Blackpool Teaching Hospitals NH S NHS Foundation Trust Single Unit Mandatory Training Workbook Medicines Management Community Services, Clinics and Intermediate Care Bed Based Services Page 1
Learning Outcomes After completion of this work book and the accompanying test the staff member should be able to:- 1. Understand what medicines management means and why medicines need managing 2. Know how to obtain supplies of medications for patients in your care. 3. Understand the legalities of prescribing and authorisation 4. Know how to appropriately store and transport medication if necessary. 5. Know and have understanding of the 6 R s of medication administration and their contribution to ensuring safe medication administration. 6. Have an understanding of which are high risk medicines 7. Understand the process of delegation and the accountability for the registrant in relation to this. 8. Be able to safely dispose of appropriate medicinal products. 9. Understand the importance of identifying patients that may be taking alternative medicines and the potential impact on prescribed treatments. 10. Input and manage untoward incidents in relation to medication errors. 11. Understand the legal and professional accountability of controlled drugs. 12. Know how to access pharmacy personnel for advice as well as access the IT resources available in relation to pharmaceutical information. Page 2
What is Medicines Management? There is no single answer to this question. The concept of medicines management has evolved over a number of years in different places in the UK. Consequently, there are a number of different definitions depending on the circumstances and context in which the term is used. For example, the Department of Health s Hospital Medicines Management Framework (1) describes two specific components. These are clinical & cost-effectiveness and safe and secure handling of medicines. Whereas, the NPC document Modernising Medicines Management (2) gives a much broader definition. It describes medicines management as a system of processes and behaviours that determines how medicines are used by the NHS and patients. Rather than getting too bogged down in definitions, a simpler way of thinking about medicines management is that it is about enabling people to make the best possible use of medicines. This workbook covers the basic principles of medicines management however individual medicines and processes are not within the scope of this package. Prescribing is the most common therapeutic intervention in the NHS. The complexity, volume and cost of medicines are all increasing. Increasingly patients are being prescribed 4 or more medications. All medicines have the potential to cause harm to our patients. There is a considerable body of evidence that medicines management needs to be improved, whether this is from the point of view of patient safety, service efficiency or cost. Medicines are an integral part of modern disease management, whether they are used for prevention, treatment or alleviation of symptoms. The volume of medicines prescribed and their cost is increasing each year. Patient safety is paramount. Good medicines management can help reduce the likelihood of medication errors and hence patient harm. Medicines play an important part in promoting well-being, preventing ill health and managing disease. Medicines management is everybody s business. The likelihood of a patient being involved in a medication error increases by 65% if they are taking 4 or more medicines. Page 3
Medicines Management Training Medicines Management Training is classed as mandatory within the Trust for all staff that manage medication. You are required to attend face to face a full days training with the Medicines Management Specialist Nurse once in every 3 year period. For the other 2 years you will remain compliant by completing this workbook and passing the assessment. You must register with the Learning and Development Department for all provided training. Medicines Management Training is recorded on OLM (Oracle Learning Management). Once completed ensure you complete the Workbook Completion Statement at the end of the book. You must send a photocopy of this statement to Learning and Development for recording on your electronic staff record. Completion of the course/workbook/e-learning package or failure to complete the course/workbook/e-learning package will be recorded on your electronic staff record and will affect your competency to undertake the administration of medicines. If a medication error is made then training must be completed after that. Page 4
Section 1 Methods of supply and/or administration of medicines Methods of supplying and /or acquisition of medicines in a the community or in a clinic setting Medicines for use in clinic settings only are obtained from the Trust Pharmacy with the exception of permitted and appropriate patients own medicines. It is not acceptable for staff to acquire any medicines directly from companies/company representatives Medicines are supplied against a Pharmacy requisition to wards/clinics with this service. There is an ordering/delivery schedule for each service. Medicines supplied for use in clinical areas must not be used for the treatment of relatives, carers or friends of patients or for the treatment of hospital/clinic staff. Medicines to be administered using a patient-specific direction (PSD) are usually supplied by either BTH pharmacy or GP practice (e.g. vaccines). A PSD is a written instruction from a qualified and registered prescriber for a medicine including the dose, route and frequency or appliance to be supplied or administered to a named patient. Medicines supplied for specific, named patients must not be issued to other patients Medicines in the community setting are usually patients own and obtained by prescription (FP10), being generated by a prescriber and dispensed by a community pharmacist. Medicines to be administered using a Patient Group Direction (PGD) are usually supplied by either BTH pharmacy or GP practice (e.g. Flu vaccine) Pharmacy Access Weekdays 0845-1700 Saturday 0845-1700 Sunday 0845-1700 Out of hours:- The Pharmacy Department is closed. A Clinical Pharmacist will be available via switch board. This pharmacist will be able to give advice over the phone or occasionally dispense medications via the robots into the Emergency Drug Cupboard. If this is not possible they may attend to dispense from the department. Section 2 Dispensing Page 5
Doctors may in exceptional circumstances label from stock and supply a clinically appropriate medicine to a patient, against a written prescription, for self-administration or administration by another professional. When supplying under PGD, this should be from the manufacturer s original packs or over-labelled pre-packs so that the patient details, date and additional instructions can be written on the label at the time of supply. Health care professionals must not split packs. Page 6
Section 3 Storage and Transportation Storage For the storage of medicines in the community: Together with patient and carers identify a safe place for the storage of medications- clean, dry and out of reach of children and animals. If temperature sensitive, medication must be stored in a fridge. Clinic Based Services: With the exception of drugs for emergency use, all medicines must be stored in a locked drug cupboard, refrigerator or trolley secured to a wall, and must be kept under conditions which meet legal requirements and manufacturers recommendations. Temperature monitoring in clinic based services: The temperature of the room where medicines are stored must be monitored at least weekly using an approved digital thermometer that records maximum and minimum temperature reached. The maximum temperature reached must be recorded on an approved trust form. The thermometer must be reset immediately after the temperature has been recorded. Containers - Including bottles, boxes and mini grip bags These are filled and labelled by the Pharmacy staff. Contents of the containers must not be transferred to other containers, nor labels altered or endorsed in any way. Drugs for External Use All medicated products for external use must be stored in a locked cupboard separate from the drug cupboard that contains medicines for internal use. Drug Refrigerators in Clinic or Bed Based Services The temperature of medicine or drug fridges must be recorded each working day / daily. The temperature must be between 2-8 Degrees Celsius. The following details must be recorded on the daily temperature record sheet; Maximum temperatures, Minimum temperatures, Actual temperatures and Thermometer reset This is particularly important as some medicines require storage within a limited temperature range, for example, refrigeration of vaccines when maintenance of the cold chain has to be evidenced. Page 7
Transportation Transportation community settings Health care professionals may transport medication to patients homes, including controlled drugs, only in exceptional circumstances where there are no other means of the patients obtaining the medications, provided the health care professional is conveying the medication to a patient for whom the medicinal product has been prescribed, (for example, from a pharmacy to the patient s home). Transportation other settings BTH transport services deliver to specified bases on specified days. Page 8
Section 4 Standards for practice of administration of medicines Principles for the Administration of Medicines The basic checks before any medication is administered are the 6 R s:- RIGHT Patient RIGHT Drug RIGHT Dose RIGHT Route RIGHT Frequency RIGHT Date In order to exercise professional accountability, in the best interests of patients, the healthcare professional must: Know the therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contra-indications Be certain of the identity of the patient to whom the medicine is to be administered Be aware of the patient s care plan Check that the prescription and the label on the medicine dispensed by a pharmacist, is clearly written and unambiguous Have considered the dosage, method of administration, route and timing of the administration in the context of the condition of the patient and co-existing therapies Check the expiry date of the medicine to be administered Check that the patient is not allergic to the medicine before administering it Contact the prescriber or another authorised prescriber without delay where contraindications to the prescribed medicine are discovered, where the patient develops a reaction to the medicine, or where assessment of the patient indicates that the medicine is no longer suitable. In the case of the patient developing a reaction to the medicine, contact the medical practitioner without delay The health care professional must also be satisfied that the drug is given according to the appropriate Trust clinical procedures. Has received Trust approved training, supervision, and is competent to use medical devices that may be employed to deliver drugs to patients e.g. Syringe Drivers. Make a clear, accurate and immediate record of all medicine administered, stating the date and time of administration, the dose and route of administration; medicines intentionally withheld or refused by the patient, ensuring that any written entries and the signature are clear and legible Page 9
Where supervising a student nurse, midwife or ODP trainee in the administration of medicines, the signature of the student nurse, midwife or ODP trainee should be clearly countersigned by the supervising registered practitioner Some drug administrations can require calculations to ensure that the correct volume, or quantity, of medication is administered. In these situations, a second registered practitioner must independently check the calculation in order to minimise the risk of error. The use of calculators to determine the volume or quantity of medication should not act as a substitute for arithmetical knowledge and skill. It is unacceptable to prepare substances for injection in advance of their immediate use or to administer medication drawn into a syringe or container by another practitioner when not in their presence (NMC 2008 Standards for Medicines Management) In an emergency, where you may be required to prepare substances for injection by a doctor, you must ensure that the person administering the drug has undertaken the appropriate checks as indicated above. Authorisation / Prescribing Staff must only supply and administer medicinal products in accordance with one or more of the following processes: Patient specific direction (PSD) Patient medicines administration chart (may be called Medicines Administration Record sheet MARs). All medicines must be prescribed by a medical/non-medical prescriber. Patient group direction (PGD) Medicines Act exemption Homely remedy protocol Prescription forms A practitioner must not administer any medicine unless it has been correctly, legibly and legally prescribed, or working to an up to date PGD. Only a qualified medical or non-medical prescriber can legally prescribe a drug for a patient. In the absence of a valid prescription / authorisation or PGD, medicines must not be administered. The clinician must ensure the correct authorization has been completed legibly e.g. Medicines administration record or MARs. If in any doubt the registered health professional concerned must seek professional advice from the pharmacist, prescriber or a senior nurse before the drug is administered. Page 10
The registered health professional must, in administering any medicines, exercise professional judgement and apply knowledge and skill to the situation that pertains at the time. Patient Group Direction (PGD) A PGD is a specific written instruction for the supply and administration of a licenced medicine in an identified clinical situation. An increasing number of medications are now on patient group direction (PGD s). The department has to get these PGD s authorised by pharmacy. Each practitioner using these also has to sign to say that they have read all the drug information and are happy to abide by the PGD. A record must be kept in the clinical area. These PGD s vary from area to area depending on clinical need. High Risk Medicines The following medicines are considered to be High Risk and as such staff should take particular care when prescribing or administering: Anticoagulants Opioids Insulin, Anaesthetics, Epidurals Injectable Medicines, Chemotherapy / Cytotoxics ALL medicines that you are unfamiliar with Page 11
Section 5 Delegation A health care professional is responsible for the delegation of any aspects of the administration of medicinal products and they are accountable to ensure that the patient, carer, health care support worker or assistant practitioner is competent to carry out the task. Refer to the Trust procedure: Process for the Delegation of Clinical Tasks http://fcsharepoint/trustdocuments/documents/corp-proc-630.docx Page 12
Section 6 Disposal The Trust and staff have a legal obligation for the safe disposal of medicines. Inappropriate handling of waste can have considerable effect on the environment. The Environment Agency can issue fines or prosecute for incorrect disposal. Medication must never be disposed of down the sluice or sinks. Staff should refer to the Trust Procedure: Safe Disposal of Medicines CORP/PROC/583 and Health Technical Memorandum 07-01: Safe management of healthcare waste. All patients should be advised to dispose of unwanted medicines by returning them to the community pharmacy for destruction. Destruction of Controlled Drugs in Clinic & Bed based settings Denaturing is to destroy in such a way that the CD is rendered irretrievable so that it cannot ever be reconstituted or reused. The pharmacy department has researched methods of denaturing and recommends the following: Place the CD into an appropriately sized and medicinal sharps bin. Tablets crush before adding. Powders add direct. Liquids add direct. Ampoules empty contents in and then add the ampoule. Patches fold. Epidurals/PCAs etc. squeeze liquid out of syringes/bags and put giving sets/syringes into the medicinal sharps bin. Add one Gel Vac/Vernagel sachet per 1 litre of liquid. Immediately seal the bin. The disposal must be witnessed by another authorised nurse, midwife, ODP, pharmacist or doctor. The disposal must be recorded in the CDR and countersigned by both parties witnessing the destruction. Expired CDs must be disposed of by a Pharmacist. The pharmacist will be requested to attend the ward and remove the CDs and dispose of within pharmacy. The removal of the CDs will be documented and witnessed within the CD drug register. This provides a clear audit trail for the purpose of legislation and compliance monitoring. Refer to BTH policy on Safe Disposal of all Medicines http://fcsharepoint/trustdocuments/documents/corp-proc-583.doc Page 13
Section 7 Unlicensed medicines An unlicensed medicine is the term used to refer to a medicine that has no marketing authorisation. Occasionally unlicensed medicinal products are used for patients. These are supplied to meet the needs of individual patients. These are only used if no licensed medication is available to be used for patients. All unlicensed medications are supplied by Pharmacy. If an unlicensed medicine is administered to a patient, the manufacturer may not have liability for any harm that ensues. The person who prescribes and dispenses or supplies the medicine carries the liability. This may have implications for you in obtaining informed consent. A health care professional may administer an unlicensed medicinal product with the patient s informed consent against a patient-specific direction (PSD) but not against a patient group direction (PGD). Page 14
Section 8 Complementary medicines and alternative therapies Complementary medicines e.g. aromatherapy, herbal or homeopathic remedies are used for therapeutic purposes and require the same safeguards as other medicines. Leeches and larvae are included in this category. Health care professionals must have successfully undertaken training and be competent to practice the administration of complementary and alternative therapies. During a patient consultation regarding medication, it should be checked as to whether they are taking any complementary medications. These complementary medications may not be thought of as medicines by the patient so they may not initially mention them. They can however interact with the medications they are being prescribed and reduce the efficacy of them. For example:- Ginkgo Biloba should not be taken with Warfarin, Heparin or Ibuprofen (MHRA 2014). St John s Wort should not be taken with cardiac drugs, anti-coagulants, antidepressants and calcium channel blockers. Advice should be sought from a pharmacist to check that there is no interaction to the medications prescribed. Page 15
Section 9 Management of adverse events (Incidents or errors) Effects of Medication As a health care professional, if you make an error you must take any action to prevent any potential harm to the patient and report any untoward effects of medication to the prescriber or nominated deputy. Adverse drug reactions (ADRs) must be reported using the Yellow Card system which is in the back of the BNF or electronically (via on-line BNF/ BNFc). It is important that any incident involving medications is reported via the Trust Untoward Incident Reporting System. These should be reported within 24 hours of the incident occurring or when the incident came to light. When completing an untoward incident that involves the administration of a medicine using a medical device you must also include, the type of device and asset number, the name, dose/rate of the medicine and a clear description of the fault. Controlled Drug (CD) Errors Controlled drug incidents must be reported in the same way as other incidents. An Untoward Incident form must be completed for ALL actual and near miss CD incidents. They should be scored dependent on the harm caused to the patient. All incidents involving CD s must be classed as Level 3 and a Root Cause Analysis completed. If a discrepancy is discovered:- Balance should be rechecked by another person Recheck that all entries have been made and are correct Recheck the balance has been calculated correctly Check stock has not been stored elsewhere 5% difference is acceptable in oral medications If the discrepancy remains, the registered health care professional in charge of the clinic must be informed. If the discrepancy cannot be resolved the ward manager must be informed. If theft is suspected senior management must be informed including the Director of Pharmacy as the Accountable Officer. The Accountable Officer must be contacted directly if there are any concerns regarding the clinical use or management of CDs. The Accountable Officer (Director of Pharmacy) must be informed via the Untoward Incident Reporting System within 24 hours of ALL CD discrepancies/losses/incidents. Page 16
Section 10 Controlled Drugs Health care professionals should ensure that patients prescribed controlled drugs (CDs) are administered these in a timely fashion in line with the standards for administering medication to patients. Health care professionals should comply with and follow the legal requirements and approved local standard operating procedures for controlled drugs that are appropriate for their area of work. The following trust policy & procedure apply to all areas: Corp/Proc/302 Controlled drugs - Safer management of controlled drugs Corp/Pol/303 Controlled Drug Policy Controlled Drugs (CDs) Clinic Settings only The administration of CDs requires the double checking by 2 registered practitioners at all stages of the process. Signatures must be clear. All documentation relating to CDs are legal documents and must be managed as per legislation and Trust policy. Safe Storage and management of CDs No ward, theatre or department should store schedule 2 and 3 CDs unless there is an appropriately registered practitioner responsible for the safe and appropriate management of CDs in that area. The registered healthcare practitioner in charge can delegate control of access (i.e. key holding) to the CD cupboard to another, such as registered practitioners. However, legal responsibility remains with the registered practitioner in charge. All CD s must be stored in a designated CD cupboard, which complies with the statutory security conditions currently in force. There is no requirement for the CD cupboard to be within another cupboard, neither is there a requirement for an indicator light to be fitted (however both these practices are acceptable). Where epidural injections and/or infusions are used, these must be stored separately from other parenteral preparations. The CD cupboard must be kept locked when not in use. The CD key must not be common to any other key in the department. Page 17
The CD cupboard must be used solely for the storage of CDs and not for any other medication or items. The CD Key must be kept separate to the main clinic keys. Identification of potential abuse in CDs Incidents in relation to CDs must be reported within 24hours to the Accountable Officer (Director of Pharmacy), Accountable Officer via the Untoward Incident Reporting System. Incidents involving CDs are serious incidents. The score of the incident is determined by the harm caused to patients, staff or the Trusts integrity. Consideration must be made into the nature of the incident and processes involved, deliberate abuse and / or concealment of incidents. Two members of staff must check CD stock every 24 hours or at shift change. One must be a registered nurse, Midwife, Doctor, Dentist, Dental nurse, Pharmacist or ODP (Operating Department Practitioner). The 2nd checker may be a Registered Nurse, Midwife, Doctor, Dentist, Dental nurse, Pharmacist, ODP or Student Nurse (UCLAN students only - who have undertaken Intermediate Medicines Management training at the end of their second year) willing to undertake the task and knowledgeable about CDs and their accountability. All cupboard contents and all Controlled Drug Registers must be checked. For oral liquid CDs, an approximation of balance will suffice, as the action of pouring liquids out to measure will cause discrepancies. However, balances must be correct at the start of a new bottle. Contact the pharmacy to make any corrections to balances. The two checkers must check every drug in the CD cupboard every day and sign on each page of the CDR that the check has been performed. Pharmacy staff will check the CD register balances against CD cupboard stock, and a sample of entries made against corresponding CD requisitions every 3 months. Management of controlled drugs stock and stationary Restricted Drug Registers are physically a Controlled Drug Register (CDR) but used for the purpose of monitoring high risk drugs e.g. High Strength Potassium injections, Midazolam 10mg/2ml. No cancellation, obliteration or alteration of any entry may be made. An entry made in error must be bracketed and endorsed error in the margin, signed, dated and as good practice countersigned by a witness. Entries must be chronological. Page 18
Every entry must be in ink. All records must be stored for two years from the date of the last entry in the register. Management and Investigation of discrepancies See Section 6 Destruction and disposal of CDs in Clinic Settings See Section 6 Controlled Drugs within Community based services Safe storage and management of CD s Together with patient and carers, identify a safe place for the storage of controlled drug medications; ideally in a clean, dry place out of the sight and reach of others (consider children and animals). In a patients home where a clinician is administering a controlled drug which has already been prescribed and dispensed to that patient the requirement for a second checker/ signatory should be based on local risk assessment. Community Pharmacy Just in Case drug scheme Just in Case medicines are held by specified pharmacies in the community. Please ensure you are familiar with the pharmacies in your Locality by accessing the link below or discussing this with your team: http://fcsharepoint/trustdocuments/documents/corp-proc-592.docx Safe disposal of controlled drugs All patients should be advised to dispose of unwanted medicines (including controlled drugs) by returning them to the community pharmacy for destruction. Community / Clinic settings - Student Nurses and Controlled Drugs This only applies to UCLAN students at present On completion of the second year pre-registration student Intermediate MedicinesManagement training day, and successful completion of the Controlled Drug Supervision Record, the preregistration students may: (At the discretion of the supervising nurse, based on knowledge and confidence of pre-registration student ) Participate in the checking of controlled drug stock as a 2nd checker. Page 19
Administer a Controlled Drug (excluding the administration of intravenous controlled drugs) under supervision by those authorised and registered staff that accepts responsibility and accountability for the process. Participate and witness the disposal of controlled drugs in hospital bases only. Complete documentation including the controlled drugs register under supervision. Audits There are a variety of audits carried out by Pharmacy to look at the safe handling and administration of medicines. The following are audits that are carried out:- Medicines management Audit (yearly) The Lead Pharmacist Community Health Services audits community clinics for the management of medicines against Trust procedure: http://fcsharepoint/trustdocuments/documents/corp-proc- 593.docx NPSA 15 Audit (yearly) This audit focusses on 15 key areas. These areas were identified by the National Patient Safety Agency (NPSA) as being involved in a high number of adverse patient incidents. A series of questions are sent to each clinical area based on these. The clinical areas then have to ensure that staff are aware of how to identify and act upon the specifics for each alert. For example staff should be aware that a purple syringe should be used for oral medications rather than a hypodermic syringe.all areas within the Trust including ALTC are audited to ensure compliance. Those alerts that are not applicable are recorded as such. Page 20
NPSA Alerts Midazolam Midazolam 10mg/ 2mls (mainly used in palliative and critical care) Needs a risk assessment before an area can stock it Staff need to be aware that flumazenil if the reversal agent Flumazenil has a shorter half-life than midazolam so additional doses may be needed Paraffin Topical paraffin based products pose a fire risk Patients often have large amounts of these emollients on their skin along with bandages. Risk of ignition if patient is exposed to naked flame Severe burns can result from this Patients need verbal and written advice on the first occasion these are used and then advice reiterated afterwards Paraffin warning posters to be displayed in all areas where paraffin used Injectable Medicines Higher risk of patient harm from injectable medicines due to fast action Errors can be as high as 49% for IV Medications Risk assessment should be in place for all injectable medicines given in clinical areas and action plans for these Information sources available in paper and electronic form on how to handle medication Main error time is during administration Ensuring staff are carrying out drug calculations safely Low Molecular Weight Heparin Patient weight must be recorded on all prescription charts and ever effort must be made to ensure this weight is accurate. Page 21
Weight needs to be monitored throughout treatment to ensure that the correct dose is given Under dosing increases risk of thromboembolic events and overdosing increases risk of bleeding Most common errors are no weight recorded or under / over dosing Risk of adverse effects increased in patients with renal impairment Need to check creatinine clearance level before patient receives the 2nd dose. Bowel Preparation Frail and debilitated elderly patients, children and those with contraindications are at high risk Full explanations need to be provided before the patient takes them and a clinical assessment Staff need to be aware of the contraindications such as patients on diuretics It may also modify the absorption of oral medications such as antibiotics or anti epileptics. Oral Medications via Incorrect Route There is an increased risk of wrong route of administration if oral medication is not given using an oral/ enteral syringe. Patients have died after receiving oral medication through central lines because the medication was placed in a hypodermic syringe. Oral syringes are coloured purple to make them distinctive from hypodermic syringes so they cannot be confused Hypodermic syringes should never be used for oral / enteral medication Anticoagulant Therapy All staff working with anticoagulants should have the necessary competence and knowledge Yellow monitoring books should be given to the patient on commencement of therapy Patients should get verbal and written advice at the start of the therapy as well as at discharge and at their first clinic appointment Patients should be aware of the importance of INR monitoring Epidurals Certain medications can only be administered via epidural form. There have been patient deaths resulting from epidural medications being given intravenously Epidurals are only in use in certain areas of the Trust Staff who are involved in these have specific training and competencies completed Page 22
Epidurals if stocked in a clinical area must be stored separately from other medication. They must also be clearly labelled as epidural use only Vaccine Cold Storage If vaccines are incorrectly stored their efficacy can be reduced causing vaccine failures Freezing of vaccines can cause cracking of the syringe leading to potential contamination Vaccines should be stored in a specified vaccine fridge This fridge should be between 2-8 degrees Celsius The fridge temperatures should be regularly monitored Intravenous Flush Solutions of Heparin When indicated Heparin 10units/ml and 100units/ml is available as a flush but only for implantable devices Therapeutic dose of heparin is 1000 units/ml Usually only stock heparin products of 1,000 units /ml or less These are restricted to use in maintenance of implanted, tunnelled or ported catheters Once this item is drawn up the syringe should be labelled immediately This concentration of heparin should be stored separately from other heparin concentrations Lithium Therapy It is important to ask patients if they are on Lithium therapy Patient on Lithium have a purple book which contains details of their therapeutic Lithium levels Lithium levels can be altered by other medications and the patient can become lithium toxic Lithium levels can only be taken within 12 hours of the last dose Opioid Medication It is important to check what current medication a patient is taking before administering opioids to them It is important to check that the dose given is not greater than 50% higher than their usual dose Page 23
Previous transdermal patches should be removed before placing another one on the patient. The location of these should be noted and sites rotated Staff should be familiar with naloxone as the antidote for opioids. Naloxone has a shorter half-life than opioids so repeated doses may need to be given CORP/POL/530. Omitted Medicines There is a list a critical medicines that should not be omitted due to risk of adverse incident to the patient Some medications are time critical such as Parkinson s medications and must be given on time every time to prevent the patient s condition deteriorating Medication Loading Doses Staff must to be aware of the differences between loading and maintenance doses to ensure that the appropriate one is prescribed and administered. Patient harms have resulted by patients being given several loading doses rather than a loading dose followed by a maintenance dose The main medications to be aware of are:- Digoxin Phenytoin Amiodarone Warfarin Aminophylline Acetylcysteine Information on the correct doses for these medications can be found in the BNF and the online resources available through the medicines management site on the Trust Intranet. Risk of Hyponatremia Children and elderly patients have suffered serious neurological injuries from receiving hypotonic solutions 0.18% sodium chloride with glucose 4% dextrose solutions are removed from most clinical areas These are restricted to critical care and specialist areas because of the risk of hyponatremia If stored in a clinical area it must be labelled as not to be administered to children Page 24
Policies and Procedures There are a wide array of policies and procedures relating to medicines management. All of these can be found in the document library available via the Trust intranet. The policies belonging to Pharmacy can be found in the Medicines Management home page also. There are a wide variety of medication policies and staff should be familiar with the ones that are relevant in they are working in. Some of the more general use policies available are:- Administration of Medicines CORP/PROC/307 Administration of Medicines / Medicines Management for Pre-Registration Student Nurses, Student Midwives and Trainee Operating Department Practitioners CORP/POL/304 Clinical Trials Involving Pharmaceutical Products CORP/Guid/302 Controlled Drug Policy CORP/PROC/303 Controlled Drug Safer Management of Controlled Drugs CORP/PROC/302 Custody and Safe Keeping of Medicine Keys CORP/PROT/302 Emergency Access to Medicines CORP/PROT/300 Management of Medication Errors CORP/PROT/310 Medicines Policy CORP/POL/300 Non Medical Prescribing Protocol CORP/PROT/509 Patient Group Directions CORP/POL/044 Prescribing a Zero Tolerance Approach to Safe Prescribing CORP/PROC/301 Safe and Secure Handling of Medicines Ordering, Receipt, Storage and Distribution on the wards CORP/PROC/593 Safe Disposal of all Medicines CORP/PROC/583 The Administration of Authorised Medicines, the 2nd Checking of Intravenous Fluids, and the Assistance with the Management of Controlled Drugs by Qualified Assistant Practitioners CORP/POL/446 Page 25
Information Resources Pharmacy Every day except Christmas day (09.45 17.00) 01253 954780 Medicines Information (0900-1700, Monday-Friday) 01253 953791: Clinical Pharmacist advice on medicines Speciality Pharmacists via Bleep: These can be contacted in normal working hours via bleep. The bleep numbers are available on the Medicines Management page or contact via switchboard. Out of hours the on call pharmacist can be contacted via switch board (Emergency only). Medicines Management Nurse (weekdays 0845-1700): Offering nursing advice on medicines management issues and professional guidance. Able to come into the clinic and help with audit completion as well as to help ward staff ensure that they are complying with medicines management practice. Also available to answer queries on patient and safety risk in relation to medicines. Medicines management advice is also available from the NMP Division Lead for ALTC by contacting Blackpool Stadium 951685. Page 26
Intranet Site: Document Library This contains guidance on all aspects of medicines management within the Trust. You need to be aware of the policies and procedures that are specific to your clinical area. Medicines Management Intranet Home Page:- This is accessible via the Intranet (green box on home page). This contains information in relation to medicines and medicines safety. This area also has useful e-learning resources. http://fcsharepoint/divisions/clinicalsupport/medicinesmanagement/pages/default.aspx Resources: ebnf Electronic version British National Formulary (paper version available on ward also) http://bnf.org/bnf/index.htm ebnfc- Children s version http://bnfc.org/bnfc/index.htm EMC Electronic Medicines Compendium (For healthcare professional information and Patient Information Leaflets) http://www.medicines.org.uk/emc/ Injectable medicines guide- http://bfwnet/departments/medicines_management/inject.htm UCL Injectable Guide Injectable medicines guide in paper form available on ward. Page 27
Now you have read the Medicines Management Work book Complete the following multiple choice questions to ensure that you have all the knowledge and information required to manage medicines safely in our Trust. Once you have completed the workbook sign the declaration form. Your Manager/Team Leader is required to witness your signature. Once completed ensure you complete the Workbook Completion Statement at the end of the book. You must send a photocopy of this statement to OLM for recording on your electronic staff record. Page 28
Questions and multi choice answers for Medicines Management Please circle your answers as you go through the questions and the pass mark must be 100%. Your manager can request the answers from L&D. As a Qualified Health Professional you are accountable for your own knowledge, therefore if you find you are not meeting the pass mark you must address this with your manager. 1. Which statement best facilitates the safer administration of medicines? a) The Authorisation is clearly written as per policy but not signed, I am familiar with the medicine and its normal dosage, and I have confirmed the identity of the patient and their allergy status. b) A verbal instruction has been given for the medicine via telephone, I am familiar with the medicine and its normal dosage, and the patient has taken the medicine before and had only a mild reaction. c) The authorization is written correctly as per policy, I am familiar with the medicine and its normal dosage, and I have confirmed the identity of the patient and their allergy status d) The authorization is written clearly as per policy, I have never seen this medicine used via this route before, and I have confirmed the identity of the patient and their allergy status. 2. Who has the authority to sign a medicines administration record sheet (MARs)? a) Medical or Dental Prescriber/Practitioner b) Team Leader c) Non-Medical Prescriber d) Clinical Specialist 3. Which of the following are high risk medications? a) Warfarin b) Anti-inflammatories c) Insulins d) Steroids Page 29
4. What would you document when administering any medication by any route? a) Date and Time b) Medication administered c) Sign the administration sheet d) Reason if medication not administered e) Any adverse events f) All of the above 5. What is a Patient Group Direction (PGD)? a) A map of the hospital b) Specific written instructions for the supply and administration of a named medicine or vaccine in an identified clinical situation c) A list of medicines that may be supplied without a prescription 6. What are your main responsibilities when administering medicines to patients? a) To ensure the patient takes the medicine correctly and safely b) To administer the medicine safely and correctly to the patient within my own competencies and knowledge, and to document as per Trust policy. c) To document if a patient declines medication or the medication is omitted. d) All of the above 7. A colleague has asked you to administer a drug that she has reconstituted when you were not present should you: a) Administer the medicine and record the administration on the prescription b) Refuse to administer the medicine and take no further action c) Inform your colleague that you will reconstitute another dose of the medicine yourself and administer the prescribed dose and document the procedure Page 30
8. The temperature of medicine fridges must be recorded daily. The temperature is to be between 2-8 Degrees Celsius. What details must be recorded on the daily temperature record sheet? a) Maximum temperatures b) Minimum temperatures c) Actual temperatures d) Thermometer reset e) All of the above 9. The ownership and storage, of controlled drugs in the patient s home is the responsibility of: a) The GP b) The District Nurse c) The Sister / Charge Nurse d) The patient/ carers 10. When completing an untoward incident that involves the administration of a medicine using a medical device what information MUST you include? a) The type of device and asset number b) The name, dose / rate of the medicine c) A clear description of the fault d) All of the above Page 31
Workbook Completion Statement Employee: I confirm that I have read and understood the content of this work book, I confirm that this is my own work and if I have concerns regarding my knowledge or practice I am will discuss them with my manager. I am aware that every 3 years I must attend face to face training with the Medicines Management Specialist Nurse. Staff Surname: (BLOCK CAPITALS)......... Forename: (BLOCK CAPITALS)......... Staff Signature:......... Job Title:......... Department Ward:......... A PHOTOCOPY of this completion statement MUST only be sent to the OLM department when your manager has completed their section, where it will be entered onto the Trusts Central Training Database (OLM). It is only when this has happened will you be compliant with the Mandatory Medicines Management workbook. Page 32
Managers: Please only sign and return this statement when you are satisfied that your staff member has completed the multiple choice questions at the end of the work book. THIS WORKBOOK SHOULD BE KEPT BY THE EMPLOYEE. A PHOTOCOPY of this completion statement MUST be sent to the Learning and Development Department by the employee where it will be entered onto the Trusts Central Training Database (OLM) It is only when this has happened that they be compliant with the Mandatory Medicines Management workbook. A Further copy of this statement should be placed in your staff members personal development file. This is to confirm that the Mandatory Medicines Management workbook requirement has been completed by:- Staff Surname: (BLOCK CAPITALS)......... Forename: (BLOCK CAPITALS)......... Job Title:......... Department Ward:......... Date Completed: (THIS MUST BE WITHIN 12 WEEKS OF RECEIPT)......... Manager: (PRINT NAME)......... Manager Signature:......... Return a copy to OLM, ESR Department, Blackpool Teaching Hospitals, Whinney Heys Road, Blackpool, FY3 8NR An electronic copy can be emailed to: olm@bfwhospitals.nhs.uk Page 33
In acknowledgement to all staff who contributed to the production of this work book Blackpool Teaching Hospitals NHS Foundation Trust Page 34 Page 27
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