single unit mandatory training workbook€¦ · · 2017-05-05input and manage untoward incidents...

Blackpool Teaching Hospitals

NHS Foundation Trust

NH

S

Single Unit Mandatory Training Workbook

Medicines Management – Community

Services, Clinics and Intermediate Care

Bed Based Services

Learning Outcomes

After completion of this work book and the accompanying test the staff member should be able to:-

1. Understand what medicines management means and why medicines need managing

2. Know how to obtain supplies of medications for patients in your care.

3. Understand the legalities of prescribing and authorisation

4. Know how to appropriately store and transport medication if necessary.

5. Know and have understanding of the 6 R’s of medication administration and their contribution to ensuring safe medication administration.

6. Have an understanding of which are high risk medicines

7. Understand the process of delegation and the accountability for the registrant in relation to this.

8. Be able to safely dispose of appropriate medicinal products.

9. Understand the importance of identifying patients that may be taking alternative medicines and the potential impact on prescribed treatments.

10. Input and manage untoward incidents in relation to medication errors.

11. Understand the legal and professional accountability of controlled drugs.

12. Know how to access pharmacy personnel for advice as well as access the IT resources available in relation to pharmaceutical information.

What is Medicines Management?

There is no single answer to this question. The concept of medicines management has evolved over

a number of years in different places in the UK. Consequently, there are a number of different

definitions depending on the circumstances and context in which the term is used. For example, the

Department of Health’s Hospital Medicines Management Framework (1) describes two specific

components. These are clinical & cost-effectiveness and safe and secure handling of medicines.

Whereas, the NPC document “Modernising Medicines Management” (2) gives a much broader

definition. It describes medicines management as “…a system of processes and behaviours that

determines how medicines are used by the NHS and patients”. Rather than getting too bogged

down in definitions, a simpler way of thinking about medicines management is that it is about

“enabling people to make the best possible use of medicines.”

This workbook covers the basic principles of medicines management however individual medicines

and processes are not within the scope of this package.

Prescribing is the most common therapeutic intervention in the NHS. The complexity, volume and

cost of medicines are all increasing.

Increasingly patients are being prescribed 4 or more medications.

All medicines have the potential to cause harm to our patients.

There is a considerable body of evidence that medicines management needs to be improved,

whether this is from the point of view of patient safety, service efficiency or cost.

Medicines are an integral part of modern disease management, whether they are used for

prevention, treatment or alleviation of symptoms. The volume of medicines prescribed and their

cost is increasing each year.

Patient safety is paramount. Good medicines management can help reduce the likelihood of

medication errors and hence patient harm.

Medicines play an important part in promoting well-being, preventing ill health and managing

disease.

Medicines management is everybody’s business.

The likelihood of a patient being involved in a medication error increases by 65% if they are taking 4

or more medicines.

Medicines Management Training

Medicines Management Training is classed as mandatory within the Trust for all staff that manage

medication.

You are required to attend face to face a full days training with the Medicines Management

Specialist Nurse once in every 3 year period.

For the other 2 years you will remain compliant by completing this workbook and passing the assessment. You must register with the Learning and Development Department for all provided training. Medicines Management Training is recorded on OLM (Oracle Learning Management). Once completed ensure you complete the Workbook Completion Statement at the end of the book. You must send a photocopy of this statement to Learning and Development for recording on your electronic staff record. Completion of the course/workbook/e-learning package or failure to complete the

course/workbook/e-learning package will be recorded on your electronic staff record and will affect

your competency to undertake the administration of medicines.

If a medication error is made then training must be completed after that.

Section 1 – Methods of supply and/or administration of

medicines

Methods of supplying and /or acquisition of medicines in a the community or in a clinic setting

Medicines for use in clinic settings only are obtained from the Trust Pharmacy with the

exception of permitted and appropriate “patients own” medicines.

It is not acceptable for staff to acquire any medicines directly from companies/company

representatives

Medicines are supplied against a Pharmacy requisition to wards/clinics with this service.

There is an ordering/delivery schedule for each service.

Medicines supplied for use in clinical areas must not be used for the treatment of relatives,

carers or friends of patients or for the treatment of hospital/clinic staff.

Medicines to be administered using a patient-specific direction (PSD) are usually supplied by

either BTH pharmacy or GP practice (e.g. vaccines). A PSD is a written instruction from a

qualified and registered prescriber for a medicine including the dose, route and frequency

or appliance to be supplied or administered to a named patient. Medicines supplied for

specific, named patients must not be issued to other patients

Medicines in the community setting are usually patients own and obtained by prescription

(FP10), being generated by a prescriber and dispensed by a community pharmacist.

Medicines to be administered using a Patient Group Direction (PGD) are usually supplied by

either BTH pharmacy or GP practice (e.g. Flu vaccine)

Pharmacy Access

Weekdays 0845 - 1700 Saturday 0845 - 1700 Sunday 0845 - 1700

Out of hours:-

The Pharmacy Department is closed.

A Clinical Pharmacist will be available via switch board. This pharmacist will be able to give advice

over the phone or occasionally dispense medications via the robots into the Emergency Drug

Cupboard. If this is not possible they may attend to dispense from the department.

Section 2 – Dispensing

Doctors may in exceptional circumstances label from stock and supply a clinically appropriate medicine to a patient, against a written prescription, for self-administration or administration by another professional. When supplying under PGD, this should be from the manufacturer’s original packs or over-labelled

pre-packs so that the patient details, date and additional instructions can be written on the label at

the time of supply. Health care professionals must not split packs.

Section 3 – Storage and Transportation

Storage

For the storage of medicines in the community:

Together with patient and carers’ identify a safe place for the storage of medications- clean, dry

and out of reach of children and animals. If temperature sensitive, medication must be stored in a

fridge.

Clinic Based Services:

With the exception of drugs for emergency use, all medicines must be stored in a locked drug

cupboard, refrigerator or trolley secured to a wall, and must be kept under conditions which meet

legal requirements and manufacturers recommendations.

Temperature monitoring in clinic based services:

The temperature of the room where medicines are stored must be monitored at least weekly using

an approved digital thermometer that records maximum and minimum temperature reached. The

maximum temperature reached must be recorded on an approved trust form. The thermometer

must be reset immediately after the temperature has been recorded.

Containers - Including bottles, boxes and mini grip bags

These are filled and labelled by the Pharmacy staff. Contents of the containers must not be

transferred to other containers, nor labels altered or endorsed in any way.

Drugs for External Use

All medicated products for external use must be stored in a locked cupboard separate from the

drug cupboard that contains medicines for internal use.

Drug Refrigerators in Clinic or Bed Based Services The temperature of medicine or drug fridges must be recorded each working day / daily. The temperature must be between 2-8 Degrees Celsius. The following details must be recorded on the daily temperature record sheet; Maximum temperatures, Minimum temperatures, Actual temperatures and Thermometer reset This is particularly important as some medicines require storage within a limited temperature range, for example, refrigeration of vaccines when maintenance of the cold chain has to be evidenced.

Transportation

Transportation – community settings Health care professionals may transport medication to patients homes, including controlled drugs, only in exceptional circumstances where there are no other means of the patients obtaining the medications , provided the health care professional is conveying the medication to a patient for whom the medicinal product has been prescribed, (for example, from a pharmacy to the patient’s home).

Transportation – other settings

BTH transport services deliver to specified bases on specified days.

Section 4 – Standards for practice of administration of

medicines

Principles for the Administration of Medicines

The basic checks before any medication is administered are the 6 R’s:-

RIGHT Patient

RIGHT Drug

RIGHT Dose

RIGHT Route

RIGHT Frequency

RIGHT Date

In order to exercise professional accountability, in the best interests of patients, the healthcare

professional must:

Know the therapeutic uses of the medicine to be administered, its normal dosage, side

effects, precautions and contra-indications

Be certain of the identity of the patient to whom the medicine is to be administered

Be aware of the patient’s care plan

Check that the prescription and the label on the medicine dispensed by a pharmacist, is

clearly written and unambiguous

Have considered the dosage, method of administration, route and timing of the

administration in the context of the condition of the patient and co-existing therapies

Check the expiry date of the medicine to be administered

Check that the patient is not allergic to the medicine before administering it

Contact the prescriber or another authorised prescriber without delay where contra-

indications to the prescribed medicine are discovered, where the patient develops a

reaction to the medicine, or where assessment of the patient indicates that the

medicine is no longer suitable. In the case of the patient developing a reaction to the

medicine, contact the medical practitioner without delay

The health care professional must also be satisfied that the drug is given according to the appropriate Trust clinical procedures.

Has received Trust approved training, supervision, and is competent to use medical devices that may be employed to deliver drugs to patients e.g. Syringe Drivers.

Make a clear, accurate and immediate record of all medicine administered, stating the

date and time of administration, the dose and route of administration; medicines

intentionally withheld or refused by the patient, ensuring that any written entries and

the signature are clear and legible

Where supervising a student nurse, midwife or ODP trainee in the administration of

medicines, the signature of the student nurse, midwife or ODP trainee should be clearly

countersigned by the supervising registered practitioner

Some drug administrations can require calculations to ensure that the correct volume, or quantity,

of medication is administered. In these situations, a second registered practitioner must

independently check the calculation in order to minimise the risk of error.

The use of calculators to determine the volume or quantity of medication should not act as a

substitute for arithmetical knowledge and skill.

It is unacceptable to prepare substances for injection in advance of their immediate use or to

administer medication drawn into a syringe or container by another practitioner when not in their

presence (NMC 2008 Standards for Medicines Management)

In an emergency, where you may be required to prepare substances for injection by a doctor, you

must ensure that the person administering the drug has undertaken the appropriate checks as

indicated above.

Authorisation / Prescribing

Staff must only supply and administer medicinal products in accordance with one or more of the following processes:

Patient specific direction (PSD)

Patient medicines administration chart (may be called Medicines Administration Record sheet MARs). All medicines must be prescribed by a medical/non-medical prescriber.

Patient group direction (PGD)

Medicines Act exemption

Homely remedy protocol

Prescription forms

A practitioner must not administer any medicine unless it has been correctly, legibly and legally

prescribed, or working to an up to date PGD.

Only a qualified medical or non-medical prescriber can legally prescribe a drug for a patient.

In the absence of a valid prescription / authorisation or PGD, medicines must not be administered.

The clinician must ensure the correct authorization has been completed legibly e.g. Medicines

administration record or MARs. If in any doubt the registered health professional concerned must

seek professional advice from the pharmacist, prescriber or a senior nurse before the drug is

administered.

The registered health professional must, in administering any medicines, exercise professional

judgement and apply knowledge and skill to the situation that pertains at the time.

Patient Group Direction (PGD)

A PGD is a specific written instruction for the supply and administration of a licenced medicine in an

identified clinical situation.

An increasing number of medications are now on patient group direction (PGD’s). The department

has to get these PGD’s authorised by pharmacy. Each practitioner using these also has to sign to say

that they have read all the drug information and are happy to abide by the PGD. A record must be

kept in the clinical area. These PGD’s vary from area to area depending on clinical need.

High Risk Medicines The following medicines are considered to be High Risk and as such staff should take particular care when prescribing or administering:

Anticoagulants

Opioids

Insulin,

Anaesthetics,

Epidurals

Injectable Medicines,

Chemotherapy / Cytotoxics

ALL medicines that you are unfamiliar with

Section 5 – Delegation

A health care professional is responsible for the delegation of any aspects of the administration of

medicinal products and they are accountable to ensure that the patient, carer, health care support

worker or assistant practitioner is competent to carry out the task.

Refer to the Trust procedure: Process for the Delegation of Clinical Tasks

http://fcsharepoint/trustdocuments/Documents/CORP-PROC-630.docx


Section 6 – Disposal

The Trust and staff have a legal obligation for the safe disposal of medicines. Inappropriate handling

of waste can have considerable effect on the environment.

The Environment Agency can issue fines or prosecute for incorrect disposal. Medication must never

be disposed of down the sluice or sinks.

Staff should refer to the Trust Procedure: Safe Disposal of Medicines CORP/PROC/583 and Health

Technical Memorandum 07-01: Safe management of healthcare waste.

All patients should be advised to dispose of unwanted medicines by returning them to the

community pharmacy for destruction.

Destruction of Controlled Drugs in Clinic & Bed based settings

Denaturing is to destroy in such a way that the CD is rendered irretrievable so that it cannot ever be reconstituted or reused. The pharmacy department has researched methods of denaturing and recommends the following:

Place the CD into an appropriately sized and medicinal sharps bin.

Tablets – crush before adding.

Powders – add direct.

Liquids – add direct.

Ampoules – empty contents in and then add the ampoule.

Patches – fold.

Epidurals/PCAs etc. – squeeze liquid out of syringes/bags and put giving sets/syringes into the medicinal sharps bin.

Add one Gel Vac/Vernagel sachet per 1 litre of liquid.

Immediately seal the bin.

The disposal must be witnessed by another authorised nurse, midwife, ODP, pharmacist or doctor.

The disposal must be recorded in the CDR and countersigned by both parties witnessing the destruction.

Expired CDs must be disposed of by a Pharmacist. The pharmacist will be requested to attend the ward and remove the CDs and dispose of within pharmacy. The removal of the CDs will be documented and witnessed within the CD drug register. This provides a clear audit trail for the purpose of legislation and compliance monitoring.

Refer to BTH policy on Safe Disposal of all Medicines http://fcsharepoint/trustdocuments/Documents/CORP-PROC-583.doc

http://fcsharepoint/trustdocuments/Documents/CORP-PROC-583.doc

Section 7 – Unlicensed medicines

An unlicensed medicine is the term used to refer to a medicine that has no marketing authorisation. Occasionally unlicensed medicinal products are used for patients. These are supplied to meet the

needs of individual patients. These are only used if no licensed medication is available to be used

for patients. All unlicensed medications are supplied by Pharmacy.

If an unlicensed medicine is administered to a patient, the manufacturer may not have liability for any harm that ensues. The person who prescribes and dispenses or supplies the medicine carries the liability. This may have implications for you in obtaining informed consent. A health care professional may administer an unlicensed medicinal product with the patient’s

informed consent against a patient-specific direction (PSD) but not against a patient group direction

(PGD).

Section 8 – Complementary medicines and alternative

therapies

Complementary medicines e.g. aromatherapy, herbal or homeopathic remedies are used for

therapeutic purposes and require the same safeguards as other medicines. Leeches and larvae are

included in this category. Health care professionals must have successfully undertaken training and

be competent to practice the administration of complementary and alternative therapies.

During a patient consultation regarding medication, it should be checked as to whether they are

taking any complementary medications.

These complementary medications may not be thought of as medicines by the patient so they may

not initially mention them. They can however interact with the medications they are being

prescribed and reduce the efficacy of them.

For example:-

Ginkgo Biloba should not be taken with Warfarin, Heparin or Ibuprofen (MHRA 2014).

St John’s Wort should not be taken with cardiac drugs, anti-coagulants, antidepressants and

calcium channel blockers.

Advice should be sought from a pharmacist to check that there is no interaction to the medications

prescribed.

Section 9 – Management of adverse events (Incidents or

errors)

Effects of Medication

As a health care professional, if you make an error you must take any action to prevent any

potential harm to the patient and report any untoward effects of medication to the prescriber or

nominated deputy. Adverse drug reactions (ADRs) must be reported using the Yellow Card system

which is in the back of the BNF or electronically (via on-line BNF/ BNFc).

It is important that any incident involving medications is reported via the Trust Untoward Incident

Reporting System. These should be reported within 24 hours of the incident occurring or when the

incident came to light.

When completing an untoward incident that involves the administration of a medicine using a

medical device you must also include, the type of device and asset number, the name, dose/rate of

the medicine and a clear description of the fault.

Controlled Drug (CD) Errors

Controlled drug incidents must be reported in the same way as other incidents. An Untoward Incident form must be completed for ALL ‘‘actual’’ and ‘‘near miss’’ CD incidents. They should be scored dependent on the harm caused to the patient. All incidents involving CD’s

must be classed as Level 3 and a Root Cause Analysis completed.

If a discrepancy is discovered:-

Balance should be rechecked by another person

Recheck that all entries have been made and are correct

Recheck the balance has been calculated correctly

Check stock has not been stored elsewhere

5% difference is acceptable in oral medications If the discrepancy remains, the registered health care professional in charge of the clinic must be informed.

If the discrepancy cannot be resolved the ward manager must be informed.

If theft is suspected senior management must be informed including the Director of Pharmacy as the Accountable Officer.

The Accountable Officer must be contacted directly if there are any concerns regarding the

clinical use or management of CDs.

The Accountable Officer (Director of Pharmacy) must be informed via the Untoward

Incident Reporting System within 24 hours of ALL CD discrepancies/losses/incidents.

Section 10 – Controlled Drugs

Health care professionals should ensure that patients prescribed controlled drugs (CDs) are

administered these in a timely fashion in line with the standards for administering medication to

patients. Health care professionals should comply with and follow the legal requirements and

approved local standard operating procedures for controlled drugs that are appropriate for their

area of work.

The following trust policy & procedure apply to all areas:

Corp/Proc/302 Controlled drugs - Safer management of controlled drugs

Corp/Pol/303 Controlled Drug Policy

Controlled Drugs (CDs) Clinic Settings only

The administration of CDs requires the double checking by 2 registered practitioners at all stages of

the process. Signatures must be clear.

All documentation relating to CDs are legal documents and must be managed as per legislation and

Trust policy.

Safe Storage and management of CDs

No ward, theatre or department should store schedule 2 and 3 CDs unless there is an appropriately

registered practitioner responsible for the safe and appropriate management of CDs in that area.

The registered healthcare practitioner in charge can delegate control of access (i.e. key holding) to

the CD cupboard to another, such as registered practitioners. However, legal responsibility remains

with the registered practitioner in charge.

All CD’s must be stored in a designated CD cupboard, which complies with the statutory security

conditions currently in force. There is no requirement for the CD cupboard to be within another

cupboard, neither is there a requirement for an indicator light to be fitted (however both these

practices are acceptable).

Where epidural injections and/or infusions are used, these must be stored separately from other

parenteral preparations.

The CD cupboard must be kept locked when not in use.

The CD key must not be common to any other key in the department.

The CD cupboard must be used solely for the storage of CDs and not for any other medication or

items.

The CD Key must be kept separate to the main clinic keys.

Identification of potential abuse in CDs

Incidents in relation to CDs must be reported within 24hours to the Accountable Officer (Director of

Pharmacy), Accountable Officer via the Untoward Incident Reporting System.

Incidents involving CDs are serious incidents. The score of the incident is determined by the harm

caused to patients, staff or the Trusts integrity. Consideration must be made into the nature of the

incident and processes involved, deliberate abuse and / or concealment of incidents.

Two members of staff must check CD stock every 24 hours or at shift change. One must be a

registered nurse, Midwife, Doctor, Dentist, Dental nurse, Pharmacist or ODP (Operating

Department Practitioner). The 2nd checker may be a Registered Nurse, Midwife, Doctor, Dentist,

Dental nurse, Pharmacist, ODP or Student Nurse (UCLAN students only - who have undertaken

Intermediate Medicines Management training at the end of their second year) willing to undertake

the task and knowledgeable about CDs and their accountability.

All cupboard contents and all Controlled Drug Registers must be checked.

For oral liquid CDs, an approximation of balance will suffice, as the action of pouring liquids out to

measure will cause discrepancies. However, balances must be correct at the start of a new bottle.

Contact the pharmacy to make any corrections to balances.

The two checkers must check every drug in the CD cupboard every day and sign on each page of the

CDR that the check has been performed.

Pharmacy staff will check the CD register balances against CD cupboard stock, and a sample of

entries made against corresponding CD requisitions every 3 months.

Management of controlled drugs stock and stationary

Restricted Drug Registers are physically a Controlled Drug Register (CDR) but used for the purpose

of monitoring high risk drugs e.g. High Strength Potassium injections, Midazolam 10mg/2ml.

No cancellation, obliteration or alteration of any entry may be made.

An entry made in error must be bracketed and endorsed “error” in the margin, signed, dated and as

good practice countersigned by a witness.

• Entries must be chronological.

• Every entry must be in ink.

• All records must be stored for two years from the date of the last entry in the register.

Management and Investigation of discrepancies

See Section 6

Destruction and disposal of CDs in Clinic Settings

See Section 6

Controlled Drugs within Community based services

Safe storage and management of CD’s

Together with patient and carers, identify a safe place for the storage of controlled drug

medications; ideally in a clean, dry place out of the sight and reach of others (consider children and

animals).

In a patients home where a clinician is administering a controlled drug which has already been

prescribed and dispensed to that patient the requirement for a second checker/ signatory should

be based on local risk assessment.

Community Pharmacy Just in Case drug scheme Just in Case medicines are held by specified pharmacies in the community. Please ensure you are familiar with the pharmacies in your Locality by accessing the link below or discussing this with your team: http://fcsharepoint/trustdocuments/Documents/CORP-PROC-592.docx Safe disposal of controlled drugs All patients should be advised to dispose of unwanted medicines (including controlled drugs) by

returning them to the community pharmacy for destruction.

Community / Clinic settings - Student Nurses and Controlled Drugs

This only applies to UCLAN students at present

On completion of the second year pre-registration student Intermediate MedicinesManagement

training day, and successful completion of the Controlled Drug Supervision Record, the pre-

registration students may: (At the discretion of the supervising nurse , based on knowledge and

confidence of pre-registration student )

• Participate in the checking of controlled drug stock as a 2nd checker.


• Administer a Controlled Drug (excluding the administration of intravenous controlled drugs)

under supervision by those authorised and registered staff that accepts responsibility and

accountability for the process.

• Participate and witness the disposal of controlled drugs in hospital bases only.

• Complete documentation including the controlled drugs register under supervision.

Audits

There are a variety of audits carried out by Pharmacy to look at the safe handling and

administration of medicines. The following are audits that are carried out:-

Medicines management Audit (yearly)

The Lead Pharmacist Community Health Services audits community clinics for the management of

medicines against Trust procedure: http://fcsharepoint/trustdocuments/Documents/CORP-PROC-

593.docx

NPSA 15 Audit (yearly)

This audit focusses on 15 key areas. These areas were identified by the National Patient Safety

Agency (NPSA) as being involved in a high number of adverse patient incidents. A series of

questions are sent to each clinical area based on these. The clinical areas then have to ensure that

staff are aware of how to identify and act upon the specifics for each alert. For example staff should

be aware that a purple syringe should be used for oral medications rather than a hypodermic

syringe.All areas within the Trust including ALTC are audited to ensure compliance. Those alerts

that are not applicable are recorded as such.



NPSA Alerts

Midazolam

Midazolam 10mg/ 2mls (mainly used in palliative and critical care)

Needs a risk assessment before an area can stock it

Staff need to be aware that flumazenil if the reversal agent

Flumazenil has a shorter half-life than midazolam so additional doses may be needed

Paraffin

Topical paraffin based products pose a fire risk

Patients often have large amounts of these emollients on their skin along with bandages.

Risk of ignition if patient is exposed to naked flame

Severe burns can result from this

Patients need verbal and written advice on the first occasion these are used and then advice

reiterated afterwards

Paraffin warning posters to be displayed in all areas where paraffin used

Injectable Medicines

Higher risk of patient harm from injectable medicines due to fast action

Errors can be as high as 49% for IV Medications

Risk assessment should be in place for all injectable medicines given in clinical areas and action

plans for these

Information sources available in paper and electronic form on how to handle medication

Main error time is during administration

Ensuring staff are carrying out drug calculations safely

Low Molecular Weight Heparin

Patient weight must be recorded on all prescription charts and ever effort must be made to ensure

this weight is accurate.

Weight needs to be monitored throughout treatment to ensure that the correct dose is given

Under dosing increases risk of thromboembolic events and overdosing increases risk of bleeding

Most common errors are no weight recorded or under / over dosing

Risk of adverse effects increased in patients with renal impairment

Need to check creatinine clearance level before patient receives the 2nd dose.

Bowel Preparation

Frail and debilitated elderly patients, children and those with contraindications are at high risk

Full explanations need to be provided before the patient takes them and a clinical assessment

Staff need to be aware of the contraindications such as patients on diuretics

It may also modify the absorption of oral medications such as antibiotics or anti epileptics.

Oral Medications via Incorrect Route

There is an increased risk of wrong route of administration if oral medication is not given using an

oral/ enteral syringe.

Patients have died after receiving oral medication through central lines because the medication was

placed in a hypodermic syringe.

Oral syringes are coloured purple to make them distinctive from hypodermic syringes so they

cannot be confused

Hypodermic syringes should never be used for oral / enteral medication

Anticoagulant Therapy

All staff working with anticoagulants should have the necessary competence and knowledge

Yellow monitoring books should be given to the patient on commencement of therapy

Patients should get verbal and written advice at the start of the therapy as well as at discharge and

at their first clinic appointment

Patients should be aware of the importance of INR monitoring

Epidurals

Certain medications can only be administered via epidural form. There have been patient deaths

resulting from epidural medications being given intravenously

Epidurals are only in use in certain areas of the Trust

Staff who are involved in these have specific training and competencies completed

Epidurals if stocked in a clinical area must be stored separately from other medication. They must

also be clearly labelled as epidural use only

Vaccine Cold Storage

If vaccines are incorrectly stored their efficacy can be reduced causing vaccine failures

Freezing of vaccines can cause cracking of the syringe leading to potential contamination

Vaccines should be stored in a specified vaccine fridge

This fridge should be between 2-8 degrees Celsius

The fridge temperatures should be regularly monitored

Intravenous Flush Solutions of Heparin

When indicated Heparin 10units/ml and 100units/ml is available as a flush but only for implantable

devices

Therapeutic dose of heparin is 1000 units/ml

Usually only stock heparin products of 1,000 units /ml or less

These are restricted to use in maintenance of implanted, tunnelled or ported catheters

Once this item is drawn up the syringe should be labelled immediately

This concentration of heparin should be stored separately from other heparin concentrations

Lithium Therapy

It is important to ask patients if they are on Lithium therapy

Patient on Lithium have a purple book which contains details of their therapeutic Lithium levels

Lithium levels can be altered by other medications and the patient can become lithium toxic

Lithium levels can only be taken within 12 hours of the last dose

Opioid Medication

It is important to check what current medication a patient is taking before administering opioids to

them

It is important to check that the dose given is not greater than 50% higher than their usual dose

Previous transdermal patches should be removed before placing another one on the patient. The

location of these should be noted and sites rotated

Staff should be familiar with naloxone as the antidote for opioids. Naloxone has a shorter half-life

than opioids so repeated doses may need to be given CORP/POL/530.

Omitted Medicines

There is a list a critical medicines that should not be omitted due to risk of adverse incident to the

patient

Some medications are time critical such as Parkinson’s medications and must be given on time

every time to prevent the patient’s condition deteriorating

Medication Loading Doses

Staff must to be aware of the differences between loading and maintenance doses to ensure that

the appropriate one is prescribed and administered.

Patient harms have resulted by patients being given several loading doses rather than a loading

dose followed by a maintenance dose

The main medications to be aware of are:-

Digoxin

Phenytoin

Amiodarone

Warfarin

Aminophylline

Acetylcysteine

Information on the correct doses for these medications can be found in the BNF and the online

resources available through the medicines management site on the Trust Intranet.

Risk of Hyponatremia

Children and elderly patients have suffered serious neurological injuries from receiving hypotonic

solutions

0.18% sodium chloride with glucose 4% dextrose solutions are removed from most clinical areas

These are restricted to critical care and specialist areas because of the risk of hyponatremia

If stored in a clinical area it must be labelled as not to be administered to children

Policies and Procedures

There are a wide array of policies and procedures relating to medicines management. All of these

can be found in the document library available via the Trust intranet. The policies belonging to

Pharmacy can be found in the Medicines Management home page also. There are a wide variety of

medication policies and staff should be familiar with the ones that are relevant in they are working

in. Some of the more general use policies available are:-

Administration of Medicines CORP/PROC/307

Administration of Medicines / Medicines Management for Pre-Registration Student Nurses,

Student Midwives and Trainee Operating Department Practitioners CORP/POL/304

Clinical Trials Involving Pharmaceutical Products CORP/Guid/302

Controlled Drug Policy CORP/PROC/303

Controlled Drug – Safer Management of Controlled Drugs CORP/PROC/302

Custody and Safe Keeping of Medicine Keys CORP/PROT/302

Emergency Access to Medicines CORP/PROT/300

Management of Medication Errors CORP/PROT/310

Medicines Policy CORP/POL/300

Non – Medical Prescribing Protocol CORP/PROT/509

Patient Group Directions CORP/POL/044

Prescribing – a Zero Tolerance Approach to Safe Prescribing CORP/PROC/301

Safe and Secure Handling of Medicines – Ordering, Receipt, Storage and Distribution on the

wards CORP/PROC/593

Safe Disposal of all Medicines CORP/PROC/583

The Administration of Authorised Medicines, the 2nd Checking of Intravenous Fluids, and

the Assistance with the Management of Controlled Drugs by Qualified Assistant

Practitioners CORP/POL/446

Information Resources

Pharmacy

Every day except Christmas day (09.45 – 17.00) 01253 954780

Medicines Information (0900-1700, Monday-Friday) 01253 953791:

Clinical Pharmacist advice on medicines

Speciality Pharmacists via Bleep:

These can be contacted in normal working hours via bleep. The bleep numbers are available on the

Medicines Management page or contact via switchboard.

Out of hours the on call pharmacist can be contacted via switch board (Emergency only).

Medicines Management Nurse (weekdays 0845-1700):

Offering nursing advice on medicines management issues and professional guidance. Able to come

into the clinic and help with audit completion as well as to help ward staff ensure that they are

complying with medicines management practice. Also available to answer queries on patient and

safety risk in relation to medicines.

Medicines management advice is also available from the NMP Division Lead for ALTC by contacting

Blackpool Stadium 951685.

Intranet Site:

Document Library – This contains guidance on all aspects of medicines management within the

Trust. You need to be aware of the policies and procedures that are specific to your clinical area.

Medicines Management Intranet Home Page:-

This is accessible via the Intranet (green box on home page). This contains information in relation to

medicines and medicines safety. This area also has useful e-learning resources.

http://fcsharepoint/divisions/clinicalsupport/medicinesmanagement/Pages/default.aspx

Resources:

eBNF – Electronic version British National Formulary (paper version available on ward also)

http://bnf.org/bnf/index.htm

eBNFc- Children’s version

http://bnfc.org/bnfc/index.htm

EMC – Electronic Medicines Compendium (For healthcare professional information and Patient

Information Leaflets)

http://www.medicines.org.uk/emc/

Injectable medicines guide-

http://bfwnet/departments/medicines_management/inject.htm

UCL Injectable Guide – Injectable medicines guide in paper form available on ward.

http://fcsharepoint/divisions/clinicalsupport/medicinesmanagement/Pages/default.aspx

http://bnf.org/bnf/index.htm

http://bnfc.org/bnfc/index.htm

http://www.medicines.org.uk/emc/

http://bfwnet/departments/medicines_management/inject.htm

Now you have read the Medicines Management Work book

Complete the following multiple choice questions to ensure that you have all the knowledge and

information required to manage medicines safely in our Trust.

Once you have completed the workbook sign the declaration form. Your Manager/Team Leader is

required to witness your signature.

Once completed ensure you complete the Workbook Completion Statement at the end of the book.

You must send a photocopy of this statement to OLM for recording on your electronic staff record.

Questions and multi choice answers for Medicines

Management

Please circle your answers as you go through the questions and the pass mark must be 100%. Your

manager can request the answers from L&D. As a Qualified Health Professional you are accountable

for your own knowledge, therefore if you find you are not meeting the pass mark you must address

this with your manager.

1. Which statement best facilitates the safer administration of medicines? a) The Authorisation is clearly written as per policy but not signed, I am familiar with the medicine and its normal dosage, and I have confirmed the identity of the patient and their allergy status. b) A verbal instruction has been given for the medicine via telephone, I am familiar with the medicine and its normal dosage, and the patient has taken the medicine before and had only a mild reaction. c) The authorization is written correctly as per policy, I am familiar with the medicine and its normal dosage, and I have confirmed the identity of the patient and their allergy status d) The authorization is written clearly as per policy, I have never seen this medicine used via this route before, and I have confirmed the identity of the patient and their allergy status. 2. Who has the authority to sign a medicines administration record sheet (MARs)?

a) Medical or Dental Prescriber/Practitioner

b) Team Leader

c) Non-Medical Prescriber

d) Clinical Specialist 3. Which of the following are high risk medications?

a) Warfarin

b) Anti-inflammatories

c) Insulins

d) Steroids

4. What would you document when administering any medication by any route?

a) Date and Time

b) Medication administered

c) Sign the administration sheet

d) Reason if medication not administered

e) Any adverse events

f) All of the above

5. What is a Patient Group Direction (PGD)?

a) A map of the hospital

b) Specific written instructions for the supply and administration of a named medicine or vaccine in an identified clinical situation

c) A list of medicines that may be supplied without a prescription 6. What are your main responsibilities when administering medicines to patients?

a) To ensure the patient takes the medicine correctly and safely

b) To administer the medicine safely and correctly to the patient within my own competencies and knowledge, and to document as per Trust policy.

c) To document if a patient declines medication or the medication is omitted.

d) All of the above 7. A colleague has asked you to administer a drug that she has reconstituted when you were not present should you:

a) Administer the medicine and record the administration on the prescription

b) Refuse to administer the medicine and take no further action

c) Inform your colleague that you will reconstitute another dose of the medicine yourself and administer the prescribed dose and document the procedure

8. The temperature of medicine fridges must be recorded daily. The temperature is to be between 2-8 Degrees Celsius. What details must be recorded on the daily temperature record sheet?

a) Maximum temperatures

b) Minimum temperatures

c) Actual temperatures

d) Thermometer reset

e) All of the above 9. The ownership and storage, of controlled drugs in the patient’s home is the responsibility of: a) The GP b) The District Nurse

c) The Sister / Charge Nurse

d) The patient/ carers 10. When completing an untoward incident that involves the administration of a medicine using a medical device what information MUST you include?

a) The type of device and asset number

b) The name, dose / rate of the medicine

c) A clear description of the fault

d) All of the above

Workbook Completion Statement

Employee:

I confirm that I have read and understood the content of this work book , I confirm that this is my own work and if I

have concerns regarding my knowledge or practice I am will discuss them with my manager.

I am aware that every 3 years I must attend face to face training with the Medicines Management

Specialist Nurse.

Staff Surname: (BLOCK CAPITALS)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Forename: (BLOCK CAPITALS)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Staff Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Job Title: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Department Ward: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A PHOTOCOPY of this completion statement MUST only be sent to the OLM department when

your manager has completed their section, where it will be entered onto the Trusts Central

Training Database (OLM). It is only when this has happened will you be compliant with the

Mandatory Medicines Management workbook.

Managers:

Please only sign and return this statement when you are satisfied that your staff member has

completed the multiple choice questions at the end of the work book.

THIS WORKBOOK SHOULD BE KEPT BY THE EMPLOYEE.

A PHOTOCOPY of this completion statement MUST be sent to the Learning and Development

Department by the employee where it will be entered onto the Trusts Central Training Database

(OLM) It is only when this has happened that they be compliant with the Mandatory Medicines

Management workbook.

A Further copy of this statement should be placed in your staff members personal development

file.

This is to confirm that the Mandatory Medicines Management workbook requirement has been

completed by:-

Staff Surname: (BLOCK CAPITALS)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Forename: (BLOCK CAPITALS)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Job Title: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Department Ward: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date Completed: (THIS MUST BE WITHIN 12 WEEKS OF RECEIPT)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Manager: (PRINT NAME)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Manager Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Return a copy to OLM, ESR Department, Blackpool Teaching Hospitals,

Whinney Heys Road, Blackpool, FY3 8NR

An electronic copy can be emailed to: [email protected]

mailto:[email protected]

In acknowledgement to all staff who

contributed to the production of this work

book

Blackpool Teaching Hospitals

NHS Foundation Trust