Midwife, the other
deemed as being competent by the Registered Nurse.
Enrolled nurses/nurse assistants, students and non-credentialed
agency health professionals must independently double-check all
medications with an ADHB credentialed employee.
An independent double-check is a process where a second person
forms an independent judgement ,without cues from the person doing
the initial work, that the right medication at the right dose and right
route, at the right time has been prepared for administration for the
right patient.
Both people are responsible for checking the right medication,
dosage, route, time and patient name against the prescription
although one Registered Nurse/Midwife person will take the
medication to the patient bedside.
The person administering the medicine is accountable for ensuring
that the right medication is administered to the right patient.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 10 of 32
Independent Double Checking Medications, Continued
Independent
Double Check
Process
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 11 of 32
Controlled Drugs Definition
Controlled Drugs
Definition
Controlled drugs are any substance listed (or classified) in the First,
Second or Third Schedules to the Misuse of Drugs Act 1975.
Substances are listed in the Schedules because of the potential harm
associated with their misuse and/or their abuse potential.
All controlled drugs must be independently double-checked by
two competent persons who have appropriate knowledge and
experience, one of whom must be a registered medical practitioner,
registered nurse/midwife, or pharmacist who is an ADHB employee.
Enrolled nurses/nurse assistants, technicians, students and agency
personnel may only independently double-check the controlled drugs
with a registered nurse, midwife, medical practitioners or pharmacist
a registered medical practitioner, registered nurse/midwife, or
pharmacist who is an ADHB employee.
There are two types of controlled drug registers – the main controlled
drugs register, which is held in Pharmacy and the ward controlled
drugs register, which is held in each ward or clinical area for each
controlled drugs safe. The ward controlled drug register must be
completed and signed by both persons checking the controlled drug.
Where a controlled drug is unusable it must be destroyed. Loss
must be recorded in the ward controlled drug register, and where a
medicine is only part-used, the remainder of the medicine must be
destroyed/disposed down the sluice or a sink with a witness present.
Any unused, complete ampoules of controlled drugs must be returned
to the safe and recorded in the ward controlled drugs register and
signed in by two people.
Syringes for incremental dosages of controlled drugs must be stored
in the controlled drugs safe, labeled with patient’s details and the
contents must be destroyed at the end of each shift.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 12 of 32
Ward Controlled Drug Register
Ward Controlled
Drug Register
In the following designated areas:
Auckland City Hospital
PACUs
CCU
DCCM
Neurology
NICU
Delivery Suite
CVICU
Greenlane Clinical Centre
Day Surgery Unit PACU
Epsom Day Unit
Starship
23B
24B
26A
27B
PICU
CED
When a controlled drug is checked out of the controlled drug safe
and either delivered to the individual patient’s bedspace or the
medication bay of a unit, it must be independently double checked by
two people. One of which must be an ADHB credentialed medical
practitioner, registered nurse/midwife or pharmacist, and the other
the registered nurse/midwife responsible for the patient.
The controlled drug is recorded in the Ward Controlled Drug
Register as being assigned to the bedspace/ medication bay (See
example Figure 1). In some units this will also be recorded in
specially designated areas on unit specific documentation.
Once checked to the individual patient/medication bay, the registered
nurse/ midwife assigned to that patient is responsible and
accountable for the administration and safekeeping of the controlled
drug. The controlled drug should be kept out of public view at all
times.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 13 of 32
Ward Controlled Drug Register, Continued
Figure 1 At the completion of each shift, it is the responsibility of the
registered nurse/midwife to ensure that any remaining controlled
drug that is drawn up and remaining in their patient’s bedspace/
medication bay is destroyed in accordance with the process outlined
previously.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 14 of 32
Controlled Drug Infusion
Controlled Drug
Infusions
Any controlled drug that is no longer required and that has been used
as an infusion (e.g. Epidurals, PCA, via Grasby pump) must be
disposed of using the process outlined previously with the
destruction witnessed, recorded and signed for on the patient’s
medication chart (infusion prescription chart) by two people; one
ADHB credentialed medical practitioner, registered nurse/midwife or
pharmacist, and one other person who has appropriate knowledge
and experience e.g. Enrolled nurse/nurse assistant, student nurse.
Patients receiving analgesics via PCA or other analgesic infusion
pumps that arrive on wards/ departments from other sites (e.g. other
Hospitals, PACU etc) must have the controlled drug double-checked
by two people (as above) and signed-in to the admitting ward
controlled drug register book (staff therefore record what is labelled
on the infusion from transferred patients ‘in good faith’ that the
substance has been correctly labelled at the originating site and not
tampered with during transfer). If there are any doubts, dispose of the
controlled drug in accordance with the procedure outlined previously
and administer a new infusion.
If any part of this controlled drug is left unused at the completion of
therapy it must be destroyed in accordance with the process
outlined previously.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 15 of 32
Operating Rooms
Operating Rooms In operating rooms:
Drug ampoules/ syringes must be signed out to a named patient,
not to an operating room, and will be subjected to the same
independent double-checking process as outlined previously.
The use of one ampoule for more than one patient is not
permitted.
Unused ampoules must be signed back into the theatre controlled
drugs register by the prescribing anaesthetist and counter-signed
by another member of staff who has appropriate knowledge and
experience. They are not to be handed to another
anaesthetist.
Part-used ampoules and syringes are to be emptied into the
clinical waste bin and then disposed of in an appropriate manner.
The security of the controlled drug is the responsibility of the
prescribing anaesthetist/ medical practitioner.
All entries in the ward book/ controlled drugs register must have
two signatures:
One by an ADHB credentialed medical practitioner,
registered nurse/midwife or pharmacist, and
One by other person who has appropriate knowledge and
experience e.g. Enrolled nurse/nurse assistant, student nurse,
technician.
The anaesthetic record must contain details of all drugs administered
including any controlled drugs.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 16 of 32
Controlled Drug Keys
Controlled Drugs
Keys
Keys must be held on a dedicated key ring and attached to the
ward/unit charge nurse/midwife or their delegated authority who
must be a registered nurse/midwife. Enrolled nurses/nurse assistants
are not permitted to hold the controlled drug keys.
The key ring should not be shared with other keys which are
accessed by non-clinical staff for other reasons.
Keys will be kept securely on the person so that they are not
accessible to unauthorised staff.
Keys are only to be held by the charge nurse/ midwife or their
delegate coordinating each shift. The charge nurse or delegate
remains responsible for the keys even when temporary access to the
keys is given to another registered health professional. When leaving
the area, key responsibility is delegated to a colleague. Keys must
not be taken home.
Keys must be handed over to the registered nurse/midwife in
charge/coordinating on the next shift. The registered nurse/midwife
in charge/coordinating the next shift is responsible for ensuring that
they receive the keys at commencement of their shift.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 17 of 32
Administration
Who Does What Prescribing
Prescribing is the responsibility of the medical practitioner, dentist,
midwife, or Nurse Practitioner with prescribing rights.
Dispensing
Dispensing is the role of the pharmacist. No nurse/ midwife/ medical
officer/ technician may handout or transfer medications to another
container to give to patients or another health care facility. For
weekend leave or overnight leave, a prescription must be written and
processed by a pharmacy.
Administration
Administration of medications is undertaken by registered nurses,
midwives, medical staff and some technicians who have met
competency requirements, and by enrolled nurses and student nurses
who are under the supervision of an ADHB credentialed registered
nurse/ midwife.
Self/caregiver administration is not recommended whilst patients are
inpatients, however some departments have a self/ caregiver
medication programme as local policy i.e. Transplant unit, SSH,
Infectious diseases, Oncology, Haematology and Rehab Plus.
Competent to
Administer
Medications may only be given with:
Reference to a prescription or standing order
Knowledge about the medication (reconstitution, stability and
storage requirements) and its effect
Knowledge about the route of administration
Knowledge of service-specific practices
Knowledge of special precautions and vital sign monitoring
required
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 18 of 32
Administration, Continued
Standing Orders Standing orders may only be administered by registered
nurses/midwives (or by technicians in specific circumstances) in
accordance with the Standing Orders policy.
Administration using standing orders must be recorded on the
prescription sheet and signed by the administering
nurse/midwife/technician. The nominated medical practitioner must
counter-sign the prescription sheet within the time period specified in
the Standing Order for that medication.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 19 of 32
Administration, Continued
Ten Rules of Safe
Prescribing &
Administration
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 20 of 32
Administration, Continued
Prescription The prescription must follow the 10 rules of safe prescribing and
administration:
The 10 rules include prescriptions issued by a Midwife, Nurse
Practitioner (with prescribing rights), and a Dentist
If prescribed by a dentist, include the words “for dental treatment
only”
If prescribed by a registered midwife, include the words “for
antenatal, intra partum and postnatal care only”
Certain medications may be prescribed on designated order sheets or
on designated parts of the medication prescription form.
For Example:
On the fluid chart:
Additive minerals and
Intravenous fluids only
On specific recording forms:
Insulin
Heparin
Warfarin
Dopamine / Dobutamine
Documentation Medications that have been administered must be documented on the
drug chart or prescription form and signed immediately after
administration using indelible ink, by the person administering the
medication (in the cases where independent double-checking is
required, both signatures must be documented).
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 21 of 32
Administration, Continued
Patient’s Own
Medication
On admission to hospital the admitting nurse must request any
medication the patient has brought into hospital. These medications
must be stored in the medication room or sent home once the
medication history and reconciliation is complete.
On discharge patient’s own medication must be returned to them
ensuring the 5R’s are met. If medication has been discontinued or
changed and the patient is willing to release the redundant
medications place them in the pharmacy return bin. If the patients is
not willing to release the medication contact the unit pharmacist.
Patients who may be exempt from this are patients who are being
taught self medication as part of their discharge planning. This may
include transplant patients, patients on HIV therapy, patients on trial
medications, and some long stay patients who are being taught self
medication in preparation for discharge. It is the nurse caring for the
patients responsibility to ensure the medication is kept in an
appropriate and safe place.
Removal from
Packaging
No medications are to be removed from their packaging where this
prevents the dose and/or expiry date being observed e.g. Cutting
paracetamol card into two tablet strips must not occur.
Red Medication
Additives Label
A red medication additives infusion label must be affixed where
intravenous medications are added to any bag or container of
intravenous fluids, and when the infusion is being administered via a
burette. Red medication additive labels must also be attached to
syringes to identify medications. In some services, other colours of
additive labels may be used.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 22 of 32
Administration, Continued
Intermittent
Intravenous Fluid
Where intermittent intravenous fluid with additive medications are
administered and a fluid chart is not in use, the fluid and the
medication must be prescribed and its administration recorded on the
drug chart.
Note: The total fluids administered may need to be taken into
account as part of the daily fluid requirement.
Low Volume
Medication
Administration
If less than 0.5ml of medication is drawn into a syringe, any further
dilution must not be drawn up through the same needle. The volume
of medication in the needle is approximately 0.2ml thus the potential
exists to actually administer a larger than prescribed medication dose.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 23 of 32
Parenteral Medications Given via Non-Parenteral Routes
Oral
Administration of
Parenteral Drugs
Not all medications are available in dosage forms (e.g. tablets, or oral
liquids) that are suitable for administration by the enteral route, i.e.
via the oral route, or via feeding tubes such as naso-gastric tubes. In
some instances, often when an alternative medication cannot be
substituted, preparations designed for administration via the
parenteral route (usually intravenously) may need to be used
enterally. However, there is a risk associated with this practice, in
particular, the inadvertent administration of an injection drawn up for
oral use being given via an intravenous route.
When medications are charted for administration via the enteral
route:
Solid or liquid dosage forms appropriate for the patient (taking
into account their age, the presence of feeding tubes, etc.) that are
designed for such use (e.g. proprietary tablets or suspensions),
should be administered.
If unavailable in an appropriate dosage form or unsure whether a
preparation is suitable (e.g. to give via a feeding tube), contact a
pharmacist for advice and to see if an alternative medication with
a similar therapeutic action can be prescribed.
If no alternative is suitable, and a parenteral preparation is available
check with the pharmacist if it is suitable for enteral administration
(some cannot be given via enteral routes due to pH, presence of
irritant excipients, etc.). Some parenteral medications have a license
to be given via the enteral route, and their use in this regard is
accepted as standard practice within the clinical setting, e.g. sedation
of children using ampoules of midazolam (Hypnovel®).
The registered nurse must observe that the medication is
administered via the correct route and undertake the usual procedures
for checking the medication, preparation for administration and
documentation. Where the medication is drawn up in a syringe for
enteral administration, the syringe must be an oral syringe or as per
service specific approved measuring and administration device.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 24 of 32
Parenteral Medications Given via Non-Parenteral Routes, Continued
Oral
Administration of
Parenteral Drugs,
continued
Medications needed for nasal administration (e.g. intranasal
midazolam), or via a nebuliser (e.g. nebulised tobramycin), may not
be available in formulations designed for this purpose. Contact a
pharmacist for advice.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 25 of 32
Emergencies & Verbal Phone Orders
Emergencies &
Verbal Phone
Orders
Medications used in an emergency must be checked, prior to
administration and signed for immediately following the emergency.
Emergency administration of oxygen therapy without a prescription
is appropriate while waiting for medical assessment of the patient.
Verbal orders for Controlled Drugs are not currently allowed in
legislation. Alternative options are:
Anticipatory prescribing - a range of pro re nata (PRN) doses
of controlled drugs can be prescribed using the medication
chart
Controlled drugs can be prescribed using Standing Orders as
per the Medicines (Standing Order) Regulations (2002)
Verbal phone orders should only be used in exceptional
circumstances and the receiver of the information must be a
Registered Nurse/Midwife ADHB-employee who then must:
Record the order on the Once-Only medication section of the
medication chart
Question the Registered Medical Practitioner giving the verbal
order if the medication type or dose seems inappropriate
Document that it was a ‘verbal instruction’, the date and time of
the order, the Registered Medical Practitioner’s name
Repeat the order back to the Registered Medical Practitioner for
confirmation of accuracy and have the Registered Medical
Practitioner repeat the order to another nurse/midwife/technician/
pharmacist for confirmation
Ensure that the nurse/midwife witness countersigns the
medication chart
The Once-Only prescription should be signed by the Registered
Medical Practitioner giving the verbal order at the earliest possible
time, i.e. Within 12 hours or as per local policy and a continuing
order prescribed on the regular side of the drug chart if
required/appropriate.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 26 of 32
Patient Consent & Refusal
Patient Consent The administration of medications is part of the clinical treatment
plan that will have been discussed by the patient’s Registered
Medical Practitioner or midwife with the patient/
parent/guardian/ caregiver/ partner. Provided this discussion
has taken place, consent for medications is not required at the
time of administration.
The Registered Medical Practitioner/ nurse/ midwife/ technician
must tell the patient what medication is being administered and what
they can expect, as appropriate. An interpreter must be made
available as necessary.
Special provisions apply where patients are under compulsory
assessment or treatment under the Mental Health (Compulsory
Assessment and Treatment) Act 1992 or other legislation providing
for compulsory treatment.
Section 29 (S29) Separate consent is required for unregistered medicines and for
registered medicines being used in an unregistered indication, dose,
frequency or route under Section 29 of the Medicines Act, or
investigational medications as part of the research protocol.
Signed consent must be obtained from the patient/ parent/guardian if
it is proposed to administer a medicine which is not registered under
the Medicines Act 1981 and the use of the drug could be considered
in any way experimental or part of research or a trial.
The Patient Consent Form, Section 29 contained in the Pharmacy
Policy Medications - Unlicensed & Off-label Use must be used and
completed prior to administration of a S29.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 27 of 32
Patient Consent & Refusal, Continued
Refusal to Take
Medications
Where a patient refuses the prescribed medication it is the
responsibility of the registered nurse/midwife to:
In every case, record the refusal on the prescription/drug and/or
fluids charts
Notify the patient’s Registered Medical Practitioner or Registered
Medical Practitioner ‘on-call’
Discuss alternatives with the patient
Document outcome in the patient’s clinical record
Obtain written “refusal for treatment” from the patient when there
is significant risk of harm to the patient.
Inform the pharmacist.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 28 of 32
Medication Omission Codes
Medication
Omission Codes
Failure to record medication administration or an omission code
constitutes as a medication error and must be reported as per ADHB
significant event reporting policy.
If a medicine can not be administered to the patient as prescribed, the
nurse accountable for the administration must record the time, the
appropriate dose omission code (see below) and initial the entry on
the administration record of the drug chart.
An ADHB dose omission code should only be used once and where
appropriate, the patient’s doctor should be informed. The need for
further omissions must be reported to the patient’s doctor or
pharmacist and action taken as directed.
A patient’s doctor or pharmacist can authorise the second or third use
of an omission code. In doing so, they accept responsibility for the
dose omission at that particular time.
A record of any action undertaken for dose omissions must be
documented in the nursing notes of the patient’s clinical record and
the patient’s doctor informed of the omission at the earliest
appropriate time.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 29 of 32
Medication Omission Codes, Continued
Code Definition Policy / Procedure Note
A Absent
from
ward/patient
on leave
from ward
If a patient is absent from ward when the dose
is due, the nurse accountable for the patient
must also document the time patient was absent
in the clinical notes. Contact Doctor if
appropriate.
D Doctor’s
instruction
Doctor to document the time of the omission
and initial this instruction, together with the
reason for omission, in the patient’s clinical
record.
Nurse, if taking a verbal order, must record the
doctor’s instruction in the patient’s clinical
record e.g. Dr Thompson instructed that
Captopril not be administered at 08.00 because
BP 90/60.
M Medicine
not
available
Medicines
Unavailable
(Pharmacy
Manual)
Inform the pharmacist or doctor.
This code must not be used more than once
unless authorised by patient’s doctor or
pharmacist.
N Nil by
mouth
Fasting for
Anaesthesia or
Parenteral Sedation
Oral medication can generally be given when
fasting prior to surgery but consult with doctor.
Any deviations from this policy must follow
code D
W Withheld Reasons for this code to be used include:
instructions unclear or illegal; unable to
swallow; nausea / vomiting; asleep; comatose
/drowsy; IV cannula not insitu / not patent.
Clinical reason and action undertaken must be
recorded in the patient’s clinical record. The
patient’s doctor must always be informed.
R Patient
refused
If a patient refuses a medicine, then the
medicine must be offered to the patient again
within 1 hr of the prescribed administration
period. If it is refused a second time, the
patient’s doctor must be contacted to review
the prescription or speak to the patient.
V Vomiting Contact doctor
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 30 of 32
Assessment of Competence to Administer
Objective Certification provides a measure of competence and ensures that the
nurse or midwife or technician (where appropriate) understands the
expectations and responsibilities of administration of medications
and intravenous infusions relevant to their scope of practice. No IV
medications can be administered unsupervised until the
competency assessment has been successfully completed.
Responsibility All ADHB nurses or midwives to participate. Technicians who
administer medications to participate.
Note: Mental Health nurses do not have to complete the IV
component of the medications competency if they are not going to
administer IV medication/fluids.
Manager to ensure that practitioner has access to the assessment
process.
Frequency Within 4-6 weeks of employment each nurse and midwife must have
successfully completed clinical practice competency assessment.
For technicians a local process will be stated.
For registered nurses and midwives, once IV competence is
established re-assessment may be required in the event of medication
error or problems with performance around medication/intravenous
therapy management administration or in negotiation between the
nurse/midwife and their charge nurse/midwife. On transfer to
another ward or department, there may be additional requirements for
assessment of competence that must be met. The staff member will
be informed in writing of additional requirements before beginning
their new responsibilities.
It is every registered nurses’/midwives’ responsibility to ensure that
they maintain and update their professional knowledge and skill
necessary for their practice.
Technicians may require re-assessment of competence on a regular
basis depending on local policy.
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 31 of 32
Managing Medication Administration Problems
Reporting Where error or omissions occurs:
The matter must be reported using the electronic Reportable
Events Process (see Reportable Events)
The matter must be reported immediately to the nurse/midwife
co-ordinating the shift, medical staff on duty and the clinical
charge nurse or clinical nurse advisor after hours.
All efforts must be made to minimise the impact of the error on
the patient.
Medical staff refer to clinical director.
Once the potential impact on the patient has been dealt with, the
nurse/midwife should document the events surrounding the error or
ommission in the clinical record.
Investigation The facts and context surrounding the incident must be carefully
identified.
The incident may be analysed as either an:
Error – Incorrect carrying out of a correct plan
Violation – Intentional departures from accepted standards
Mistake – Formation of a wrong plan by the Clinical Charge
Nurse/Charge Nurse Manager/Charge Midwife for follow up by
the Quality Manager.
Resolution The aim is to create a safe learning environment so that incidents are
reported and quality improvement may occur, i.e. Not overly
punitive
The nurse/ midwife/ technician/ medical officer should have the
opportunity to:
Provide explanation of the events
Demonstrate that there has been reflection on the causes
Discuss what future actions will occur to prevent recurrence
The following actions are recommended. They should be discussed
with the quality manager and, where appropriate, the ADHB Legal
Counsel.
Continued on next page
Auckland District BOARD Clinical Practice
Health Board (Section 1) Manual
MEDICATION ADMINISTRATION
Section: Board Issued by: Executive Director of Nursing
File: Medication Administration 2015-11-16.docx Authorised by: Chief Medical Officer Classification: CP01/BRD/002 Date Issued: Updated November 2015
Medication Administration Page: 32 of 32
Managing Medication Administration Problems, Continued
Error and /or
Mistake
The nurse/midwife/technician/medical officer/medication safety
pharmacist may be required:
To formally review the sequence of events with the clinical
charge nurse/midwife, nurse/midwife educator, or clinical nurse
advisor in a formal coaching interview. (If in a study protocol –
advise principal researcher).
To identify what went wrong and how the contributing factors
could be identified and addressed to minimise occurrence.
To review the policy and unit-specific procedures.
To study the impact of the error on the patient and discuss this
with a senior colleague.
Document what should have happened and what changes in
practice will result.
Skill, rule or knowledge-deficits should be addressed using
formal review, with re-testing and up-skilling where appropriate.
Violation The nurse/midwife/technician/medical officer may be required to:
Review the policy and unit-specific procedures.
Document what should have happened.
Explain why there was intentional departure from accepted
practice.
Study the impact of the error on the patient and present a case
review to colleagues.
Work under supervision for a period of time if appropriate.
Disciplinary action may be considered where there is:
Repetitive error which demonstrates that the nurse/midwife has
not learned from the above process.
Apparent lack of professional accountability.
Intentional violation of agreed safe practice.
Recommended