Medication Administration - Starship...the administration of medications, intravenous fluids, infusions and use of medical gases. Scope Applies to all medical staff, registered nurses

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







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.







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

http://adhbintranet/adhb_policies_and_procedures/1Organisation_Wide/ADHB_Generic/Generic/Staff/Enrolled_Nurse_Scope_Practice.htm

http://adhbintranet/adhb_policies_and_procedures/1Organisation_Wide/ADHB_Generic/Generic/Clinical%20Practice/PainMgmtEpiduralAnalgesiaAdult.pdf

http://adhbintranet/adhb_policies_and_procedures/2HSGs/Adult_Health/Combined/Nicotine%20Withdrawal%20Management.pdf

http://adhbintranet/adhb_policies_and_procedures/1Organisation_Wide/ADHB_Generic/Generic/Staff/private_agency_personell.htm

http://adhbintranet/adhb_policies_and_procedures/1Organisation_Wide/ADHB_Generic/Generic/Clinical%20Practice/standing_orders.htm

http://adhbintranet/AkPharmacy/standing_orders.htm

https://www.starship.org.nz/for-health-professionals/starship-clinical-guidelines/m/morphine-administration/

http://adhbintranet/adhb_policies_and_procedures/Index_ADHB_all_Pain_Management.htm

https://www.starship.org.nz/for-health-professionals/starship-clinical-guidelines/p/prescribing-guidelines/

http://adhbintranet/hr/eLearning/ADHB%20elearning/portal/AboutCatalogue.htm#IV_Therapies







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.







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.

http://adhbintranet/adhb_policies_and_procedures/1Organisation_Wide/ADHB_Generic/Generic/Clinical%20Practice/PainMgmtEpiduralAnalgesiaAdult.pdf

http://adhbintranet/adhb_policies_and_procedures/Index_ADHB_all_Pain_Management.htm







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.







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







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.







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







Independent Double Checking Medications, Continued

Independent

Double Check

Process







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.







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.








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.







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.







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.







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.







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








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.


http://adhbintranet/adhb_policies_and_procedures/1Organisation_Wide/ADHB_Generic/Generic/Clinical%20Practice/standing_orders.htm








Ten Rules of Safe

Prescribing &

Administration









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).









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.









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.







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.








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.







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.







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.








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.







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.








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







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.







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.








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.