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Medication Administration and Management

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Alice Skull

on 13 October 2014

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Transcript of Medication Administration and Management

Why do errors occur - Design

Multiple factors involved in each medication error.
Contributing factors as perceived by nurses (Tang et al 2007)
The number of prescription items dispensed in the community per year topped one billion for the first time in 2012 - equating to 2.7million a day, or over 1,900 a minute. (HSCIC 2013)
Why do things go wrong - prescription
Types of medicines most frequently associated with severe harm:

Why do things go wrong?
NPSA (2007) Safety in doses document identified:

100 medication incident reports of death and severe harm
41% of serious incidents were caused by errors in medicine administration
31% of serious incidents were caused by prescribing errors
incidents involving injectable medicines represented 62% of all reported incidents leading to death or severe harm
Why do things go wrong?
Drug names

Brand name -

Generic/Approved name
Prescribing Information
Check time on prescription chart
Check how often it should be given in a 24 hour period
Right Time
Right Route
Know your patient
Handwriting of prescription
Label/presentation of medicine
Check prescription chart - signed, dated
Start and stop date
Total dose administered
Expiry date/date opened

Right Medicine
Right Patient
Right Medicine
Right Route
Right Dose
Right Time
Right Documentation

Medicines Administration - 6 R's
Where do I find this information?
NMC monthly hearings
'Sheila is a registered nurse, and she is conducting a medicines round in the ward. She checks Mr Rogers' medicines (placing them in the medicines pot) and because he is not beside his bed she places the medicines on his bedside locker for him to take on his return. She makes a mental note to remind him. Sheila then becomes distracted by another patient; she locks the medicine trolley and goes to attend to the patient. In meantime Mr Daly, who is in the bed next to Mr Rogers and is disorientated, ingests Mr Rogers' medicines. When Mr Rogers returns to his bed he calls Sheila and asks for his medicines. She tells him they are on his locker, but when they investigate the medicines pot is found empty on Mr Daly's bedside locker. Mr Rogers has not received his medication.'
Standard 8

'You must know the therapeutic use of the medicine, normal dosage, side effects, precautions and contraindications.'
NMC Standard for Medicine Management (2010)

Use of controlled drugs in healthcare - Misuse of Drugs Regulations (2001)

Schedule 1 - no clinical use (e.g. cannabis)

Schedule 2 - opiate drugs used in acute palliative care (e.g. morphine)

Schedule 3 - less likely to be open to abuse than schedule 2 (e.g. fentanyl)

Schedule 4 - PoM Benzodiazepines and anabolic steroids

Schedule 5 - Medicines that contain very low dosages of drugs (e.g. codeine)
The law governing medicines
The Medicines Act (1968)
compulsory for all medicines to be licensed before introduced to UK market
licensing is based on the safety and effectiveness of the drug and its overall benefit

The Medicines Act was initiated by the thalidomide tragedy

The Act covers many different aspects from animal testing, licensing to quality control.

The law governing medicines

"People can trust the newly registered graduate nurse to ensure safe and effective practice in medicines management through comprehensive knowledge of medicines, their actions, risks and benefits".

Edna Alker

Needed potassium IV

Died as a result of inappropriate administration

Errors caused by ignorance

Why do things go wrong - common problems
Correctly mark the administration chart whether the patient has taken or been given the medication
Omitted doses
Note adverse effects - nursing notes, medical notes & adverse drug reaction form (yellow card, BNF, online MHRA)
Right Documentation
If you don't know the normal dose of a medicine, then you will not recognise an abnormal dose
Right Dose
Know your patient
Patient ID - NPSA 2007
Check Allergies
Right Patient

name and class
of the medicine e.g. Atenolol, Beta blocker
what it is used for
- hypertension, angina, arrhythmia's
route of administration
- oral, intravenous injection
actions and effects
- Reduces heart rate and blood pressure
adverse effects
- bradycardia, wheeze
- caution in patients with asthma
its mechanism of action - blocks beta-adrenoceptors in the heart, peripheral vasculature, bronchi, pancreas and liver.
What information about pharmacology do I need to know?
Patient Safety
the patient himself
Mr Daly's relatives - might complain about Sheila's actions
nurse manager would instigate an investigation
employer as part of a disciplinary process
NMC - fitness to practise
family may sue the nurse if physical or psychological harm was caused to Mr Daly - seek compensation or criminal conviction
court of law
effect of drugs on the body and mode of drug action

'not solely a mechanistic task to be performed in strict compliance with the written prescription'

'requires thought and the exercise of clinical judgement'

NMC Standard for Medicine Management (2010)

The Misuse of Drugs Act 1971
Important Legislation that controls drugs that are liable to abuse and misuse.
It is the Act under which proescution for illegal manufacture, supply and possession of substances such as heroin, cocaine, cannabis and amphetamines.

Defines 3 classes of drug according to how harmful they are perceived to be if abused
Class A: Ecstasy, LSD, heroin, cocaine, methylamphetamine (crystal meth)
Class B: Cannabis, amphetamines, methylphenidate (Ritalin), barbituates, pholcodine
Class C: Tranquilisers, some painkillers, ketamine, anabolic steroids, benzodiazepines
The law governing medicines

The Medicines Act (1968, 1971 amended directions 2000)
3 categories of drugs for public use:

P (pharmacy medicines) sold under supervision of pharmacist in a registered premises
GSL (General Sales List) sold without supervision ('Over the counter')
PoM (Prescription only Medicines) sold in accordance with a prescription from an authorised prescriber
The law governing medicines

Consider the issues raised in medication management

Identify key stages involved in this process
Explain the nurses responsibility
Identify the legal framework
Describe the important safety considerations
Be aware of relevant calculations

Aims and objectives

Medication Administration
and Management

Alice Skull

NMC Essential Skills Cluster (2010)
drug action in the body - dependent on
Imagine you are the nurse in Sheila's position. Who might ask you to explain what you did in regard to this incident?
Beverly Allitt - 1991 - 1993
Grantham and Kesteven General Hospital
killed 4 children and injured 9 others by administering lethal doses of potassium and lethal doses of insulin
Harold Shipman - 2000
Former GP, murdered 15 patients by giving lethal doses of morphine
Consider reliability, evidence base and is it up-to-date
British National Formulary
literature that manufacturers produce
pharmaceutical & medical journals
regulatory authorities - NICE Medicines & Prescribing Centre
check documented correctly by prescriber
can the patient actually receive the drug via the route prescribed
Some drugs have a very narrow therapeutic index
Calculate correct dose - may need patient's weight
If there are any doubts about legibility it is your duty to ask for the prescription to be written more legibly.
Omitted for clinical reasons;
Drug unavailable;
Nil by mouth/fasting;
Patient refused (has capacity);
Patient refused (lacks capacity);
Self administered;
No IV/NG/PEG access;
Patient absent from ward;
Do not administer.
Guidance on Prescribing - use Approved names
- written in indelible ink
- dose written in full metric units e.g. 500mg not 0.5g
write micrograms in full, not mcg
write UNITS in full, not u
- write time using 24 hour clock
- full signature, full date (bleep number)
Got the
Accountability and responsibility
Consent - consider covert admin.
Principles of medicine administration
NPSA - National Patient Safety Agency
Now part of NHS England

3 incident types:
unclear/wrong dose of frequency
wrong medicine
omitted/delayed medicine
Doctors and some nurses
Hand written, electronic and pre-printed
This is the first point where errors may occur

Interruptions and distractions

Poor labelling and packaging

Need to solve other problems whilst administering medication
Advanced drug preparation without rechecking
Increased workload - dependency & understaffing
Unfamiliarity with medications
Insufficient training

The case of Edna Alker
Administration of Medicines 6 R's
Right Patient
Right Medicine
Right Route
Right Dose
Right Time
Right Documentation

NMC Standard for Medicines Administration
18. Students must never administer/supply medicinal products without direct supervision
ARU Student Nurses are not permitted to administer intravenous medication
Full transcript