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CHAPTER 10
Medicines Management
Introduction
This chapter explores the principles of medicines management in the perioperative environment. It covers issues related to the law, as well as those relevant to professional practice. Most patients in the acute environment will be given medicines, and safety in their use is particularly relevant in the perioperative environment. The chapter will focus primarily on the administration of medicines, although aspects related to prescribing, where relevant, will be discussed.
The Law Governing Medicines
The process of administering medicines has developed due to both legal and professional regulation. In the UK, the Medicines Act was first passed in 1968, and has had various additions in the form of amended directions since then. It governs many aspects of medicines use, and categorises medicines into three main types:
- GSL (General sales list) – medicines that may be sold directly to a consumer without a prescription or intervention from a healthcare professional
- P (Pharmacy medicines) – can be sold without prescription under the supervision of a registered pharmacist, in a registered premises
- POM (Prescription only medicines) – available from a pharmacist using a prescription from an authorised prescriber.
Prescriptions may be generated using either of two methods: a patient-specific direction or a patient group direction.
A patient-specific direction is the traditional written instruction, from a doctor, dentist, nurse or pharmacist independent prescriber, for medicines to be supplied or administered to a named patient. The majority of medicines are still supplied or administered using this process (Department of Health 2006). Examples of patient-specific directions are the inpatient drug chart used in most NHS hospitals, or in the theatre environment, an anaesthetic chart determined to be suitable by the organisation using it.
A patient group direction (PGD) is a written instruction for the supply or administration of a licensed medicine (or medicines) in an identified clinical situation, where the patient may not be individually identified before presenting for treatment (Department of Health 2006). A PGD is drawn up locally by a group of health professionals and must meet certain legal criteria and approved by the organisation in which it is to be used. PGDs can only be used by the following registered healthcare professionals, acting as named individuals: nurses, midwives, health visitors, paramedics, optometrists, chiropodists and podiatrists, radiographers, orthoptists, physiotherapists, pharmacists, dieticians, occupational therapists, prosthetists and orthotists, and speech and language therapists. Of note is the fact that registered operating department practitioners (ODPs) are not named on this list. Some organisations will have a local agreement which allows the use of PGDs by ODPs, although in practice they are not routinely used in the theatre environment.
Medicines may also be prescribed by qualified non-medical prescribers. Over the last 15 years, the role has developed significantly in order that patients can receive medicines in a more timely fashion. This development also ensures that the skills of appropriate healthcare professionals are better utilised, and that multi-disciplinary teams can develop processes to improve the patient pathway. This extension of responsibility now allows qualified and registered (with the Nursing and Midwifery Council (NMC)) nurse prescribers to prescribe any medicine to a patient with any medical condition, including some controlled drugs, if it is within their sphere of competence (Department of Health 2006). Pharmacist and optometrist prescribers may also now prescribe independently, but not controlled drugs, and other professional groups (physiotherapists, podiatrists and radiographers) may be trained to prescribe using a supplementary prescribing route.
Any suitably trained member of staff can legally administer medicines that have been prescribed by an authorised prescriber for an individual patient. This principle applies to registered and non-registered staff at all levels. However, non-registered staff cannot administer medicines using a PGD, and cannot train to prescribe medicines. Most NHS organisations have policies in place that limit the administration of medicines by non-registered practitioners to an identified list of medicines used in given situations. An example of this would be the administration of a 0.9% sodium chloride flush following insertion of a peripheral cannula.
Medicines used in the UK are granted a licence for use by the Medicines and Healthcare products Regulatory Agency (MHRA). The licence is granted for use of the medicine for defined indications, and is given following the pharmaceutical company providing proof of its safety and efficacy. Any medicine used for an indication outside of that for which it is licensed is used ‘off licence’. This must be at the direction of an appropriate prescriber, and patients should be informed of medicines used in these circumstances.
Professional Practice and Medicines
All healthcare regulators and most healthcare organisations will set standards for the prescribing and administration of medicines. The NMC Standards for Medicines Management (Nursing and Midwifery Council 2008) contains guidance relevant to all healthcare professionals administering medicines.
Patient identification is an essential step in ensuring safety. The patient wristband is most often used as the method of identification in theatres, and should be used to confirm identity before medicines are given.
Prior to administration of medicines, allergies or hypersensitivities must be confirmed and documented. Usually this will be on the patient’s medications prescription. Organisational policy will determine who can document allergies, but in most cases this will include any registered professional who is competent to do so. In documenting an allergy, it is important to also determine the reaction type and severity. Some allergies will affect others, for example an allergy to benzylpenicillin will mean that a patient should be documented as allergic to all penicillins. Individuals who are allergic to penicillins may also be hypersensitive to other antimicrobials, and a pharmacist will usually be involved to determine appropriate medication choices in this group of patients. In some cases it may be determined by a prescriber that medicines should be prescribed and given even though the patient has a documented sensitivity. In these instances, the person administering the medicine is responsible for confirming the credentials of the prescriber, and ensuring they are aware of any documented allergy before administration.
The practitioner responsible for the administration of a medicine must not rely solely on the information contained within the prescription. Mistakes in prescribing can occur, and the person administering must understand the indication for the medicine, as well as potential side-effects and usual doses. It is important to consider these factors in context with the patient’s past medical history as well as his or her current diagnosis. This information is particularly important for certain medicines, for example digoxin where the patient’s pulse rate must be known or preparations of intravenous fluids containing potassium, where the blood levels must be known.
When preparing the medicine for administration, a non-touch technique should be used, and an appropriate method of administration chosen. This may involve choosing liquid or dispersible preparations. If medicines are to be given in liquid form by mouth, an oral syringe designed specifically for this purpose must be used (NPSA 2007). In practice, these are usually purple in colour to distinguish them from those used for intravenous administration, and they must have connectors which prevent them from being inadvertently fitted onto an intravenous device. Medicine preparations must also be checked for their suitability for use, particularly that they are being given prior to the expiry date set by the manufacturer.
Paper-based systems for medicines prescription can be problematic in terms of their legibility. Many hospitals are moving towards electronic methods for prescription, administration, pharmacy validation and supply and also for discharge prescriptions and information to colleagues based in primary care. Distinct benefits will be seen in the legibility, timeliness, accuracy of prescriptions and patient safety through use of decision support, but it is essential that all users are given opportunity to be trained on their use, as well as understanding the local governance arrangements.
When you have administered a dose of a medicine, you must clearly document the date and time of administration, ensuring the name, dose and route are also clear. All of this information can be paper-based or electronic. There must also be a signature recorded for each medicine, and in the case of a controlled drug the signature of a second registered practitioner. Some organisations also mandate a second signature on other occasions, for example when the medicine is given via the intravenous route.
Where medicines are not administered for any reason, this must also be documented. The NPSA (2010) have highlighted the problem of missed and delayed doses of medicines, reporting incidences of patient harm. It is essential that medicines due for administration are obtained and administered promptly, especially where timeliness is essential such as antimicrobials, anticoagulants and medicines for treatment of Parkinson’s disease. Of particular importance in the perioperative environment is that all administrations are documented clearly in order that colleagues subsequently caring for the patient have all the information they need. For example, they can only safely determine a time for a second dose of paracetamol if they have clear information about when the previous dose was given.
Medicines Storage
Different clinical areas will have different guidance on storage of medicines, which are likely to be documented as part of the overarching medicines policy. All cupboards and cabinets must conform to the appropriate national standards, usually BS 2881:1989, Specification for cupboards for the storage of medicines in healthcare premises.
There should be guidance in place about the locking of cabinets and cupboards. This will generally state that in normal circumstances all medicines cupboards must be kept locked when not in use, and the key held by a registered practitioner, usually a nurse, midwife or ODP. Some theatre areas will have guidance in place which allows cupboards to remain open during a theatre list, as long as there is an individual responsible for monitoring the removal of medicines during this time.
Medicines must be stored in the container in which they are supplied. Medicines should not be transferred from one container to another, nor should they be taken out of their containers and left loose. Some medicines need to be stored at a certain temperature, including some which must be stored in a fridge. If a medicine needs to be stored at low temperature, this will be highlighted on its packaging. The fridge must be specifically designated for storage of medicines, and should not contain other items. The fridge must have a thermometer, and it is essential that someone is designated to be responsible for monitoring and recording the fridge temperature .
Controlled Drugs
The registered nurse or midwife in charge of an operating theatre or theatre suite is responsible for the safe and appropriate management of controlled drugs. Even if the theatre or theatre suite is managed by an ODP, the most senior registered nurse or midwife present is responsible for controlled drugs under the present regulations (Department of Health 2007). The registered practitioner in charge will usually delegate control of access (i.e. key-holding) to the controlled drugs cupboard to another, such as a registered nurse or an ODP. Similar considerations apply to requisitioning and checking of controlled drugs. There are designated responsibilities for professional groups who are involved in the management of controlled drugs in theatres;
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