POLICY FOR THE SAFE MANAGEMENT OF INJECTABLE MEDICINES (ADULTS AND CHILDREN)

Version / 5
Name of responsible (ratifying) committee / Formulary and Medicines Committee
Date ratified / 22 September 2017
Document Manager (job title) / Director of Pharmacy
Date issued / 07 November 2017
Review date / 06 November 2019
Electronic location / Clinical policies
Related Procedural Documents / Medicines Management Policy
Key Words (to aid with searching) / Medicines; Prescribing; Administration; Dispensing; Injection; injectable Drugs; Intravenous; Intramuscular; Subcutaneous; Prescriptions; Pharmacy; Label; Preparation; Patients; Children; Young People; Adults.

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
5 / 22.09.2017 / Policy updated to include the following roles (aligned with Medicines Management Policy):
  • Assistant Practitioner (Nursing) (Section 4, 5.1.2, 7.2)
  • Nurse Associates (Section 4, 5.1.2, 7.2)
  • European band 4 nurses awaiting professional registration ( Section 4, 5.1.2, 7.2)
Administration of IV fluids (aligned with Medicines Management Policy):
  • Add IV fluids that can be administered by bank and agency nurses (5.1.4)
  • Removed glucose/saline and added Hartmann’s solution to list of fluids student nurses are allowed to administer (5.1.5)
/ HM
4 / May 2016 / Update to definitions – CDs and PGDs.5.1.3 Duties and responsibilities updated. 5.1.4 Addition of sodium chloride. 5.9 Pharmacist duties and responsibilities updated. 5.10.2 PSSG changed to G&Q Cttee. 5.10.5 Medication Safety Committee duties updated. 7.2 Training requirements updated to include requirements for nurses recruited from the EU. / HM
3 / June 2014 / Student nursing and student midwife duties and responsibilities updated. Reference to the UCL guide as to determine which infusion pumps should be used for various drugs included. Removal of section on Midwife administration of epidural top ups. / HM
2 / Sept 2011 / New author, incorporation of NPSA recommendations in to Policy / HM
1 / July 2010 / New policy / HM

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9EQUALITY IMPACT STATEMENT

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

APPENDIX 1: Standard Operating Procedure for Prescribing, Preparing and Administering Injectable Medicines in Clinical Areas

APPENDIX 2: Prevention of Over Infusion of Intravenous Fluids and Medicines in Neonates.

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

This policy applies to all healthcare workers who prescribe, handle, supply or administer INJECTABLEmedicines in the course of their duties. This includes, but is not exclusive to, doctors, dentists, pharmacists, nurses, midwives, operating department practitioners, radiographers, podiatrists, dental nurses, nursery nurses, dialysis assistants, pharmacy technicians/assistant technical officers, healthcare support workers, and delivery drivers including taxi drivers delivering medicines.

The policy covers professional accountability of groups of workers, and the following processes regarding intravenous medicines:

Risk assessment

Prescribing

  • Preparation
  • Administration
  • Resources required for the safe prescribing, preparation and administration of injectable medicines
  • Procurement
  • Training
  • Exemptions to medicines legislation in the event of a pandemic

1.INTRODUCTION

The use of injectable medication has many health care benefits for patients of all ages. The complexities associated with prescribing, preparing and administering injectable medicines means that there are greater potential risks for patients than for other routes of administration. The risks associated with injectable medicines include:

  • Incomplete and/or ambiguous prescriptions which do not include important information.
  • Presentations of injectable medicines that may require complex calculation, dilution and handling procedures before the medicine can be administered.
  • Lack of information about injectable medicines available to health care professionals at the point of use.
  • Selection of the wrong medicine or diluent.
  • Use of a medicine, diluent or infusion after its expiry time and date.
  • Calculation errors made during prescription, preparation, administration of the medicine, leading to administration of the wrong dose and/or at the wrong concentration or rate.
  • Unsafe handling or poor aseptic technique leading to contamination of the injection and harm to, or infection of the patient.
  • Incompatibility between the diluent, infusion, other medicines and administration devices.
  • 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.
  • Variable levels of knowledge, training and competence amongst health care practitioners.
  • Incorrect programming of infusion pumps.

The National Patient Safety Alert 20 “Promoting safer use of injectable medicines,” made six key recommendations for action to identify and minimise risks associated with the administration of injectable medicines.

1)Undertake a risk assessment of injectable medicines procedure and products in all clinical areas to identify high risks, and develop an action plan to minimise them

2)Ensure there are up to date protocols and procedures for prescribing, preparing and administering injectable medicines in all clinical areas.

3)Ensure essential technical information on injectable medicines is available and accessible to healthcare staff in clinical areas at the point of use.

4)Implement a ‘purchasing for safety’ policy to promote procurement of injectable medicines with inherent safety features.

5)Provide training for, and supervision of, all healthcare staff involved in prescribing, administering and monitoring injectable medicines.

6)As part of the annual medicines management audit programme, healthcare organisations should include an audit of medication practice with injectable medicines.

This policy documents actions to be undertaken within Portsmouth Hospitals NHS Trust

2.PURPOSE

Ensure compliance with National Patient Safety Agency (NPSA) Patient Safety Alert 20 Promoting Safer Use of Injectable Medicines. To minimise risks associated with the management and administration of injectable medicines.

3.SCOPE

This policy covers the risk assessment, prescribing, preparation, administration of all injectable medicines to all patients requiring medication via an injectable route.

Injectable routes not covered within this policy are:

  • Intrathecal (see PHT Trust Policy for IntrathecalChemotherapy in Adults – Oncology and Haematology Departments)
  • Epidural (see PHT Trust Policy for Continuous Epidural Infusions)
  • Other routes such as intra-arterial, intraventricular, intravitreal, intrapleural and intraocular - The Royal Marsden Manual should be used as the default reference, and other specialist competences and techniques are also used in specific clinical areas. The principles and basic preparation procedures covered in this policy will generally apply.

It also outlines the required:

  • resources for safe prescribing, preparation and administration of injectable medicines,
  • procurement
  • training

All staff within Portsmouth Hospitals with responsibility for the procurement, supply, prescription, preparation, administration and monitoring of injectable medicines are required to read and apply the recommendations set out below and to ensure that the policy document is continually available for reference.

Exemptions to medicines legislation in the event of a pandemic

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

Administer

To give to a patient a medicinal product, dressing or medical device, either by introduction into the body, either orally or by injection, etc., or by external application (e.g. application of an ointment or dressing).

ADR

Adverse Drug Reaction

ATO

Pharmacy Assistant Technical Officer

Assistant Practitioners (Nursing)

Assistant Practitioners (Nursing) refer to unregistered practitioners who have completed a Foundation Degree or equivalent within Health & Social Care and who have successfully completed the competencies relating to their scope of practice in medication administration if this is required for their particular role.

BNF/BNFc

The British National Formulary (latest edition).

CD

Controlled Drug – medicines that are liable to misuse, that are subject to special controls under the misuse of drugs act 1971.

CIVAS

Centralised Intravenous Additives Services

Clinician

A health care professional who is engaged in the direct examination, diagnosis, treatment

and care of patients.

Clinical Support Worker

A clinical support worker is not registered with a professional body. They may be registered within the Trust. For the purposes of this policy these include:

  • Healthcare Support Workers (HCSW)
  • Pharmacy Assistant Technical Officers (ATOs)
  • Nursery Nurses
  • Dental Nurses
  • Clinical/ Medical Technicians
  • Radiographic Department Assistant
  • Assistant/Associate Practitioners

Dispense

To prepare and/or supply a clinically appropriate medicinal product to a patient for self-administration or for administration by another, usually a healthcare professional. Dispensing must be in response to a legally valid prescription. The act of dispensing should be accompanied with the provision of advice to the patient on safe and effective use of these products.

European Band 4 nurses awaiting professional registration

These are nurses who are registered within the European Union who are not yet registered to practice within the UK. They must have completed a six month probationary period and have been assessed as competent to undertake a Band 4 role.

FMG

Formulary and Medicines Group

GMC

General Medical Council

HCSW

Healthcare Support Workers

HPC

Health Professions Council

Healthcare Professional

A registered practitioner in an occupation which requires specialist education and training in practical skills in health care. The professions concerned are self-regulating and practitioners are expected to satisfy their profession’s accepted standards of practice and conduct.

For the purposes of this policy, these practitioners are accepted to include:

•Registered nurses or midwives

•Doctors (medical practitioners)

•Dentists

•Dietitians

•Pharmacists

•Radiographers

•Registered Pharmacy Technicians

•Registered Operating Department Practitioners

  • Paramedic

•Podiatrists

Injectable medicine

An injectable medicine may be given by one of the following methods:

  • Intramuscular injection
  • Direct subcutaneous injection
  • Subcutaneous infusion
  • Intradermal injection
  • Intravenously by
  • Direct injection (bolus) into a vein
  • Direct injection into infusion line tubing (bolus)
  • Intravenous infusion – either continuous or intermittent

Other injectable routes covered by the NPSA Patient Safety Alert 20, but not covered within this policy are:

  • Intrathecal (see Trust Policy for Intrathecal Chemotherapy in Adults – Oncology and Haematology Departments)
  • Epidural (see Trust Policy for Continuous Epidural Infusions)

Other routes such as intra-arterial, intraventricular, intravitreal, intrapleural and intraocular - The Royal Marsden Manual should be used as the default reference, and other specialist competences and techniques are also used in specific clinical areas. The principles and basic preparation procedures covered in this policy will generally apply.

Medication error

Any preventable event that may cause or lead to inappropriate medication use and/or patient harm while the medication is in the control of the healthcare professional, patient or carer.

Medicinal product

Any substance or article (not being an instrument, apparatus or appliance) which is manufactured, sold, supplied, imported or exported for use wholly or mainly in either or both of the following ways:

(a) use by being administered to one or more human beings for a medicinal purpose

(b) use as an ingredient in the preparation of a substance or article which is to be administered to one or more human beings for a medicinal purpose

Multi-disciplinary Health Record

Also known as Patient’s Notes, Medical Notes, Casenotes

NHS

National Health Service (UK)

NHSP

NHS Professionals. This is the public sector locum agency for NHS professional staffs. Each individual practitioner’s professional credentials are vetted by NHSP before admission to the scheme

NMC

Nursing and Midwifery Council (UK).

NPSA

National Patient Safety Agency (a Special Health Authority of the DoH) This role has now transferred to the NHS England.

Nurse Associates

Nursing Associates refer to a national pilot program of unregistered practitioners who have completed a Foundation Degree or equivalent within Health & Social Care and have successfully completed their competencies relating to the scope of practice in medication administration.

PGD

Patient Group Direction – A specific written instruction for the supply or administration of medicines to clinical groups of patients who may not be individually identified before presentation for treatment.

PHT

Portsmouth Hospitals NHS Trust

Prescribe

To order in writing (or electronically) the supply of a medicinal product (within the meaning of the Medicines Act, 1968, this means a POM) for a named patient (see “Prescription”).

Prescriber

A healthcare professional that is legally authorised to prescribe a medicinal product, including medical and non-medical prescribers.

Prescription

An order for the dispensing of a medicinal product. The order is presented to a professional who is legally authorised to dispense. The order must be either:

a) in writing in a legally prescribed format and signed by the person authorised by law to prescribe

b) made, using a Trust-agreed electronic prescribing system, by the person authorised in law to prescribe medicinal substances, and who has been provided with a secure, individual computer access password.

Prescription Record Chart

Authorised Drug chart for recording inpatient prescriptions and administration. There are also “Long Stay” and Mental Health Unit versions.

QAH

The QueenAlexandraHospital, Cosham, Portsmouth

rINN

Recognised International Name – European Law requires the use of the rINN for medicinal substances except for adrenaline and noradrenaline which remain the British approved names.

SCIP

South Central Injectables Practice Group

SOPs

Standard Operating Procedures

Treatment

The management and care (including medicines and procedures) of a patient to prevent or cure disease or to ameliorate suffering and disability.

TTO

To Take Out Medication (Medication the patient is discharged on)

UCL Guide

Injectable Medicines Administration Guide – book on injectable drug administration

5.DUTIES AND RESPONSIBILITIES

The Director Medicines Management and Pharmacy is responsible for the preparation, implementation and audit of this policy.

All staff must comply with their responsibilities when undertaking their duties involving injectable medicines both at ward/department level and within pharmacy.

5.1. Nurses

5.1.1. Registered Nurses

Each registered nurse is accountable for her/his own conduct and practice in accordance with the Nursing and Midwifery Council, TheCode: Professional standards of practice and behaviour for nurses and midwives (2015)and in exercising professional accountability will:

  • Always act in a manner as to promote and safeguard the interests and well being of patients and clients
  • Ensure that no action or omission on their part, or within their sphere of responsibility, is detrimental to the interests, condition or safety of patients and clients.
  • Maintain, update and improve their professional knowledge and competence
  • Acknowledge any limitations in their knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe manner.
  • Report to a senior person or authority any circumstance in which a safe and acceptable care for patients and clients cannot be provided.
  • Avoid any improper delegation to others, which compromises the interests, wellbeing or safety of patients and clients.

5.1.2 Assistant Practitioners (Nursing), Nurse Associates and European Band 4 Nurses awaiting registration

Staff in these roles work autonomously in support of registered staff and allied healthcare professionals.

Although not professionally registered they are required to meet the same standard of practice as any competent professional within the agreed scope of their role. Their preparation will enable them to competently undertake administration of prescribed medications, via agreed specified routes.

They must take responsibility for their own actions and ensure that their knowledge and skills are maintained to ensure safe and competent administration of medications.

They must be assessed against the Trust Medicines Management Competency by a Registered Nurse holding a level 3 competency, prior to undertaking any medicines administration in practice without a second checker.

These staff will not be deemed competent to administer medications in any ward or department outside that in which they completed competency training without additional assessment of competence.

Assistant Practitioners (Nursing), Nurse Associates and European Band 4 Nurses awaiting registration may not administer:

  • Controlled drugs
  • Intravenous medication, with the exception of the standard maintenance intravenous fluids glucose 5%, sodium chloride 0.9% and compound sodium lactate (Hartmann’s solution as follows:

Administration of standard IV fluids by Assistant Practitioners (Nursing), Nurse Associates, and European Band 4 Nurses awaiting registration.

These staff may administer prescribed pre-prepared standard IV bags of 0.9% sodium chloride or 5% glucose or compound sodium lactate (Hartmann’s solution) via an existing intravenous or subcutaneous line. This activity must be carried out only under the direct and continuous supervision of a qualified nurse, midwife or medical practitioner.

These staff may not participate in the initiation or alteration of administration of medication by routes which involve infusion, mechanical pumps or a patient controlled device.

5.1.3. Ward/Department Managers

Ward/Department managersare responsible for ensuring that their staff meet required competencies for the administration of medicines. It is every manager’s responsibility to ensure that all their staff are informed as to which members of the team are competent to accept delegation of duties.

First level nurses and European Band 4 nurses awaiting registration will have established basic competencies in pre-registration education and competency will be maintained. If evidence cannot be presented, then further training should be undertaken.

Assistant Practitioner (Nursing) and Nurse Associates will have completed a level 5 university based education Medicines Management module and established competency as part of their programme competency framework.