Injectable Medicines Policy. (Prescribing, Preparing and Administering Injectable Medicines Policy)

Document Control Title Injectable Medicines Policy (Prescribing, Preparing and Administering Injectable Medicines Policy) Authors Directorate Trustwide Date Version Issued 0.1 May 2013 1.0 July 2013 1.1 Sept 2013 1.2 Oct 2015 1.3 Nov 2015 1.4 Jan 2016 1.5 Nov 2017 1.6 Dec 2017 2.0 Jan 2018 Status Draft Author s job title Clinical Nurse Specialist Intravascular Fluid Management Medicines Safety and Governance Pharmacist Department Trustwide Comment / Changes / Approval Initial version for consultation Final Harmonised policy as a result of the merging of Northern Devon Healthcare NHS Trust and NHS Devon community services. Approved by Drugs and Therapeutics Committee on 18 th July 2013 following consultation Revision Minor amendments by Corporate Governance to document control report, headers and footers, hyperlinks to appendices, formatting for document map navigation and semi-automatic table of contents. Revision Change of author, references updated 1.4 Addition of risk assessments 5.4 Link to community intravenous therapy referral Final Updated template. Minor amendments to section 5.4 (community) following consultation. For approval by DTC Final Minor amendments to document footer. Local Path confirmed. Approved by Acute Trust Medicine Working Group 17/12/2015 Revision Updated template and references Removal of reference to merged policy with Exeter Removal of reference to the UCL guide 4.8 Role of Paramedics added 5.3.3 Infusion Device checklist 5.4. Update community nursing referral Section 6 clarification on second checks 7.5 Risk of not flushing or removing iv cannula (NHS/PSA/D/2017/006) 7.5 Clarification on the use of gloves Section 8 Training requirements updated Final Following consultation For approval at DTC 18 th Jan 2018 Final Addition of SACT to 1.3 and section 12 4.9 Addition of role of 3 rd year student nurses and student midwives regarding intravenous medications Approved by DTC 18 th Jan 2018 For posting on BOB Main Contact CNS Office Seamoor Unit Level 1 North Devon District Hospital Tel: Direct Dial 01271 322440 Injectable Medicines Policy v1.7 Jan2018 Page 1 of 15

Raleigh Park Barnstaple, E31 4JB Lead Director Director of Operations Superseded Documents NDHT Policy for the Prescribing, Preparation and Administration of Injectables v1.6 Issue Date January 2018 Review Date January 2021 Review Cycle Three years Consulted with the following stakeholders: (list all) Medicine Management Teams Senior Nurses Clinical Leads Heads of Departments for non-medical staff groups Head of Workforce Development Approval and Review Process Drugs and Therapeutics Committee Local Archive Reference G:\Public\ Local Path Policies & Procedures:\Policy - Injectable Medicines Filename Inj Meds Policy-v2.0 following DTC Policy categories for Trust s internal website (Bob) Tags for Trust s internal website (Bob) Drug Administration, Intravenous Medicines, IVs, Parenteral, Medication, Infusion Injectable Medicines Policy v2.0 Page 2 of 15

CONTENTS Document Control... 1 1. Introduction... 3 2. Purpose... 4 3. Definitions... 4 4. Responsibilities... 5 5. Prescribing, Preparing and Administering Injectable Medicines... 7 6. Second check for Injectable Medicines... 8 7. Reduction of Risks Associated with Injectable Medicines... 9 8. Training requirements... 11 9. Monitoring Compliance with and the Effectiveness of the Policy... 11 Standards/ Key Performance Indicators... 11 Process for Implementation and Monitoring Compliance and Effectiveness... 11 10. Equality Impact Assessment... 12 11. References... 12 12. Associated NDHT Documentation... 13 Appendix A... 15 1. Introduction 1.1. This document sets out Northern Devon Healthcare NHS Trust s (NDHT) policy for prescribing, preparing and administering injectable medicines. It provides a robust framework to ensure a consistent approach across the whole organisation. 1.2. The use of injectable medicines has many healthcare benefits for patients. The complexities associated with prescribing, preparing and administering injectable medicines mean that there are greater potential risks for patients than for other routes of administration. Weak systems of work increase the potential risk of harm and safe systems of work are needed to minimise these risks. 1.3. This policy should be used in conjunction with the NDHT Medicines Policy, Intravascular Device Policy and relevant Standard Operating Procedures. It applies to the prescribing, preparing and administration of all medicines given by any route of injection except systemic anti-cancer treatment (SACT) which is covered by NDHT SACT Administration and Operational Policy. 1.4. Monographs to specific medicines and risk assessments are available through Medusa via the Trust intranet: Injectable Medicines page. Injectable Medicines Policy v2.0 Page 3 of 15

2. Purpose 2.1. The purpose of this document is to ensure standardised, safe and competent practice for all professionals prescribing, preparing and administering injectable medicines. 2.2. The policy applies to all Trust staff. 2.3. Implementation of this policy will ensure that: Risks associated with the use of injectable medicines are reduced. Staff have clear guidelines to follow when prescribing, preparing and administering injectable medicines. 3. Definitions 3.1. This policy relates to drugs administered by injection by the following routes: Intra-articular Administration of an injection into the cavity of a joint. Intracardiac Administration of an injection into the heart muscles or ventricles. Intradermal Administration of an injection into the skin. Intralesional Administration of an injection into a lesion. Intramuscular (IM) Administration of an injection into a muscle. Intraocular Administration of an injection into the eyeball. Intraosseous Administration of an injection into the bone. Intrapleural Administration of an injection into the pleural space Intravenous (IV) Administration of an injection or infusion into a vein. Intravitreal Administration of an injection inside the vitreous cavity (eye) Injectable Medicines Policy v2.0 Page 4 of 15

Patient Controlled Analgesia (PCA) Infusion of analgesia controlled by patient to control pain. Subconjunctival Administration of an injection beneath the conjunctiva. Subcutaneous (SC) Administration of an injection or an infusion under the skin. 3.2. The administration of intrathecal (into the arachnoid membrane of the brain or spinal cord) and epidural (into the epidural space of the spinal cord) injections are covered by separate policies. Intrathecal Chemotherapy is not given at North Devon District Hospital. 3.3. This policy covers the use of licensed and unlicensed medicines. 4. Responsibilities 4.1. All staff prescribing, preparing and administering injectable medicines must practice within the guidelines laid down by their regulatory bodies. 4.2. All Staff must be aware of the drugs which have administration restrictions and work according to their training, competencies and job description. 4.3. Role of Prescribers Doctors, dentists and non-medical independent prescribers must work within this policy and be able to demonstrate their competency as outlined in the Medicines Policy. 4.4. Role of Registered Nurses and Midwives 4.4.1 Registered nurses and midwives may give intravenous medicines once they have undergone additional post-registration training. They must also demonstrate their competency and knowledge base by completing the Trust Intravenous Drugs Administration Programme and be reassessed as competent as per NDHT Assessment and Maintenance of Clinical and Medical Device Competence in Nurses, Midwives, AHPs and Support Workers Policy 4.4.2 In addition, midwives may administer without a prescription, drugs as listed in the standard operating procedure for midwives exemptions. 4.4.3 In exceptional circumstances in the community setting an unregistered practitioner who has been assessed as competent may accept the delegated task from a registered nurse. The accountability for the delegation remains with the registrant.. Refer to the Trust Medicines Injectable Medicines Policy v2.0 Page 5 of 15

Policy for Skilled Not Registered (SNR) Community Staff which is available on the Trust intranet. 4.5. Role of Radiographers Registered radiographers may administer injections as part of radiological procedures following training ratified by their professional bodies and completing the departmental specific training and competency programme. 4.6. Role of Operating Department Practitioners (ODPs) Operating Department Practitioners may administer drugs involved in anaesthetic, scrub and recovery procedures throughout the critical care areas of North Devon District Hospital. They must also demonstrate their competency and knowledge base by completing the Trust Intravenous Drugs Administration Programme and be reassessed as competent as per NDHT Assessment and Maintenance of Clinical and Medical Device Competence in Nurses, Midwives, AHPs and Support Workers Policy. 4.7. Role of Physiotherapists and Podiatrists Registered physiotherapists and podiatrists may administer injectable medicines as part of their practice, following training ratified by their professional bodies and completing the departmental specific training and competency programme. 4.8. Role of Paramedics Paramedics may administer injections as part of their role. For intravenous medicines they must demonstrate their competency and knowledge base by completing the Trust Intravenous Drugs Administration Programme and be reassessed as competent as per NDHT Assessment and Maintenance of Clinical and Medical Device Competence in Nurses, Midwives, AHPs and Support Workers Policy. 4.9. Role of Student Nurses, Student Midwives and Student ODPs Student Nurses, Student Midwives and Student Operating Department Practitioners may administer subcutaneous and intramuscular injections under the direct supervision of a registered nurse, midwife or ODP. For intravenous medications refer to NDHT Student Nurse and Student Midwife 3 rd Year Final Placement Clinical Skills Policy. 4.10. Role of Drugs and Therapeutics Committee The Drugs and Therapeutics Committee is responsible for: Approving the policy Injectable Medicines Policy v2.0 Page 6 of 15

Ensuring that it complies with national guidance and standards 5. Prescribing, Preparing and Administering Injectable Medicines 5.1. Prescribing 5.1.1 All medicines should be prescribed on the approved NDHT prescription documentation, which may be generated electronically, in accordance with the Trust Medicines Policy. 5.1.2 Non-Medical Prescribers must ensure that prescribing and administering activities remain separate whenever possible. 5.2. Preparing All medicines should be prepared following the SOP for preparing injectable medicines. 5.3. Administering 5.3.1 All medicines should be administered following the SOP for administering injectable medicines. 5.3.2 Where medicines are to be administered intravenously, an appropriate assessment must be conducted to ensure an appropriate vascular access device is inserted as detailed in Appendix A. 5.3.3 The NDHT Infusion Device checklist is available for infusions administered using a medical device. 5.4. Administering Injectable Medicines in the Community 5.4.1 It is accepted that healthcare professionals will be required to administer injectable medicines in a variety of settings including the patient s home environment as part of their practice. 5.4.2 The Community Nursing Services Referral Form (e-referral) must be completed. 5.4.3 The Authority to Administer/Medication Administration Record for Community Services must be completed and sent together with a supply of the injectable medication with the patient on discharge from NDDH. 5.4.4 In exceptional circumstances, the administration of an injectable medication may be delegated to an unregistered practitioner team member who has been deemed competent to undertake the task. Injectable Medicines Policy v2.0 Page 7 of 15

5.4.5 Where patients or their carers are to administer injectable medicines and they are visited by the community nursing team, the community nursing team will need to assure themselves of the patients or carers competence to undertake the delegated administration. 5.4.6 If another provider is undertaking the medication administration via the injectable route the community nursing team may ask for assurance on the competence of the staff undertaking the delegated administration. 5.4.7 Any injectable medicine being administered by the community nursing service must obtain an up to date copy of the injectable medicine risk assessment to support safe administration, following the injectable medicines flowchart for community services, which can be found on the Trust Injectable Medicines intranet page. 5.5. Further information Further information on the administration of injectable medications can be found in the relevant standard operating procedures for the care of vascular access devices. 6. Second check for Injectable Medicines 6.1. The Trust requirements for a second check by another registered healthcare professional according to current competencies are for preparing and administering the following medications: Cytotoxics Epidurals Controlled drugs Neonatal and paediatrics 6.2. A second check for other injectable medicines may be requested at the discretion of the healthcare professional. 6.3. Both staff must be present throughout the whole preparation and administration process and must both sign the prescription/administration record. 6.4. A second check involves both staff confirming: Correct prescription for the patient Correct medication Correct dose/volume of the medication required Correct diluent as required Injectable Medicines Policy v2.0 Page 8 of 15

Calculations as required Correct administration set and infusion device as required Correct patient Correct connections and correct rate of infusion set as required 6.5. It is essential that the second checker understands their role and has the necessary experience and competence to detect any problem, challenge and intervene as necessary. If this is not the case, the second checker may decline to carry out the task of second checking, stating their reasons. 6.6. When completing the second check, it is best practice for the second checker to begin the process by assuming that an error has been made and then carry out sufficient checks to ensure that no error exists. 7. Reduction of Risks Associated with Injectable Medicines 7.1. Staff should seek advice if any prescription is unclear or incorrect or there are any concerns in relation to the administration of the drug. Advice should be sought from the prescriber, pharmacist or senior colleagues. 7.2. Prior to administration of injectable medicines, the staff involved in the administration must ensure that they are familiar with the medicine/s to be administered (accessing appropriate information sources, for example, the British National Formulary [BNF], the Summary of Product Characteristics [SPC] and/or local Joint Formulary). 7.3. Prior to administration, staff must ensure that the area in which they are to be administered is appropriate. 7.4. Prior to administration, staff involved in the administration must ensure that a risk assessment for the preparation and administration of injectable medicines in clinical areas has been obtained and documented in the patient record for non-stock injectable medicines (injectable medicines kept as ward stock are risk assessed annually via agreement of the ward stock list with the ward pharmacist). 7.5. Staff must be aware that the main risks associated with injectable medications are: Incomplete and/or ambiguous prescriptions which do not include important information: for example, details of the solution to be used to dilute the injectable medicine (diluent), the final volume of medication to be administered, the final concentration or intended rate of administration. Injectable Medicines Policy v2.0 Page 9 of 15

Allergy to any of the components. The patient s allergy status must be stated on all drug charts and checked before any medication is administered. Selection of the wrong medicine, diluent or device e.g. failure to use an insulin syringe. Use of a medicine, diluent or infusion after its expiry time and date (infusions prepared must have an expiry date not greater than 24 hours). Calculation errors made during the prescribing, preparing or administering the medicine, leading to the administration of the wrong dose and / or at the wrong concentration or rate. Unsafe handling or poor aseptic non-touch technique leading to contamination of the injection and harm to, or infection of the patient. Gloves should be used with discretion when performing infusion related procedures. The use of non-sterile or sterile gloves will depend on the procedure being undertaken and its technical difficulty, contact with susceptible sites or clinical devices and the risks involved, including the risk of exposure of the health care worker to blood and / or body fluids (RCN 2016. Incompatibility between diluent, infusions, other medicines and administration devices. NHS/PSA/D/2017/006 highlights the risks of leaving residual anaesthetic or sedative drugs in intravenous lines and cannulae unless they are effectively flushed at the end of the procedure. Failure to follow patient identification procedures leading to administration to the wrong patient. Failure to follow administration checking procedures leading to administration via the wrong route. Health and safety risks to the operator or environment e.g. Needle Stick Injuries. The Trust promotes the safe use and disposal of medical sharps and provides equipment with safety features for use where possible. 7.6. Patients being transferred between clinical settings for continued treatments using injectable medications must be appropriately handed over prior to transfer to ensure appropriateness of treatment and availability of all consumables. Injectable Medicines Policy v2.0 Page 10 of 15

8. Training requirements 8.1. Training requirements for Prescribing, Preparation and Administration of Injectable Medicines will be identified through service need and discussion with line managers 8.2. Booking for all training will be undertaken via STAR (Staff Training Access & Resources). Signed attendance sheets should be sent to Workforce Development for all training undertaken in the Trust and on updating STAR, line managers will be notified of all non-attenders. These records will be held centrally and individuals are encouraged to keep a copy of all training they have attended in their portfolio. 8.3. Staff must keep their knowledge and skills up to date and relevant to their scope of practice through continuing professional development and must only practice within their own limits, skill and experience. 8.4. All registered staff must complete their drug calculation e-learning annually via STAR. 9. Monitoring Compliance with and the Effectiveness of the Policy Standards/ Key Performance Indicators 9.1. Key performance indicators comprise: Risk Assessments of injectable medicine procedures and products Incidents reports relating to injectable medicines. Process for Implementation and Monitoring Compliance and Effectiveness 9.2. Line managers are responsible for ensuring this policy is implemented across their area of work. 9.3. Support for the implementation of this policy will be provided by the authors, and the Clinical Training Team. 9.4. Monitoring compliance with this policy will be the responsibility of the Clinical and Therapy Leads, Ward Managers and Pharmacists. Incidents involving injectable medicines will be reviewed by the Medicines Governance Group (Drugs and Therapeutics subgroup). 9.5. Where non-compliance is identified, support and advice will be provided to improve practice. Injectable Medicines Policy v2.0 Page 11 of 15

9.6. New clinical areas will be risk assessed to determine suitability for the preparation and administration of injectable medicines. Where an issue in the preparation or administration of injectable medicines has been identified, an audit and a re-risk assessment will be undertaken. 9.7. All incidents relating to injectable medicines to be reported through Datix. For cases of extravasation, advice can be sought from the Extravasation Policy, MEDUSA or through. 10. Equality Impact Assessment 10.1. The author must include the Equality Impact Assessment Table and identify whether the policy has a positive or negative impact on any of the groups listed. The Author must make comment on how the policy makes this impact. Age Group Positive Impact Negative Impact No Impact Comment Disability Gender Gender Reassignment Human Rights (rights to privacy, dignity, liberty and nondegrading treatment), marriage and civil partnership Pregnancy Maternity and Breastfeeding Race (ethnic origin) Religion (or belief) Sexual Orientation 11. References European Council Directive 2010/32/EU Prevention from sharp injuries in the hospital and healthcare sector https://osha.europa.eu/en/legislation/directives/sector-specific-and-workerrelated-provisions/osh-directives/council-directive-2010-32-eu-preventionfrom-sharp-injuries-in-the-hospital-and-healthcare-sector (31/5/13) Injectable Medicines Policy v2.0 Page 12 of 15

Health and Care Professional Council Standards of conduct, performance and ethics Injectable Medicines Guide (Medusa online) National Patient Safety Agency (NPSA) (2007) Promoting safer use of injectable medicines, Multi professional safer practice standards for: prescribing, preparing and administering injectable medicines in clinical areas. www.npsa.nhs.uk/health/alerts NHS Improvement (2017) NHS/PSA/D/2017/006 - Confirming removal or flushing of lines and cannulae after procedures https://improvement.nhs.uk/ Nursing and Midwifery Council NMC The Code: Professional standards of practice and behaviour for nurses and midwives RCN (2016) Standards for Infusion Therapy 4 th Edition 12. Associated NDHT Documentation Acute Pain Guidelines Administration of subcutaneous medication via the T34 syringe pump policy Assessment and Maintenance of Clinical and Medical Device Competence in Nurses, Midwives, AHPs and Support Workers Policy Controlled Drugs Policy Intravascular Devices Policy and associated Standard Operating Procedures Medicines Policy and associated Standard Operating Procedures Medicines Policy for Skilled Not Registered Community Staff Non-Medical Prescribing Policy Paediatric Infusion Policy Peri-operative Guidelines for the Management of Patients with Diabetes SOP Administration of Sodium Chloride 0.9% via the subcutaneous route SOP Midwives Exemption Orders Student Nurse and Student Midwife 3 rd Year Final Placement Clinical Skills Policy Systemic anti-cancer treatment (SACT) Administration and Operational Policy Systemic anti-cancer treatment (SACT) Extravasation Policy Injectable Medicines Policy v2.0 Page 13 of 15

Waste Management Policy Injectable Medicines Policy v2.0 Page 14 of 15

Appendix A Vascular Access Device Selection Algorithm Osmolarity < 500 ph between 5-9 No Intimal Damage Peripheral Delivery Duration of therapy Patient Requiring Intravenous Therapies Patient Assessment Therapy Related factors Osmolarity >500 ph <5 or >9 Intimal Damage Central Delivery Duration of therapy <3 days <4 weeks >4 weeks <4 weeks >4 weeks Patient Specific considerations A Midline or PICC may also be considered if any of the following are identified: History of difficult access Long term repeated treatments Administration of vesicants Needle phobia Presence of co-morbid factors i.e. - Skin lesions, burns or infections close to site of device - Previous surgery affecting lymph nodes or peripheral vascular system - Thrombotic occlusions from previous devices - Low platelets - Clotting abnormalities - Lymph oedema - Contractures or weakness to a limb - Radiotherapy - Obesity - Maintenance of veins is paramount Cannula Midline Cannula (Exchange every 72 hours) Midline PICC ACUTE CVC PICC Tunnelled CVC Implanted Port Patients to receive intravenous therapies in a community setting Where the healthcare professional deems it would be in the patients best interest < = less than > = greater than References: RCN (2010) Standards for infusion therapy, London Bard (2007) Accessability (www.accessabilitybybard.co.uk) Injectable Medicines Policy v2.0 Page 15 of 15