St. Gemma’s Hospice

ST GEMMA’S HOSPICE

POLICIES AND GUIDANCE

Category: / Medicines
Title: / Medicines - Administration
Responsibility of: / Director of Nursing
HLT Member Accountable: / Director of Nursing
Developed in consultation with: / Hospice Pharmacist/ANP
Staff with operational responsibility for development, implementation and review: / Advanced Nurse Practitioners
Ward Sisters
Hospice Pharmacists
Target audience: / IPU / Day Hospice Staff
Key words: / Medicines Administration
Associated policies: / All Medicine Policies & SOPs
Date most recently validated: / June 2015
Date originally validated: / October 1995
Review date: / May 2018

MEDICINE - ADMINISTRATION

1.0 Preamble

1.1The following policy and associated Standard Operating Procedure is written in accordance with the following:

Nursing and Midwifery Council (2007) Standards for Medicines Management

Care Quality Commission (2010) Essential Standards of Quality and Safety

1.2 This policy should be read in conjunction with other policies &protocols relating to symptom management and medicines management. It is supported by the Standard Operating Procedure “Administration of Medicines”.

1.3If medicine is to be administered within a patient’s home, staff member must refer to CommunityMedicine Policy.

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1.4 As a Specialist Palliative Care Unit the management of physical symptoms isan important aspect of our practice. Within this, the administration and evaluation of pharmacological therapies requires specialist knowledge and expertise. The Registered Nurse (RN) is encouraged to request the assistance of a second responsible person if at any timehe/she, in considering his/her personal accountability deems it preferable. This enables the sharing of knowledge and clinical expertise within a supportive environment.

1.5 Resources to assist in decision making regarding medication include Hospice Pharmacists, Medical staff,Advanced NursePractitioners (ANPs), senior nursing staff throughout the unit, the current Palliative Care Formulary, current BNF, current Syringe Driver Handbookand Hospice Policies andprotocols.Information is also available on line at

1.6 The administration of medicines provides an opportunity for emphasisingto patients and their carers, the importance and implications of the prescribed treatment and for enhancing their understanding of its effects and side effects.

1.7 In the event of a drug error refer to the ‘Medicines – Management of Errors or Incidents’ policy.

2.0 Policy

2.1 RNs are to successfully complete a competency assessment prior to being given authority to administer medicines. This includes the reading of all policies referring to medicines and completionof the medicine assessment in their Orientation Pack.

2.2 Bank RNs will undertake a medicines competency assessment on induction prior to being given authority to administer medication. They will also be reassessed annually.

2.3RNs who have had prolonged absence (more than four weeks) will meet with Ward Sister/ANP on their return to practice in order to discuss their support/learning needs relating to medicines management. A medicines assessment may be necessary as part of return to work.

2.4 Where there is any concern about an individual RN’s ability to administer medication competently, an individualised action plan is developed by Ward Sister/ANP. This may involve education; supervised practice and medicines reassessment (see policy Management of Errors, Incidents and Near Misses)

2.5St Gemma’s Hospice aims to provide a supportive environment in which staff are able to administer medicines safely. It is the responsibility of Ward Sisters to appraise each RN in order to identify individual needs and discuss these with them. It is the responsibility of the individual RN to discuss his/her needs with the Ward Sister. In both cases specific needs are documented as an Individual Performance Review objective. A clear plan for further education and training is developed and discussed with the ANP and Pharmacist. The ANP and Community and Day Services Manager are available to support Ward Sisters and RNs.

2.6RN assesses the patient’s current condition, planned programme of care and environment in which care is being given as well as any likely dangerous drug interactions or contra-indications prior to administering medicines.

2.7RN only administers medication that is prescribed in accordance with St Gemma’s Hospice prescribing policy.

2.8RN is aware of the therapeutic uses of any medicine to be administered, its normal dosage and side effects, precautions and contra indications before administration

2.9Following 2.1, RN administers medicines without involving a second person except in the following circumstances, when a second RN, Doctor or Pharmacist is required to check:

  • injectable medicines including sub cutaneous, intravenous and intra muscular injections and infusions
  • all controlled drugs (except Temazepam,oral ketamine and tramadol when given regularly)
  • all ‘As required’ (prn) oral medication with the exception of:

Paracetamol

Zopiclone

Sodium Chloride 0.9% Nebules

Gaviscon Advanced

Simple Linctus

Peppermint Water

2.10RN should seek a second opinion prior to any medicine administration should they have reservations or are unclear about prescription.

2.11Medicines for injection are prepared for immediate use only.

2.12RNs only administer medicines prepared by themselves.RNs preparing IV/Subcutaneous infusions are also responsible for commencing the infusion.

2.13Where medication has been prescribed within a range of dosages, it is acceptable for RNs to titrate dosages within this range according to ability to measure doses accurately, patient response/symptom control. .

2.14RN follows advice on drug chart regarding general prn administration and repeating doses. If RN’s are uncertain about the best course of action they should contact a senior more experienced nursing colleague within the unit or a doctor for further advice.

2.15RN informs Doctor at the next handover in the event of medicines being omitted due to an alteration in the patient’s condition unless RN deems it necessary to contact immediately. The omission is documented on the medicine chart using the appropriate code

2.16Remote prescribing/remote direction to administer (verbal orders) for newdrugs or dose changes are not permitted.

2.17Covert administration of medicines is not acceptable unless the patient is deemed to beincapacitousas per St Gemma’s Assessing Patients CapacityPolicy and the administration of medication is deemed to be in the patients’ best interest. In such cases a decision is made by at least one doctor and RN with input from a Consultant that disguising medication in food and drink is in the patient’s best interest. A Pharmacist should be contacted for advice on the pharmacological implications of disguising the medication.This decision is discussed with the family. All discussions are documented in the patient’s clinical record.The need for covert administration is reviewed on a daily basis.

2.18Students must never administer medicinal products without direct supervision of a RN. In order to achieve the standards required for registration, students must be given opportunities to participate in the administration but this must always be under direct supervision and the medicines administration chart must be signed by both the RN and the student. Where it is considered the student is not yet ready to undertake administration in any form, this should be delayed until such time the student is ready. Equally a student may decline a task if they do not feel confident enough to undertake it.

2.19RNs may delegate a Health Care Assistant to assist a patient in the ingestion or application of a medicinal product (e.g to swallow tablets or apply cream) with the exception of schedule 2 and 3 controlled drugs. (The swallowing of these must be witnessed by an RN – see Administration of Medicines Standard Operating Procedure 5.6.5). The RN remains accountable to ensure that the HCA is competent to carry out the task.

2.20Patients’ own medicines are used with consent from the patient. These remain the patient’s property and must not be removed from the patient without permission or used for other patients.

3.0 Procedure

3.1Follow St Gemma’s Hospice “Standard Operating Procedure for Medicines Administration”

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