INJECTABLE MEDICINES POLICY

Transcription

1 Wirral University Teaching Hospital NHS Foundation Trust Policy Reference: 045c INJECTABLE MEDICINES POLICY Version: 5 Name and Designation of Policy author(s) Ratified by (committee/ group) Debbie Hughes, Critical Care Pharmacist Wirral Drug & Therapeutics Committee Date Ratified 9 th September 2015 Date Published 10 th September 2015 Review Date 9 th September 2018 Target audience Links to other strategies, policies, procedures All Trust staff involved in injectable medicines. Trust Policy 045 Medicines Management Policy (General) Trust Policy 045a Non Medical Prescribing Policy Trust Policy 045b Controlled Drugs Policy Trust Policy 045d Intravenous Potassium Policy Trust Policy 045e Cytotoxic Medicines Policy Trust Policy 045f Intrathecal Chemotherapy Policy Trust Policy 045h Unlicensed Medicines Policy #PROUD TO CARE FOR YOU #proud

2 CONTENTS Content Page 1 Introduction... Error! Bookmark not defined. 2 Purpose Scope Information Sources Education & Training Prescribing Preparation and Administration Prescribing Injectable Medicines General Preparation of Injectable Medicines General Policy and Procedural Guidance General Preparation Principles Checking of Injectable Medicines Prior to Administration Persons authorised to provide a second check Prescription check required before administration Medication Check Prior to Administration Clinical Emergency Anaesthetics Labelling Injection and Infusion Containers (excluding theatre areas) Labelling Syringes in Theatre Areas Preparation of batches of medication Expiry Stability and Compatibility Products Supplied from Pharmacy Aseptic Services Unit Administration of Injectable Medicines General Policy and Procedural Guidance Staff Authorised to Administer an Injectable Medicine Before Administering Injectable Medicines Anaphylaxis Reversal of Opiates and Benzodiazepines After Administration of Injectable Medicines Disposal Monitoring Flushing Intravenous Medicines Prescribing Intravenous Medicines Post Administration of Intravenous Medicines Subcutaneous and Intramuscular Medications Prescribing Medication via subcutaneous syringe driver At WUTH, the only approved continuous subcutaneous syringe driver is the McKinley T34 syringe driver Prescribing Preparation Administration Monitoring of Syringe Driver Wirral University Teaching Hospital NHS Foundation Trust Page 1 of 21

3 11.5 Discharge/transfer of patient with a syringe driver Other Injectable Medicines Disposal of Sharps Clinical Incident Reporting Procurement Audit Definitions Administration Devices Aseptic Technique Bolus (Push) Diluent Flush, Flushing Solution Infusion Injectable Medicines Risk Second Check Duties / Responsibilities Director of Pharmacy and Medicines Management All WUTH Staff Ward / Department Managers Prescribers Nursing Staff Pharmacy Staff References Wirral University Teaching Hospital NHS Foundation Trust Page 2 of 21

4 1 Introduction The use of injectable medication has many healthcare benefits for patients. The complexities associated with the prescribing, preparation and administration of injectable medicines means that there are greater potential risks for patients than with other routes of administration. Safe systems are needed to minimise these risks (NPSA March 2007). 2 Purpose The purpose of this policy and procedure is to inform staff of their responsibilities in relation to safe and secure procurement, handling and storage, prescribing, administration and dispensing of injectable medicines to ensure that: All healthcare professionals involved with the use of injectable medicines understand the standard procedures for dealing with these medicines and follow these procedures at all times. All legislation and guidance is adhered to with respect to injectable medicines. Risks associated with the incorrect procurement, prescribing, preparation, administration, monitoring and storage of injectable medicines are reduced to a minimum. 3 Scope This policy and procedure applies to all members of staff at Wirral University Teaching Hospitals (WUTH) who handle injectable medicines in any way (e.g. procuring, prescribing, supplying, administering, disposal and transportation), irrespective of their grade or contract status. This policy covers the use of all injectable medicines except cytotoxic intrathecal injections, which are covered in the Trust s Intrathecal Chemotherapy Policy (Ref: 045f). This policy should be read in conjunction with the following Trust policies: Medicines Management Policy General (Ref: 045), Non Medical Prescribing Policy (Ref: 045a), Controlled Drugs Policy (Ref: 045b), Intravenous Potassium Policy (Ref: 045d) and Cytotoxic Medicines Policy (Ref: 045e) and Unlicensed Medicines Policy (Ref 045h). 4 Information Sources Information sources include: Primary source of administration information for injectable medicines: Electronic injectable medicines guide called Medusa is available via the Medicines Formulary, under Clinical Guidance on the Trust intranet or WUTH Medicines Guide available on the intranet under clinical guidance British National Formulary (BNF) Including Appendix 6 Intravenous additives (accessed via intranet, medicines formulary) British National Formulary for Children (BNFC) Alder Hey Injectable Medicines Guide (paediatrics only) available as an e- copy on the intranet Neonatal Unit Intravenous Guidelines available as an e-copy on the intranet Paediatric Procedures for Injectable Medicines available on the intranet Wirral University Teaching Hospital NHS Foundation Trust Page 3 of 21

5 Product package insert for the injectable medicine Summary of Product Characteristics (SPC) available on electronic medicines compendium at Contacting the ward pharmacist available via bleep from 9am to 5pm Monday to Friday, Medicines Information on extension 5126 available 9am to 5pm Monday to Friday or the on-call pharmacist via bleep outside of the above hours. WUTH Critical Care Guidelines, available as an e-copy on the intranet under clinical folder. Royal Marsden Hospital Manual of Clinical Nursing Procedures, a link is available on the hospital intranet Gravity controlled infusion medicines guideline. Available on the Trust intranet, in clinical guidelines, injectable medicines. If staff who are involved in the prescribing, preparing, administration or monitoring of injectable medicines are unclear about any aspect of this policy, then it is imperative that they clarify any issues before proceeding. Below are some sources of information. 5 Education & Training 5.1 Prescribing All staff authorised to prescribe injectable medicines must deem themselves competent to do so. Junior medical staff must have attended training provided by the clinical skills team. Non-medical prescribers must prescribe in accordance with Trust Non-Medical Prescribing policy (Ref: 045a) available on WUTH intranet. 5.2 Preparation and Administration Prior to being eligible to prepare and administer injectable medicines, all nursing staff at WUTH must have completed the injectable medicines training sessions provided by the clinical skills team. This consists of one full day of training for new staff as part of the safer use of medicines course day. In children s areas staff must attend an annual update with the key trainer. If the skill is not used for more than six months then re-attendance at the safer use of medicines course is necessary. F1 doctors will also undergo training in injectable medicines by the clinical skills team. Doctors who are administering injectable medicines must deem themselves competent, if they are not confidant in administering an injectable medicine this should be escalated to a colleague. Note: For anaesthetists, training in the administration of injectable medicines is an inherent part of their role and therefore training has already been provided - additional sessions by the clinical skills team are not required. Wirral University Teaching Hospital NHS Foundation Trust Page 4 of 21

6 For any other route (e.g. epidural, intraarticular, intraocular, etc.) individual practitioners will require specific training in the preparation and administration of the injectable medicines via this route and have proven competence. Pharmacy staff preparing injectable medicines within the Pharmacy Aseptic Unit must have undertaken the appropriate training programme and must undertake regular competency assessments. 6 Prescribing Injectable Medicines General Medicines should be given by injection only when the practicality and appropriateness of other routes of administration have been excluded. The use of this route should be regularly reviewed in favour of switching to alternative routes of administration, e.g. enteral or transdermal as soon as clinically possible. Injectable medicines must be prescribed according to section 7 of the Trust Medicines Management Policy General (Ref: 045). In summary the following details must be present on all prescriptions for injectable medicines: Patient s name NHS number and hospital number Prescriber s signature (electronic or printed) On paper prescriptions the prescriber s printed name or GMC number Approved name of the medicine and diluent or infusion fluid Dose and frequency of administration Date Route of administration Rate of administration: for bolus injections state the duration, for infusions state the rate of infusion in ml per hour and duration. Allergy status of patient (check primary prescription and/or the electronic prescribing system) Weight (when dose is based on patient weight and in children s areas) Note: it is important if any calculations are required that the prescriber has done these so the prescription reads the number of ml per hour to be given. For example: If a patient requires rifampicin 300mg in 500mLs over two hours, the rate of infusion is 250mL per hour. In addition where relevant, the prescription, or a readily available local protocol, must specify the following: Generic name, formulation and when clinically appropriate brand name, (required when there is a difference in dose between products e.g. amphotericin or products such as immunoglobulin when the same brand should be used for the full treatment course), of the injectable medicine. Concentration or total quantity of medicine in the final infusion container or syringe Name and volume of diluent and/or infusion fluid Stability information to determine the expiry date of the final product if less than 24 hour expiry Date on which treatment should be reviewed (if not a stat dose) Arrangements for fluid balance or clinical monitoring should be made on an individual patient basis and according to local protocol and clinical need Wirral University Teaching Hospital NHS Foundation Trust Page 5 of 21

7 The appropriate intravenous site for administration e.g. must the medicine be administered via a central line. When two or more prescription charts are in use, it is essential that they are cross referenced so that practitioners are aware of all prescribed medicines, e.g. labelling 1 of 2 and 2 of 2. This includes patients who are registered on the electronic prescribing system as inpatients. Where patients are registered on the electronic prescribing system but are in clinical areas that do not utilise the electronic prescribing system for prescribing, such as day units, critical care and outpatient departments, then injectable medicines should be prescribed on the WUTH parenteral prescription chart or other appropriate prescription form or care pathway. Certain medications have a specific prescription charts, these include: Parenteral cytotoxic medication must be prescribed on a green cytotoxic chart Patient Controlled Analgesia (PCA) must be prescribed on a PCA chart (and on the electronic prescribing system) Epidurals must be prescribed on an epidural chart Insulin must be prescribed on an insulin prescription chart (and on the electronic prescribing system as see chart) Glucose, potassium and insulin (GKI) infusions must be prescribed on the purple GKI prescription form. More details on prescribing specific injectable routes can be found in: Section 8.1 for intravenous injections Section 9.1 for intramuscular and subcutaneous injections 7 Preparation of Injectable Medicines General 7.1 Policy and Procedural Guidance For adult patients: WUTH uses the Royal Marsden Hospital Manual of Clinical Nursing Procedures, a link is available on the hospital intranet. Full procedures can be found detailing how to: Withdraw medicines from single-dose ampoules (solution and vial) Withdraw medicines from multidose vials Add medicines to infusions Dilute medicines in syringes for use with a pump or in a syringe driver For paediatric patients: WUTH uses locally developed paediatric procedures. These are available via the hospital intranet, WUTH intranet / Trust-wide policies and procedures / clinical procedures / paediatric procedures. Insulin: All regular and single insulin (bolus) doses must be measured and administered using an insulin syringe or commercial pen device. When preparing infusions containing insulin such as a GKI infusion, an insulin syringe must be used to measure the required insulin dose. Insulin infusions should not routinely be prepared Wirral University Teaching Hospital NHS Foundation Trust Page 6 of 21

8 on wards; pre prepared syringes of insulin 50 units in 50mL are made by the pharmacy aseptic unit. 7.2 General Preparation Principles Medicines must be prepared in clean and uncluttered areas. Staff must be as free from interruption and distraction as possible. Where possible, preparation should take place in an area dedicated to this process away from sinks, sluices, food and drink. All materials and equipment must be assembled before starting the procedure, this includes: prescription sheet and record of medicines previously given, Medicine ampoule(s)/vial(s), diluent, infusion fluid, syringe(s), needle(s), alcohol wipes, disposable protective gloves, apron, appropriate labels clean re-usable plastic tray with sharps bucket for waste disposal. Clean hands according to the Trust Clinical Governance Standard 13. Put on a pair of disposable protective gloves. Use a 70% alcohol wipe or spray to disinfect the surface of the plastic tray. Use an aseptic non-touch technique (i.e. avoid touching areas where bacterial contamination may be introduced, such as syringe-tips, needles, vial tops and bungs). Never put down a syringe attached to an unsheathed needle. A blunt filter needle should be used to draw up from a glass ampoule. A blunt fill needle may be used when drawing up via a bung or a plastic ampoule. Prepare the injection by following: The Medusa Injectable guideline (available on the intranet) The manufacturer s product information or local guidelines The Royal Marsden Hospital Manual of Clinical Nursing Procedures (available on Trust Intranet) Paediatric procedures (paediatrics only) More details on preparing specific injectable routes can be found in: Section 8.1 for intravenous injections Section 9.1 for intramuscular and subcutaneous injections Beware of the risk of confusion between similar looking medicines packs, names and strengths. Read all labels carefully. 7.3 Checking of Injectable Medicines Prior to Administration All injectable medicines must receive an independent second check against the prescription and patient (excluding low molecular weight heparin in pre-filled syringes for VTE prophylaxis) Persons authorised to provide a second check The following people may provide a second check: Registered nurse or registered children s nurse Registered midwife Registered medical practitioner or dentist Pharmacist Wirral University Teaching Hospital NHS Foundation Trust Page 7 of 21

9 Registered operating department practitioner (ODP) only in theatre areas with the appropriate training where the person preparing the medicine is a registered medical practitioner Nurse or midwife in training or a student under the supervision of a registered practitioner i.e. the student nurse is involved in the check in an observational capacity only. Other professional staff groups in specific clinical areas provided they have undertaken appropriate training, e.g. radiographers, pharmacy technicians Prescription check required before administration Both practitioners must check the details of the prescription: Patient s name, date of birth Patient s weight (where necessary e.g. treatment doses of LMWH and paediatrics) Patient s allergy status is complete on the primary prescription Hospital or NHS number Approved drug name Dose, route and frequency of administration Administration details, including infusion fluid and infusion time. Signed and dated by the prescriber In children s areas and for controlled drugs both practitioners must go to the beside to confirm the patients identity The person administering the medicine must confirm that the dose is required and has not already been administered. Prior to preparing the medicine, both practitioners must independently check any calculations required on the prescription (e.g. volume of medicine to give the prescribed dose). If the calculation is complex, write it down and obtain an independent check by another qualified healthcare professional (as listed above) and file in the patient s medical record Medication Check Prior to Administration For each medicine container, diluent, infusion fluid and item of equipment to be used the following must be checked by both practitioners: Expiry dates of all products used in the preparation Damage to containers, vials or packaging Infusion containers must be checked for particulate matter Storage is as recommended (e.g. in the refrigerator) Formulation, dose, diluent, infusion fluid, route and rate of administration correspond to the prescription and product information Patient has no known allergy to the medicine That you understand the method of preparation. There should be sufficient information available for you to prepare the product Clinical Emergency In clinical scenarios whereby the patient requires emergency intervention, restorative injectable medicines may be administered without a 2 nd check as delay in therapy may be more hazardous to patient safety. However, parent ampoules/syringes should be retained for a retrospective check. Wirral University Teaching Hospital NHS Foundation Trust Page 8 of 21

10 7.3.5 Anaesthetics In the theatre complex the anaesthetist works closely with an Operating Department Practitioner (ODP), forming a highly specialised team. Unlike in other clinical areas this team is involved in both prescription and administration of medication. The anaesthetist employs a number of risk reduction strategies in addition to specific anaesthetic colour coded labels (see 7.5.) The anaesthetist records administration of all medication on the anaesthetic chart, in line with AAGBI guidelines. The anaesthetist may also prescribe additional medication such as analgesia on this chart, for nursing staff to administer in recovery. The conduct of anaesthesia regarding the 2nd check is currently awaiting national guidance through discussions between the NHSE and the Royal College of Anaesthetists and is currently outside the scope of this policy. Once these guidelines are published this policy will be updated. It is incumbent on the anaesthetist to select, check, draw up and administer intravenous drugs correctly. 7.4 Labelling Injection and Infusion Containers (excluding theatre areas) All injections including flushes and infusions should be labelled immediately after preparation. Exception: For syringes intended for immediate push (bolus) or flush administration by the person who prepared them if, once prepared, the injection does not leave their possession. If preparing two injections for administration at the same time then the syringes must be appropriately labelled. No operator should be in possession of more than one unlabelled syringe at any one time. Only labelled syringes are to be fitted to a syringe driver or similar device. The use of flag labelling should be used to ensure that volume graduations on small syringes are not obscured. Yellow labels are used on injectable medicines prepared in clinical areas, (other than for epidurals) and should be applied to the front of the infusion bag or the barrel of a syringe. Both practitioners must check that the label contains the following information: Name of the medicine Strength Route of administration Diluent and final volume Patient s name Expiry date and time (this must not exceed 24 hours after preparation) Name of the practitioners preparing and checking the medicine These labels are stock items in all clinical areas and are supplied on top up from pharmacy. 7.5 Labelling Syringes in Theatre Areas This must be done in accordance with Syringe Labelling Standards May 2003 and its subsequent update in 2014 produced by the Royal College of Anaesthetists, the Association of Anaesthetists of Great Britain and Ireland, the Intercollegiate Faculty of Accident and Emergency and the Intensive Care Society. This document specifies what Wirral University Teaching Hospital NHS Foundation Trust Page 9 of 21

11 label colour is to be used for what class of injectable medicine and has provided consistency throughout the UK. It is generally for use in patients in theatres where they are under the direct care of an anaesthetist. These labels are ordered by theatre staff from Henleys Medical Supplies Ltd. 7.6 Preparation of batches of medication Batches of the same medicine for a number of patients or for repeated doses should not be prepared in advance of when the dose is due. Nursing staff should not administer a medication prepared by another nurse and should always prepare the injection immediately before administration. 7.7 Expiry All injectable medicines prepared in clinical areas must be used immediately and should not be stored for use at a later time. An infusion prepared on the ward may only be infused for a maximum of 24 hours (less if pharmaceutically required or stability information dictates e.g. propofol infusions should be administered for a maximum of 12 hours). If therapy is to continue and there is a proportion of the infusion remaining after 24 hours then it should be discarded and a new infusion prepared and administered. All infusions should be checked prior to administration to ensure they are free of haziness, particles and discolouration. Sodium chloride 0.9% bags are used on critical care as flushes for arterial and central lines; these may be administered for 72 hours. No further additions are to be made to an infusion bag once an infusion has started or to a preparation provided in a ready to use form from the pharmacy aseptic unit. No additions should be made if the fluid is blood (or blood products including immunoglobulin s), plasma, mannitol, gelatins e.g. Isoplex, sodium bicarbonate, potassium or nutrition solutions. 7.8 Stability and Compatibility Administration details should be confirmed for all injectable medicines; if medicines require reconstitution or addition to a fluid then compatibility details must be confirmed to ensure an appropriate fluid is used. Medusa (available on the intranet) is recommended as the first line information source. If the medication has been verified by a pharmacist then it may be assumed that an independent check of the infusion fluid and compatibility has been carried out. If two or more additives are prescribed for use within one infusion fluid, it is essential that the stability and compatibility are checked using Medusa or contacting pharmacy. It is not usually advised to administer more than one medicine intravenously in the same infusion bag, exceptions include GKI infusions. If more than one medicine is going to be administered via the same cannula concurrently then the compatibility of the two infusions should be checked before administration using Medusa or by checking with pharmacy (there is also compatibility information on the critical care guidelines). The compatibility of medicines administered as a subcutaneous infusion in a single syringe should be checked with pharmacy or palliative care. Wirral University Teaching Hospital NHS Foundation Trust Page 10 of 21

12 7.9 Products Supplied from Pharmacy Aseptic Services Unit All injectable medicines prepared and supplied in a ready to use form from the pharmacy aseptic unit will be labelled appropriately and will not require additional labels to be added in clinical areas. The label will always include expiry details. All cytotoxic medicines, monoclonal antibodies and parenteral nutrition fluids for administration are to be supplied by pharmacy. These preparations must never be prepared, or further additions made, outside of the Pharmacy Aseptic Services Unit. 8 Administration of Injectable Medicines General 8.1 Policy and Procedural Guidance For adult patients: WUTH uses the Royal Marsden Hospital Manual of Clinical Nursing Procedures which are available on the hospital intranet. For paediatric patients: WUTH uses locally developed paediatric procedures. These are available on the WUTH intranet / Trust-wide policies and procedures / clinical procedures / paediatric procedures. Both of these sets of procedures provide the required information for: Administration of drugs by direct injection, bolus or push Administration of drugs by intermittent infusion Administration of injections Administration of intravenous medicines by continuous infusion 8.2 Staff Authorised to Administer an Injectable Medicine All staff who have completed the injectable medicines course provided by the clinical skills lab at WUTH or have satisfactorily demonstrated competence in parenteral administration of medicines may administer injectable medicines provided the checks listed in 6 are carried out. Student nurses may not administer injectable medicines. All F1 doctors who have attended training by clinical skills in administration of bolus medication and flushes. All other doctors who deem themselves competent to administer an injectable medicine. Under no circumstances should any practitioner administer an injectable medicine that has been prepared by another practitioner in a clinical area unless they have witnessed the preparation themselves. 8.3 Before Administering Injectable Medicines Explain and discuss the procedure with the patient. Wirral University Teaching Hospital NHS Foundation Trust Page 11 of 21

13 When injectable medicines are given in a child s home, by the Hospital at Home service, medicines must be checked by an authorised second healthcare professional in the hospital and transported thereafter in a sealed bag. The administration should be checked by the parent. Prime the device according to the appropriate policy for the access device being used immediately before starting an infusion (e.g. WIVAG guidance, central line guidance or the relevant paediatric procedure). For intermittent or short infusions and continuous or long infusions make a record of the administration commencing on the electronic prescribing system and/or on the appropriate prescription chart on which the injectable medicine is prescribed. For bolus doses make a record of administration being completed. Check that an appropriate access device is in place. Attach appropriate administration sets to infusion containers carefully, on a flat surface and using the technique appropriate to the type of container. More details on the administration of specific injectable routes can be found in: Section 8.3 for intravenous injections Section 9.3 for intramuscular and subcutaneous injections Section 10 for other routes of injection Anaphylaxis All clinical areas involved in the administration of any type of medicines should have access to anaphylaxis treatment kits (yellow boxes). The kits will have ampoules of adrenaline 1 in 1000 for intramuscular administration, chlorphenamine 10mg and hydrocortisone 100mg ampoules for intravenous administration, these will form part of their ward medicines stock Reversal of Opiates and Benzodiazepines All clinical areas where opiates are administered should ensure that they have a stock of naloxone. All clinical areas where benzodiazepines are administered should ensure they have a stock of flumazenil. 8.4 After Administration of Injectable Medicines Ask the patient/carer to report promptly any redness, local inflammation or soreness at the injection site or discomfort of any sort Disposal Once injection administered or an infusion is commenced, discard the empty ampoules/vials from which the injection was prepared and any unused medicine. Ampoules or vials should never be used to prepare more that one injection unless specifically labelled by the manufacturer for multi-dose use. Wirral University Teaching Hospital NHS Foundation Trust Page 12 of 21

14 8.4.2 Monitoring Re-check the administration site for signs of leakage, infection or inflammation and continue to monitor the patient, contents of the infusion container and the rate of infusion according to the Trust policy relating to the particular access device being used Flushing For intravenous medicines, flush the device immediately before and after the administration of a medicine and between doses of different medicines administered consecutively, according to: WUTH Flushing peripheral and central intravenous lines prescribing guideline available on the Trust intranet Wirral Intravenous Access Group (WIVAG) guidelines for peripheral access available as an e-copy on WUTH intranet Wirral Intravenous Access Group (WIVAG) guidelines for central line access available in all clinical areas as an e-copy on the WUTH intranet (as with all injectable medicines, only staff who have had appropriate support and competency assessment and attended the injectable medicines course provided by the clinical skills lab can administer injectable medicines via central lines). Paediatric and Neonatal Intravenous Access Group guidelines for injectable medicine administration via access catheters. Peripherally inserted central catheters and broviac lines being used for total parenteral nutrition, consult the nutrition team protocols available from the nutrition support team WUTH paediatric clinical procedures 1.1 intravenous additives, 1.2 intravenous bolus doses,1.3 and 1.4 intravenous access to totally implanted venous access devices (TIVAD) these procedures are available as a paper copy in the appropriate clinical areas and on the WUTH intranet. 9 Intravenous Medicines 9.1 Prescribing Intravenous Medicines In addition to the general guidelines for prescribing injectable medicines section 6 the following apply for inpatients: Intravenous boluses and Intermittent intravenous infusions should be prescribed on the electronic prescribing system. Continuous infusions must be prescribed on the blue paper parenteral infusion charts and on the electronic prescribing system as parenteral medication see blue parenteral infusion chart as directed by the drug catalogue on the electronic prescribing system. Patients with diabetic ketoacidosis in paediatrics must have injectable medicines for this condition prescribed on a pink ketoacidosis prescription chart Note there is ongoing work to update the electronic prescribing system to accommodate prescribing continuous infusions; the date of implementation for this is unclear at the time of writing the policy. Wirral University Teaching Hospital NHS Foundation Trust Page 13 of 21

15 9.2 Post Administration of Intravenous Medicines After completion of an intravenous infusion or injection, flush the access device according to Wirral intravenous access group (WIVAG) or using paediatric and neonatal clinical procedures and infection control policies. Following an NPSA alert it is recommended as good practice in theatres/areas where anaesthetics are administered that after intravenous administration, the anaesthetist/nurse should ensure that the cannulae have been flushed through to remove any residual anaesthetic drug before patients are returned to recovery wards, or wards where they may be given further fluids or medication intravenously. The flushing of the cannulae should be documented. Whenever inotrope or vasopressor infusions are discontinued medical or nursing staff should draw back any residual medication and the then flush the line. 10 Subcutaneous and Intramuscular Medications 10.1 Prescribing All subcutaneous and intramuscular injections for inpatients should be prescribed on the electronic prescribing system or an appropriate paper prescription form or care pathway. There is a pink paper prescription for 24 hour subcutaneous infusions. 11 Medication via subcutaneous syringe driver At WUTH, the only approved continuous subcutaneous syringe driver is the McKinley T34 syringe driver. If a patient is admitted with a different syringe driver in situ a new prescription must be initiated to allow the device to be discontinued and a McKinley T34 syringe driver initiated whilst maintaining adequate symptom control. All staff using this medical device must have received the appropriate training provided by the key trainer/ Clinical Skills Centre. This training should be updated every 2 years Prescribing Medication via syringe driver should be prescribed on the McKinley T34 Syringe Driver Prescription and Monitoring Chart to a set volume of 23 ml and to run over a 24 hour period Preparation Syringe Driver and equipment required can be obtained from the central equipment library (CEL) on extension The Equipment supplied will include McKinley T34 Syringe driver and lockable box, 30ml BD Plastipak Syringes, additive labels, occlusive dressings, 9 vault battery, 100cm extension set and 2 x BD Saf-T-Intima 24g insertion devices. Wirral University Teaching Hospital NHS Foundation Trust Page 14 of 21

16 11.3 Administration For detailed guidelines on set up see competency document on intranet and the subcutaneous syringe driver guideline Monitoring of Syringe Driver Monitoring should commence on insertion, after 30 minutes, one hour and thereafter four hourly. Monitoring requirements are included on the prescription chart Discharge/transfer of patient with a syringe driver When a patient is discharged or transferred to another hospital, the following steps need to be taken; Follow protocol for discharge District nurse referral 14 day supply TTH Community drug card (PMAC) - faxed to district nurse. Note there are two different PMAC forms available; one for syringe driver and one for subcutaneous/intravenous. The PRN doses should be prescribed on the subcutaneous/intravenous PMAC. Inform CEL of discharge/transfer 12 Other Injectable Medicines For all other routes of administration of injectable medicines, follow the general information on prescribing, preparing, administering injectable medicines within this policy. See also separate guidance specific for chemotherapy and intrathecal chemotherapy. Staff administering injectable medicines via routes not specifically mentioned within this policy must be competent to do so. The individual departments responsible for the administration of injectable medicines via these routes must provide adequate training and competency assessment for staff responsible for performing the administration. It is the responsibility of the individual administering the injectable medicine to ensure that they have received the appropriate training and have up-to-date competency assessments. 13 Disposal of Sharps Sharps must be disposed of into the appropriate sharps container as detailed in Trust Waste Management Policy (Ref: 071). Careless disposal of needles, giving sets and cannulae is a continuing hazard for staff and may result in disciplinary action. 14 Clinical Incident Reporting An incident form, or care improvement form in paediatrics must be completed to report all incidents that occur involving injectable medicines at any stage of the process prescribing, supply, preparing, administering and monitoring. Wirral University Teaching Hospital NHS Foundation Trust Page 15 of 21

17 15 Procurement The pharmacy procurement department is responsible for purchasing all injectable medicines. The pharmacy internal Purchasing for Safety Risk Assessment procedure will be followed and the pharmacy department will perform a risk assessment to ensure that, when injectable medicines are procured, the quality and safety of the preparation is taken into consideration before a purchase is made. If a new injectable medicine is requested through the Drug and Therapeutics Committee, a risk assessment of this new drug must be carried out before use of this drug is implemented. When high risk injectable medicine products and procedures are identified, risk reduction strategies will be implemented to reduce the risk. If these methods do not sufficiently lower the risk then it will be added to the risk register. 16 Audit Compliance with this policy will be audited via the incident reporting system. 17 Definitions 17.1 Administration Devices Appropriate medical devices designed to mechanically or electronically regulate or control the administration of medicines by injection or infusion Aseptic Technique Handling technique designed to minimise the risk of microbial contamination of a sterile medicine during preparation Bolus (Push) Administration from a syringe of a small volume of a single dose of a sterile solution directly into a tissue, organ or vein, over a short period of time, usually between 30 seconds and 10 minutes. The required time for IV bolus administration varies between drugs. It is important to clarify the time required for a bolus injection of a particular drug prior to prescribing using a reference resource such as the current BNF or BNFC, summary of product characteristics for the drug in question, the Injectable medicines guide (MEDUSA) or the Alder Hey book of injectable therapy Diluent Any sterile injection solution, such as water for injection or sodium chloride 0.9%, commonly used to dissolve (reconstitute) or dilute a medicine immediately before administration. Wirral University Teaching Hospital NHS Foundation Trust Page 16 of 21

18 17.5 Flush, Flushing Solution A sterile solution of diluent such as sodium chloride injection 0.9%, used to purge (flush) access devices (e.g. cannulae) before and/or after injection of a medicine, or between injections of different medicines Infusion Administration, from a syringe or other rigid or collapsible container, of a volume of sterile solution in the form of an injectable medicine directly into a tissue, organ, vein or artery at a controlled rate. This infusion can be administered under gravity, by means of an electronic or mechanical pump or other means of rate control, over a defined period usually of at least 10 minutes Injectable Medicines Sterile medicines intended for administration by bolus injection or infusion by various routes of injection including intravenous, intramuscular and subcutaneous Risk Defined as the probability or likelihood that harm, damage or loss may occur, coupled with the consequence of that harm Second Check A second check involves a second qualified person checking the details of the prescription, selection, calculation, preparation and labelling of the medicine. In children s areas the second checker must also confirm the identity of the patient before the dose is administered. 18 Duties / Responsibilities 18.1 Director of Pharmacy and Medicines Management The Director of Pharmacy and Medicines Management is accountable for the systems and processes associated with medicines management on behalf of the Trust board of directors. Medicines management is governed through a series of Wirral-wide Trust committees and groups with responsibility for medicines issues All WUTH Staff The policy applies to all members of staff who handle injectable medicines in any way (e.g. procuring, prescribing, supplying, administering, disposal or transportation), irrespective of grade or contract status. Individuals have a professional responsibility to update themselves on this policy on a regular basis Ward / Department Managers It is the responsibility of ward / department managers to ensure that their nursing staff are made aware of this policy. It must be included in Trust competency training and local induction programmes. Wirral University Teaching Hospital NHS Foundation Trust Page 17 of 21

19 18.4 Prescribers It is the responsibility of medical staff and other WUTH approved prescribers to follow this policy when prescribing medicines. Prescribers are expected to attend corporate induction medicines management sessions and annual update sessions Nursing Staff It is the responsibility of nursing staff to follow this policy when administering medicines and ensure safe storage on wards and departments. Nurses must attend corporate induction medicines management sessions, appropriate annual mandatory medicines management sessions and have completed the intravenous additive course provided by the clinical skills team / key trainer Pharmacy Staff It is the responsibility of WUTH Pharmacy staff to follow this policy when involved in managing medicines and providing information. The policy is included in the induction of new staff and all staff are informed of any updates. 19 References The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6 th Edition. Blackwell Publishing Ltd, NPSA template standard operating procedure for use of injectable medicines. March NPSA multi-professional safer practice standard for injectable medicines. March 2007 Wirral Medicines Guide 6 th Edition. WUTH Paediatric clinical procedures available on the Trust intranet. Cheshire and Merseyside NHS North West Collaborative Intravenous Nursing Service (C.I.N.S) edition 8.4. WUTH pharmacy department standard operating procedure, PROCURE 01 - purchasing for safety risk assessment. Medicines Management Policy (2014) Wirral University Teaching Hospital NHS Foundation Trust Management of Diagnostic and Therapeutic Equipment (2011) Wirral University Teaching Hospital NHS Foundation Trust NMC Guidelines for Administration of Medicines (2006) Smiths Medical International Ltd (2005) Training Package for MS26 Syringe Driver Skills for Health (2007) CHS49,50 and 51 National Patient Safety Agency (NPSA), Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI). Feasibility of confirming drugs administered during anaesthesia, A qualitative study in pilot NHS sites, England and Wales. October 2010 Wirral University Teaching Hospital NHS Foundation Trust Page 18 of 21

20 Consultation, Communication and Implementation Consultation Required Authorised By Date Authorised Comments Equality Analysis Debbie Hughes 30 th June 0215 Initial Equality analysis completed Policy Group Pippa Roberts 7 th July 2015 Other Stakeholders / Groups Consulted as Part of Development Trust Staff Consultation via Intranet 11 th August - 25 th August 2015 Checked for workforce / development, medicines, finance, NHSLA standards or wider corporate implications. Date notice posted in the News Bulletin September 2015 Date notice posted on the intranet September 2015 Describe the Implementation Plan for the Policy / Procedure (Considerations include; launch event, awareness sessions, communication / training via DMTs and other management structures, etc.) Staff will be informed of the policy during corporate medicines management induction training, annual updates and through TIE brief. By Whom will this be Delivered? All staff involved in the medicines management process. Version History Date Ver Author Name and Designation Summary of Main Changes Feb Andrew Merriman, Aseptic Services Manager Feb Andrew Merriman, Aseptic Services Include section on checking injectable therapies for Manager administration within Hospital at Home. Nov Pharmacy Helen Nelson, Risk Management Weblink for the Royal Marsden Clinical Nursing Specialist, Medicines Management & Procedures updated. Feb Andrew Merriman, Aseptic Services Manager. There have been minor wording amendments made throughout the document. Major amendments have occurred with an additional section (12) being incorporated into the policy providing information on subcutaneous syringe drivers for adult patients. Section 4.3 amendment of definition of an I.V Bolus administration. Oct th February Simon Purcell, Lead Pharmacist Haematology Luca Galvani, Clinical Governance Assistant July Debbie Hughes, Critical Care Pharmacist Updated links to new Trust website. Updated Governance Groups and re-formatted to current Trust Policy templare. 5, 8.1, 8.3, 8.5, 9.1, 9.3, Wording amended- PCIS replaced with electronic prescribing system. Pharmacy technicians added as second checkers Subcutaneous syringe driver updated to the McKinley T34. Duplication removed Information sources updated Clarification of policy in theatre areas Second check now required prior to the administration of all injectable medicines (with the exception of prophylactic low molecular weight heparins). Maximum hanging time of all infusions whether Wirral University Teaching Hospital NHS Foundation Trust Page 19 of 21

21 prepared on ward or in pharmacy aseptic unit 24 hours. On critical care sodium chloride 0.9% infusion bags for arterial line flushes may hang for 72 hours. Wirral University Teaching Hospital NHS Foundation Trust Page 20 of 21

22 Monitoring Compliance with the Policy Describe Key Performance Indicators (KPIs) Target How will the KPI be Monitored? Which Committee will Monitor this KPI? Medication will be prescribed and administered in line 100% Via incident reports Pharmacy Clinical with the Trust Policy standards Governance Frequency of Review Annual Lead Pharmacy Clinical Governance Team Performance Management of the Policy Who is Responsible for Producing Action Plans if KPIs are Not Met? Which Committee Will Monitor These Action Plans? Frequency of Review (To be agreed by Committee) Director of Pharmacy and Medicines Management Clinical Governance Group Annual Wirral University Teaching Hospital NHS Foundation Trust Page 21 of 21