Administration of medicines to adults who are physically ill or injured is part of the adult nurses responsibility to provide holistic care and promote health (Veitch & Christie 2007). Medicines are manufactured in several forms and can be administered by different routes. According to the form of the medications there are different requirements and equipment for their administration and storage (Burton and Donaldson 2007). This essay will focus on the administration of oral medicines, the standards and the legal requirements for their safe administration. The essay will also look at areas where problems are most likely to arise and will describe the measures which nurses can take to ensure patient’s safety when administering oral medicines.
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The National Patient Safety Agency (NPSA) defines patient safety as a process which involves identification, analysis and management of risks and incidents, including medication errors so potential or actual harm to patients can be prevented or minimised. Medication errors have a significant impact on patients, their families and health professionals involved. They can compromise patient’s safety and result in actual harm to patients. A total of 72,482 medication errors of which 14,111 caused harm of various extents to patients and 37 resulted in death were reported to the NPSA (2009) in one year. The same report showed that nearly half of the incidents were concerned with administration of medicines. Another report by the Department of Health (2004) estimated the cost of medication errors in NHS hospitals between £200-400 million per year. Therefore it is vital that nurses adopt safe, methodical and skilled approach to administration of medicines.
LEGAL
The management of all medicines in the United Kingdom is governed by several legislations, the Standards for Medicine Management (2008) and the Standards of conduct, performance and ethics issued by the NMC (2008). The Standards outline the nurse’s responsibilities in relation to the current UK legislations. Burton & Donaldson (2007) summarise these legislations in the latest edition of the “Foundations for Nursing Practice”. The Medicines Act (1968) regulates the requirements by which medicines are manufactured, prescribed and administered. The Medicines Act (1968) also classifies medicines into four categories which are Prescription only medicines (POMs), Pharmacy only medicines (Ps), General sales medicines (GSLs) and Control drugs (CDs).The Misuse of Drugs Act (1971) and the Misuse of Drugs Regulations (1985) provide the legal framework for the management of the controlled drugs and differentiate medicines according to the level of harm they may cause. The Mental Capacity Act (2005) provides the foundations for care delivery including medicine administration to people who lack the ability to make informed decisions. For Scotland these foundations are contained within The Mental Health (Care and Treatment) (Scotland) Act (2003) and The Adults with Incapacity (Scotland) Act (2000). These regulations are in place to assist and guide nurses and are fundamental in protecting patient safety. Anex1 of the Standards for Medicine Management (NMC 2008) specifies the nurse’s responsibility to comply with these regulations.
However the administration of medication is “not solely a mechanistic task to be performed” and requires more than just following written instructions (NMC 2004). In respect to oral medicines and their administration the nurse should take a person centred approach and assess and assist each patient individually according to patient’s general condition. Kelly and Wright (2009) draw attention on the high number of medication administration errors in patients with swallowing difficulties, where physiological abnormalities can lead to difficulties in swallowing of liquids or tablets. Griffith (2005) suggests that alternative form of medicines should be considered if patients have difficulties swallowing tablets. The nurse’s responsibility in this respect is to perform the initial and ongoing assessment of patient’s condition to establish the suitability of certain type of oral medicine and the ability of the patient to take this medicine (NMC 2008).
Physical or mental health conditions could also have an impact on the medication compliance by patients leading to crushing, mixing or disguising medicines in food or drink (Kelly & Wright 2009). The Department of Health (2010) and The National Prescribing Centre (2010) outline the parameters and principles for safe mixing of medicines and the nurse’s role in this relation. Following these principles when nurses consider mixing of medicines they should always act in line with local policies, consult a pharmacist and obtain written instructions and also obtain consent from patients.
Crushing and mixing of medicines without a careful assessment and justification could present safety risks for patients and nurses (Paparella 2010) because of their chemical formulations. Examples of these are the enteric coated tablets, slow released formulations and products containing carcinogenic substances. Crushing or splitting of these medicines may lead to undesirable effects for example unintended rapid absorption. Griffith (2005) points out the legal consequences of crushing tablets. If crushing of oral formulation results in harm for the patient the nurse responsible will be liable for negligence. Paparella (2010) suggests simple steps such as careful consideration whether a tablet is safe to crush and consultations with pharmacist could significantly minimise the risk for patients and nurses. It is also essential that nurses have a sufficient level of knowledge of how medicines interact with the human body in order to be able to observe if they achieve the desired therapeutic effect and to avoid any adverse reactions (NMC 2008).
Covert administration of medicines represents not only safety risks to patients but also has legal and ethical aspects which nurses have to consider before making a decision for such action (Griffith 2007).
Although most of the nurses do not prescribe medicines it has been found that the administration of a wrong dose of medicine causes the largest number of deaths and serious harm to patients, followed by the administration of wrong medicine and omitted or delayed medicine (NPSA 2009). Subsequently, administering wrong dose of medicines has been linked to poor mathematical skills (Pentin & Smith 2010). The nurse’s responsibility in connection with administering correct doses of oral medicines is outlined in the Standards for medicine administration (NMC 2008) which states the nurses must be aware of the patient’s care plan, check prescription and dosage before administering medicines.
Administering of a wrong oral medicine is often associated with similar medicine or patient names, packaging, labelling or poor storage systems (NPSA 2009). This is particularly common issue in nursing and care homes where no wrist bands for identification are used (Pountney 2010).
CONCLUSION
“Safe administration of medicines requires a methodical approach that follows local policies” (Burton,C & Donaldson,J 2007).
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