Chapter 3: Drug administration by nurses

Introduction

The aim of this chapter is to explore the recommended procedures for the safe administration of both controlled and non-controlled drugs by nurses. The responsibilities of nurses in drug administration as stipulated by the Nursing and Midwifery Council (NMC) will also be discussed, as well as common routes of drug administration that a nurse may be asked to use. The situations in which nurses may delegate drug administration to another individual, such as a student nurse or a healthcare assistant, will also be reviewed. Drug administration safety will also be introduced; however, this will be discussed in greater detail in Chapter 4. Finally, two hands on scenarios will be presented to guide you through the correct procedure for administering drugs, and for delegating the administration of drugs to others.

Who can administer which drugs, and under what circumstances?

Under the NMC Code (2015), nurses can prescribe or administer medicines in accordance with the limits of their training, the law and in accordance with any local or national policies and guidance. This also includes following the specific restrictions in place for the administration of controlled drugs discussed in the previous chapter. In line with prescribing rules for other healthcare professions, nurses should not prescribe for anyone they have a close personal relationship with, or prescribe drugs for themselves unless absolutely necessary.

A Note About Midwives:

It should be noted that midwives are subject to special rules regarding the administration of drugs. For example, they may possess and administer controlled drugs such as pethidine as analgesia for labouring women, or prescription only drugs such as synotocin to augment the third stage of labour and control postpartum bleeding. These drugs are usually obtained from a supply order countersigned by either a doctor or the supervisor of midwives. This is because they require rapid access to these drugs during the course of their work in order to ensure quality patient care. The drugs available to the midwife to administer are usually agreed by local policy and in accordance with the specific instructions for this in the NMC Code (2015).

Preparation of Medication for Administration

Medication should never be prepared in advance (except in the case of some chemotherapy infusions) and should only be administered by a registrant who was involved in its preparation. No healthcare professional should ever administer medication they have not helped prepare. Nurses should have a good understanding of the weight systems used in prescription and be able to calculate drug dosages correctly. They should also understand common abbreviations used in prescribing, although it should always be remembered that any lack of clarity in the instructions should be questioned. It is also important to understand any necessary requirements for the safe handling of harmful medications, for example cytotoxic medications used to treat cancer. By their nature, these drugs have the potential to damage cells, and extreme care should be taken in accordance with local procedure when handling and preparing these drugs. For example, many of these drugs are known to be harmful in pregnancy, and it may be local policy that nurses who know or suspect that they may be pregnant are not involved in the administration of these drugs. The nurse should also be aware of the correct local procedure for dealing with spillages, and safe disposal of any contaminated equipment.

Medicines in tablet form should not routinely be crushed to make it easier for the patient to take it without approval by a pharmacist. This is because crushing will change the way in which the medication is absorbed into the body and this may make the drug less effective. Many tablets are prepared by the manufacturer with an enteric coating which prevents the tablet from breaking down in the acid contained in the stomach, so that it can progress to the small intestine where the tablet can break down gradually and be absorbed into the body more readily. Crushing removes the protective effects of this coating.

Introduction to Safe Drug Administration Procedure

The NMC Standards for Medicines Management (2016) outline the nurse's responsibilities for safe drug administration in more detail. A registered nurse can administer any prescription only medicine, or general sales list or pharmacy medication with a single signature. Before administering a drug, a nurse should be certain of the patient's identity and confirm this with wrist bands and asking the patient for their name and date of birth, as well as checking that the patient is not allergic to the drug. The nurse should have a good understanding of the drug they have been asked to administer - for example, its therapeutic use, normal dosage, known adverse effects and any specific contraindications or precautions associated with that medication. The nurse should also be familiar with the patient's care plan and the need for that patient to receive that medication.

The nurse should also check that the prescription for the medication and the labels on the container are clear and unambiguous. If there is any uncertainty over any aspect of the prescribed instructions, the nurse should investigate this further by contacting the prescribing healthcare professional for clarification. Although this may be challenging due to the historical imbalance of power and position between doctors and nurses, the nurse has a responsibility to check any ambiguous information and discuss this in a constructive manner. The nurse should also consider the prescribed dosage, route and timing and compare this with their knowledge and experience. Any concerns should also be discussed with the prescribing healthcare professional, as this could help to identify a prescribing error and thus ensure the patients safety. Finally, the nurse should always check the expiry date on the medication.

The patient's current condition should also be considered when administering a prescribed drug. For example, if the patient's current condition or vital signs contraindicate the medication then the drug should not be given and advice should be sought. For example, Digoxin is contraindicated in patients with a pulse <60 beats/min. If a nurse discovered that the patient had a lower pulse rate than this, then the scheduled dose of Digoxin becomes contraindicated and should not be given. Likewise, the patient's current condition could suggest that there is no need for this dose of medication, in which case the nurse should contact the prescriber to discuss this further. The patient may also choose to withdraw their consent to receive the medication, and this should be respected and adhered to, assuming that the patient is assessed as having the mental capacity to refuse treatment.

The medication administration should immediately be clearly and accurately recorded in the patients notes, with the nurse signing and printing their name, and recording the date and time that the drug was administered. If the drug was deliberately not administered, for example if the nurse felt the need to question its administration with the prescriber, or if the patient declined it, this should also be recorded in the notes along with the reason. Nurses have a legal responsibility to ensure that they clearly record this information. This should also be undertaken if the registered nurse has delegated the drug administration to another individual, but this will be discussed in more detail later in the chapter. Safe drug administration will be discussed in more detail in the next chapter.

Finally, after receiving the medication, the patient should be monitored for any evidence of an adverse reaction; for example, a response in line with a known or unknown adverse effect, or an allergic reaction. Nurses should seek support from the prescriber in this event, but also be aware of the necessary emergency care required to support a patient having a serious reaction. Allergic reactions are commonly characterised by a rash, hives, sneezing and bronchospasm but may progress to anaphylaxis, a systemic allergic response which can cause respiratory distress and loss of consciousness. Patients suspected of having an allergic response should be monitored for signs of the reaction developing into anaphylaxis, e.g. regular monitoring of vital signs including blood pressure, oxygen saturation and respiratory rate, which can also be used to confirm improvement of the patient's condition. An antihistamine such as hydroxyzine and a corticosteroid such as prednisolone should be administered. However, if anaphylaxis is suspected, the patients should receive high flow oxygen therapy and an emergency intramuscular injection of adrenaline, which can be repeated every 5 minutes until the patient has stabilised. Bronchospasm can be treated with salbutamol, delivered by a nebuliser.

The nurse's responsibilities under the NMC Standards for Medicines Management (2016) may be condensed into the "5 rights" rule, which prompts the nurse to consider these points in an easy to remember fashion. The right patient should receive the right dosage of the right medication via the right route at the right time. This has been expanded on by some experts to become the "7 rights rule" or even the "9 rights rule" to cover the other aspects of drug administration covered in this section. These rules expand on the "5 rights rule" by also including the addition of checking that the right form of the drug has been prescribed, that the drug is being administered for the right reason, and that the patient exhibits the right response to it. Finally, the nurse should complete the right documentation after administering the medication. These rules are shown below in Figure 1.

Figure 1: The "rights" of drug administration

Administration of Controlled vs Non-Controlled Drugs

Controlled drugs can also be administered by nurses, but these are subject to additional legislation and local protocols, which should always be followed. Second signatories are usually other nurses, student nurses, doctors or pharmacists; however, if none of these professionals are available, the NMC recommends not compromising patient care by waiting for a suitable professional to countersign, but to consider another competent person instead. Good practice suggests that ideally this second signatory should witness the entire drug administration process, and this is usually reflected in local policies. Normally, a second signature is required for the administration of controlled drugs in the hospital environment. However, as discussed in the previous chapter, this is not always possible in the community setting and in this case, local policy and procedures should be followed. When a patient has been prescribed oral controlled medication for immediate consumption, for example the administration of methadone in a substance misuse clinic, the administration and the patient's consumption of the medication should be witnessed by the administering nurse, and a second registered nurse, as well as following any other relevant local procedures. The recommendations produced by the National Institute of Health and Care Excellence (NICE) for the use of controlled drugs stipulate that the name of the patient receiving the drug should be recorded, along with the date and time of the dosage, the name, dose, formulation and strength of the controlled drug. This should be supported with the clearly printed name and signature of the registered nurse administering the nurse, as well as the name, date and signature of the person witnessing the medication administration.

Delegation of Drug Administration

A registered nurse can delegate the administration of drugs to a healthcare assistant or student nurse, but this should never be administered without supervision. Student nurses may act as a witness in the management and administration of controlled drugs, however this will vary according with local policy. This introduces the possibility of errors into the patient's care, therefore delegation of drug administration should be carefully considered. If it becomes necessary to delegate this task, for example if the registered nurse needs to share their workload in order to concentrate on urgent tasks, the nurse has the responsibility to ensure that the person they delegate to is a competent individual. Additionally, delegation to a competent student nurse is an important part of their practical training and a registered nurse should therefore undertake this assuming they believe their student to be competent. If the nurse has any doubts regarding competency, they should not delegate drug administration even if this means refusing a direct request from another healthcare professional. This is because the registered nurse is considered to be accountable for the practice of any individuals they have delegated the task to. A student nurse is legally considered in the UK to be responsible for their practice, but to not yet have the experience and ability to be considered fully accountable for their practice. Legal and ethical accountability therefore resides in the supervising registered nurse. The nurse should ensure that the individual has adequate education and training to understand how and why the medication should be administered, and should offer further support if necessary. Any training or education should be recorded, and the NMC Standards for Medicines Management (2016) stipulate that the overseeing registered nurse should always countersign the administration of drugs by a student. Safe and effective delegation can be guided using the "5 rights of delegation" rule as shown in Figure 2. Following this rule ensures that only the right task is assigned to the right person under the right circumstances, and that they receive the right directions to carry out the task safely, and that the delegation is planned appropriately to ensure quality patient care and a positive learning experience for the person being delegated to. The delegation should also be supervised and evaluated in the right (appropriate) way.

Figure 2: The "5 rights" of delegation

Conclusion

In conclusion, this chapter has introduced the role of the nurse in drug administration in the context of NMC guidance and UK law. Good nursing practice surrounding drug administration has also been introduced, ready for more in-depth discussion in the next chapter. We have also reviewed the benefits of delegation of routine drug administration tasks to other colleagues, and how this can be approached in a safe manner in order to ensure patient safety and care quality. These concepts will now be applied in two hands on scenarios to guide you through the application of these rules and guidelines into everyday nursing practice.

Hands on Scenarios

Scenario A - Correct Procedure for Drug Administration

The case study scenario covering the storage and disposal of controlled drugs in Chapter 2 will now be continued to include the correct administration of a controlled drug. To recap, Clare is a registered nurse, who has recently taken receipt of a new delivery of controlled drugs, and has then prepared a dosage of 25mg morphine sulphate for her patient, Mary. This drug has been prescribed to Mary by the supervising doctor as analgesia for pain associated with Mary's advanced breast cancer. Clare's actions are being witnessed by another registered nurse, Fiona, in accordance with the "Controlled drugs (supervision of management and use)" regulations, NMC guidance on the management of medications and the local protocols and procedures in place at her hospital. Clare has already undertaken the correct disposal procedure for the 5mg of excess morphine sulphate contained in the original ampule in accordance with these rules.

With Fiona witnessing, Clare ensures that the 9 rights rule is followed. Firstly, Clare checks that she has the right patient by asking Mary her name and date of birth, and checks that this matches the name on Mary's wrist bands. Clare checks that the medication was prescribed at the right dosage. Based on her knowledge and experience, a 25mg dose of morphine sulphate seems appropriate, therefore Clare does not think that this dosage needs to be questioned. From reviewing Mary's notes, it appears that previous administrations of this drug at this dose have given Mary adequate analgesia, so Clare feels confident that this dose is both safe for Mary, likely to be well tolerated and likely to make her more comfortable. Had Mary's notes indicated otherwise, Clare could have questioned the dosage with the prescribing doctor to ensure that Mary's care plan met her needs. The doctor's handwriting is also clear, so Clare is confident that she has understood the instruction correctly. Clare asks Mary if she has any history of allergy to this medication to identify if Mary is at a risk of an adverse reaction. However, Mary assures her that she does not have a known allergy either to morphine sulphate or a related drug. Clare therefore feels confident that carrying out the administration of this dosage is safe and not contraindicated.

Clare then checks that the right form of the right medication for the right route has been prepared, in this case a solution of morphine sulphate designed for IV administration. Clare checks the time of the previous dose to ensure that this dose is not being given too early (which could result in overdose) or that a previous dose has been missed (which could indicate a medical error). However, the previous dose was administered at the time expected so Clare is confident that once again, no contraindication has been found.

Once it has been confirmed that everything is correct, Clare double checks the chart again, and then administers the drug to Mary via her IV infusion of saline. Clare then signs and dates the prescription chart to confirm that the medication has been administered, and Fiona then signs and dates the chart as well to confirm that she has witnessed the procedure. This prevents the dosage being inadvertently duplicated, and ensures that Clare's practice is in keeping with the law on the use of controlled drugs, local hospital policy and the NMC guidelines. It also ensures that if any adverse reaction or toxicity occurs, or it does not appear that the prescribed 25mg dose of morphine adequately controls Mary's pain, then Mary's team of healthcare professionals can review the prescription knowing exactly what medication Mary has received and when.

Clare then checks Mary's vital signs to ensure that there is no sign of toxicity, and that the administration of medication has been effective. If Mary showed signs of an adverse reaction, for example symptoms of opioid toxicity such as drowsiness, hallucinations or respiratory depression, Clare could then alert Mary's doctor immediately and take any necessary actions to control the situation (e.g. the administration of the drug naloxone). However, in this instance, Mary does not show any signs of toxicity or adverse reaction, and reports that her pain is more controlled. This indicates that the right response to the medication has occurred. Clare and Fiona double check once more that the right documentation has been completed - specifically, Mary's notes and the ward controlled drug record.

Scenario B - Delegation of Drug Administration to Others

Sam is a registered nurse with 10 years' post qualification experience working on an elderly care ward. She has recently been designated as a mentor to Phil, a final year student. Sam's ward is short staffed today due to illness. She must complete her drug rounds to ensure that all her patients receive their prescribed medications. To complete this task in a timely manner, she decides to delegate some of the drug administration tasks to Phil. Sam and Phil have worked together for 6 months and she feels confident that Phil can perform this task and that he has the appropriate skills and knowledge to administer the medication safely. Sam is also aware that Phil is very nearly a qualified nurse and will soon be professionally accountable for his practice, therefore it is an appropriate part of his training to increase his responsibility so that he can complete his development into an autonomous professional nurse. To ensure that the delegation process runs correctly, Sam considers the situation through the "5 rights" of delegation rule.

Sam selects three patients - Bill, Yvette and George - who require the routine administration of subcutaneous insulin. She feels that this is a suitable task to delegate, as it is specific and straightforward and in keeping with local policies on delegation as well as NMC guidance. The procedure does not involve the administration of a controlled drug; therefore, this is a legally acceptable task to delegate to Phil. Sam is also aware that Phil has been shown how to perform this procedure many times, and has also performed the procedure repeatedly under supervision as part of his training. Together these factors support her theory that this is the right task to delegate to Phil.

Phil is keen to take on more responsibility and is confident that he has the appropriate experience, ability and knowledge to perform the task safely and correctly. Sam therefore feels confident that he is the right person to be delegated to, and as she will be on the ward at the same time attending to other patients, she is also the right person to do the delegating as she will still be available to oversee the process and give Phil support if required. Sam confirms that the delegation will happen under the right circumstances, as Phil will be working on a ward he is very familiar with and as Sam knows that Phil has recently checked the supply cupboards; she is confident that he will have access to the right resources and equipment to carry out the task safely.

Sam then ensures that she gives Phil clear instructions about the tasks she wishes him to complete. She ensures that he understands the objective (namely the administration of routine subcutaneous insulin injections to Bill, Yvette and George). She confirms with Phil that he is happy with the delegation and that he is confident that he can complete the task. Sam also confirms that Phil is aware of his own limits; specifically, he will not attempt to administer any other types of medication and knows to ask for advice or assistance if he has any queries (rather than going ahead despite any uncertainty). Sam also confirms that Phil knows how to complete the required patient documentation, and that as the supervising nurse delegating the task to him, she will need to countersign the notes.

Phil then completes the drug administration. He visits Bill first and uses the 9 rights rule to ensure that the medication is administered correctly. He confirms that he has the right patient, that the insulin was prescribed at the right dosage and via the right route. Bill's history of type 1 diabetes confirms that the insulin has been prescribed for the right reason. Phil checks that the instructions are clear and unambiguous. He then prepares the drug for administration, checking that he has the right form and right preparation of insulin and that subcutaneous injection is the right route for the prescribed drug. Phil then checks the time of the last dose to confirm that the current dose is indeed due, in accordance with the doctor's instructions, and that no doses have been omitted. Phil administers the dose in accordance with local guidelines, ensuring that he uses a different site to the most recent doses and in accordance with hygiene regulations (washing his hands before patient contact, using gloves, and using alcohol wipes to prepare the skin). After completing the procedure and disposing of the clinical waste and sharps correctly, Phil monitors Bill for any evidence of an adverse reaction. He then completes Bill's patient records with the appropriate information.

After completing the task of administering sub cutaneous insulin to each patient, he asks Sam to review the notes and countersign to confirm that procedures have been followed safely and correctly. Once the drug round is complete, Phil and Sam can then fully review and evaluate the delegation. Sam evaluates Phil's performance, identifying any areas of improvement and discussing any issues she found when reviewing the notes. For example, when Phil completed the record of Yvette's insulin administration, Sam noticed that he had forgotten to print his name next to his signature so that he was easily identifiable. They discuss the importance of this and Phil is confident that he will not make this omission again. The delegation experience can also be included in Phil's performance review from the placement on the ward as part of his ongoing training record.

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