NHS

Single Unit Mandatory Training WorkbookAcute Staff

Learning Outcomes

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

1) Know how to obtain supplies of medications for patients in your care. 2) Understand how One Stop Dispensing works.

3) Know how to appropriately store and transport medication if necessary. 4) Know and have understanding of the 6 R‟s of medication administration and their contribution to ensuring safe medication administration.

5) Have an understanding of which are critical medicines and how to obtain these in a timely manner. 6) Understand the process of delegation and the accountability for the registrant in relation to this.

7) Be able to safely dispose of appropriate medicinal products. 8) Understand how clinical trials medication is utilised.

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.

Why Medicines Management? „The administration of medicines is an important aspect of the professional practice of persons whose names are the Council‟s register. It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner (can now also be an independent and supplementary prescriber). It requires thought and the exercise of professional judgement.‟ Standards for Medicines Management (NMC 2010) Medication errors form one of the most common patient harms accounting for 10% of all harms (National Reporting and Learning system 2014). Prescription errors account of 7% of adverse events with administration errors accounting for 3-8%. The annual cost to the NHS related to the adverse effects of medication was estimated to be £770 million (Department of Health 2014). This workbook covers the basic principles of medicines management however individual medicines and processes are not within the scope of this package. .

Medicines Management Training Medicines Management Training is classed as mandatory within the Trust for all staff that administer medication. You are required to attend training every third year via workbook or e learning. If a medication error is made then training must be completed after that in line with CORP/PROC/310 Management of Medication Errors. The e learning package is available via the one HR section on the home page. Face to face sessions can be booked via learning and development.

Methods of Supply of Medicines  

Medicines are only obtained from the Trust Pharmacy with the exception of permitted and appropriate “patients own”. If patients bring their own medication in this should be checked by the nursing / pharmacy staff to assess its suitability for use. The following questions must be satisfied:- Is it the patient‟s own medication? Details need to be correct and legible - In original packaging and packaging in good condition? - Dated within the last six months? - Drug form and strength correct? - Only one drug per container? - Can identity of drug be confirmed? - Is it within its expiry date? The checklist to be completed is can be found in Appendix 1 CORP/PROC/307 Administration of Medicines.

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Medicines are supplied on a „top-up‟ basis based on ward stock item levels.

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Medicines supplied for use in clinical areas must not be used for the treatment of relatives, carers or members of hospital staff.

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Medicines supplied for specific, named patients must not be issued to other patients.

Pharmacy Access Weekdays

0845-1700

Saturday Sunday

0845 - 1700 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. Emergency Drugs cupboard- This is access to drugs that are not routinely stocked within the Trust. Access to this is restricted to the senior nursing staff holding 002, 048, 050, 930.

Accessing Medicines 24-7 If you require access to medication out of hours Medicines 24-7 can be accessed via the Intranet. This can be found via the green Pharmacy box on the homepage.

Medicines 24 - 7 Access To locate drugs out-of-hours: Intranet Homepage → Divisions and Departments → Medicines 24-7 → Type in a minimum of 3 letters (the more letters the better) of the drug name (check spelling) e.g. type phenytoin into the Drug Location List search box → Click View Report.

All available ward stock and EDC stock locations will be displayed over several pages.

This list is updated monthly by Pharmacy, it allows staff to source medicines within the hospital and identify where they are stocked or accessed from.

‘One Stop Dispensing’

One stop dispensing is available on a large number of wards on the Trust site.

Pharmacy staff can assess patient medication needs and supply appropriate medication to last during their hospital stay and for their discharge home.

Patients are encouraged to bring their own medicines into hospital and these are assessed to see if they are suitable and appropriate. The patient should be asked if they are happy to use their own medication. If they are then further supplies will be issued once these are exhausted. If not then supplies can be obtained from pharmacy.

On discharge pharmacy staff will ensure and if necessary dispense medication for patient discharge. All „One stop‟ wards have designated Pharmacy staff that take responsibility for patient supplies for that ward. They visit each day Monday to Friday and can be contacted via a bleep throughout the working day for individual patient supplies and discharge medications.

On Saturdays, Sundays and Bank Holidays if any urgent items are required for in-patient administration, the in-patient chart should be sent to Pharmacy marked with a red dot indicating items required.

For discharges during this time, the e-discharge should be written as normal then the inpatient chart and any medicines for the particular patient should be taken to Pharmacy for checking and dispensing as required.

Storage and Transportation Storage It is important that medications are stored in an appropriate manner for legal and practical reasons. All medications have optimum conditions that they need to be kept in to ensure that they are still safe and effective for patient use. Some medications need to be protected from the light whilst others need to be kept in a fridge for example. It is important to ensure that when medications are arriving from pharmacy that they are placed in their optimum storage location as soon as possible. Fridges should have a thermometer within them displaying minimum and maximum temperatures. The fridge temperature should be checked and recorded daily and any discrepancies should be dealt with in a timely manner. The fridge should also be kept locked. Ideally the room containing the pharmacy cupboards should also have a thermometer within to ensure that the temperatures in there are optimum also with a weekly check and recording of these. All medication should be in a locked cupboard to prevent misuse of medication either accidentally or maliciously. These keys should be kept by an authorized member of staff on the ward at that time. The CD keys should be kept separately from the other ward keys. All external medication should be stored separately from other medication. If drugs trolleys are used these should be kept locked when not in use. They should also be attached to the wall using the holders again when not in use. This is to ensure that the trolley cannot be removed from the ward. Treatment rooms should be kept clean and tidy. The storage locations of medications should also be labelled clearly. Medication that is waiting collection by pharmacy as a return should be kept securely until it is collected. Medications must be kept within their original containers this is to ensure easier identification. It is also to ensure that information such as batch numbers and expiry dates are present so these can be checked. It is not suitable to just have loose strips of medication in medicines trolleys or unidentified tablets. There is a yearly audit from pharmacy which looks at safe and secure handling of medication to ensure that standards are met. This audit is known as the Duthie Audit. This audit looks at the storage of the medication at ward level to check that items are being stored securely. It also checks that medications are being kept in the correct temperature and light conditions.

Transportation All items that arrive from pharmacy are transported in a sealed green bag. This is to ensure that they remain as secure as possible. Ward orders are transported in a sealed red box. It is important that staff empty this box as soon as possible and decant into the ward storage. Staff should be aware if fridge items are contained within. If fridge items are inside then a sticker will be on the top of the box. It is important they are placed back in a fridge as soon as possible. A signature is always required by pharmacy when they deliver items to ensure that the audit trail for the medicines is complete. If items are collected from pharmacy by ward staff they should be aware that they will requested to print and sign their name. Trust ID will also be required to be shown. If ward staff collect Controlled drugs from pharmacy the nurse will have to sign in pharmacy to confirm they have collected them. They must then sign them in on ward level to document that the medications have been placed in the controlled drug cupboard. When patients are transferred from ward area to ward area the patient green bags should be used. These must have a patient sticker on them for easier identification. These bags can also be used for patient own drugs being transferred.

Patients should always be transferred with their medication it should not be sent retrospectively. Always ensure that the patient‟s locker area is checked before transfer.

Medication transfer should be SAFE and SECURE.

Standards for practice and 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

Staff should be aware of the contraindications of medication as well prior to giving them. Practitioners should also ensure that medication is being given using the appropriate medical equipment. For example oral medication should be given using an oral syringe not a hypodermic syringe. It should also be checked that the patient has no allergies to the medication to be given and that the drug is in date. The drug should only be given according to appropriate clinical procedures and the practitioner must have received appropriate training. Medication should only be administered with a valid prescription. This prescription should be legible and appropriately signed.

All patients must have a hospital wristband on to confirm identity prior to medication being given. A red wristband should be used for patients with allergies. The wristband must contain the following information :-

Full Name Date of Birth Hospital Number NHS Number Gender Barcode

A verbal confirmation should also be made to ensure the correct patient. Medication should not be drawn up in advance. Medication should also not be drawn up just in case it is needed as this can lead to drug errors.

It is unacceptable to prepare medication in advance for another practitioner to given when not in their presence. If medication is drawn up for a Dr to give they should ensure that they have checked the medication as well.

If any adverse reactions are noted or for some reason the medication cannot be given then this must be documented and the prescriber must be informed. Adverse effects should be reported using the Yellow Card System if appropriate – see CSM guidelines for use, printed on cards in the back of the BNF. Adverse effects can also be reported electronically. Nurses may now report independently.

Some drug administrations 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 be a substitute for arithmetical knowledge and skill. Drug calculation worksheets are available on the medicines management site to help with this. They are also available from the Medicines Management Nurse. Staff should ensure they are comfortable working out these calculations before doing so.

Practitioners should always ensure that they have signed the prescription to make it clear that the medication has been given. It should also be documented in the patient‟s notes that this has happened. The efficacy should also be noted especially in the case of antiemetics or analgesia. If any medication is not given the reason for this needs to be clearly documented. An omission code should be documented on the prescription code.

Medications that are delayed or omitted can have an adverse effect on the patients we care for. It is important that whenever a medication cannot be given an omission code is recorded on the prescription as well as documentation in the notes as to the reason for the omission. The medical staff should also be informed. The following omission codes are used in the Trust:1234567-

Patient refused Patient away from ward Patient unable to receive medication / no access for example IV Nil by mouth Medication unavailable Self-administered Other reason

All efforts should be made to obtain medicines rather than have to use an omission code. Critical medications should never be omitted. If a blank box is noted on the prescription and the medication has not been given then an incident form should be completed by the member of staff completing this. This should apply to all omitted medications but particularly critical medicines.

Nil By Mouth –Surgical Patients Only When a patient is to take oral medication on the day of surgery – it can be taken up to 2 hours prior to induction of anaesthesia, with up to 30mls of water. When the patient does not receive the prescribed dose because they are „Nil by Mouth‟, the nurse must enter Trust approved non-administration code „4‟ Corp/Guid/439 Administration of Medicine Peri Operatively

PGD‟S An increasing number of medications are now on Patient Group Direction‟s (PGD‟s). These are when the practitioner prescribes and administers a set medication. 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. These PGD‟s vary from area to area depending on clinical need.

Critical Medicines

Critical medicines are a list of medicines that have been agreed by the Trust; these medicines MUST not be omitted or delayed without justifiable reason. This is a result of the National Patient Safety Alert RRR 009 Reducing harm from omitted and delayed medicines in hospital. The omission or delay in the administration of these medicines may result in HARM to patients. There are 2 lists, one for use in Neonatal Care / SCBU and one for General use. Paediatrics may use both lists dependent on the age of the child (See Corp/Proc/307 Administration of medicines). If you are involved in the supply, dispensing, prescribing or administration of medicines ENSURE THAT YOU ARE AWARE OF THESE MEDICINES AND THE LIST APPROPRIATE TO THE GROUP THAT YOU ARE PROVIDING MEDICINES FOR. Omission or delay of any of these medicines without justifiable reason must trigger the completion of a Trust Untoward Incident Report. To access critical medicines out of hour‟s staff should use Medicines 24/7 to look at storage locations of these medications and access. Critical Medicines must not be omitted or delayed. There are very few medicines that CANNOT be accessed via Pharmacy or the on call Pharmacist 24 / 7. A list of critical medicines is at the back of this booklet in the resource section. This list is also available from the medicines management homepage.

Delegation It is the responsibility of the registered practitioner to ensure that any person they delegate any aspect of medication administration is competent to carry out the task. They also must ensure that the task once delegated is carried out. The two main groups that tasks are delegated to are unregistered practitioners and student practitioners. Assistant Practitioners Before delegation to an assistant practitioner (AP) the registered practitioner must be sure that they have completed the Trusts mandatory training on medicines management and been assessed as competent. It is the registered practitioner that holds the duty of care and legal liability. The AP must have completed the full Foundation Degree course and not be a trainee AP. Assistant practitioners are able to carry out the second check for stock balances and second check the administration of controlled drugs. This does not include IV medication. They must fully understand the legalities, differences and responsibility of controlled drugs. They may also check simple IV fluids such as 0.9% Sodium Chloride. They cannot check any IV fluids with additives such as Potassium. Pre-Registration Students Students are never allowed to administer medication without direct supervision of a registered practitioner. Where supervising a student in the administration of medicines, the signature of the student should be clearly countersigned by the supervising registered practitioner. 2nd year Student Nurses from UCLAN complete a Controlled Drug Study Day and a Controlled Drug supervision record. Mentor discretion based on student ability should be exercised before allowing the student to:

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

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Administer a Controlled Drug (excluding the administration of intravenous controlled drugs) under supervision by authorised registrant that accepts responsibility and accountability for the process.

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Participate and witness the disposal of controlled drugs.

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Complete documentation including the controlled drugs register under supervision.

After qualifying Nurses / Midwives are not allowed to give medication until they have received their PIN from the NMC.

Disposal of Medicinal Products Safe Disposal of Medicines 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. At ward level all part used or empty medicines and containers must be disposed of in accordance with Trust procedures. Staff should be aware that some commonly used medicines including chloramphenicol and hormone treatments are “Cytostatic” and as such should be disposed of in purple lidded containers as Cytostatic/cytotoxic waste. Wards may return unwanted and unused medicines to pharmacy for safe disposal. However “sharps” or broken glass vials and ampoules must NEVER be returned to pharmacy. Unwanted medicines must be safely stored on the ward while awaiting return to pharmacy. Please discuss any issues relating to medicine waste, disposal or returns with your ward based pharmacy teams. Destruction of Controlled Drugs All Controlled Drugs entered into a ward CD register must be returned to pharmacy for destruction and an appropriate entry made in the CD register by a registered pharmacist or technician and the nurse in charge. Part used controlled drugs must be denatured prior to disposal. An entry should be made in the Controlled Drug Register and witnessed to state part used controlled drug is being disposed of. Denaturing is undertaken to ensure the CD is irretrievable at the point of destruction. This is usually undertaken by removing the contents from syringes etc. and placing in a Medicinal sharps bin with the addition of a Gel Vac sachet which solidifies when water is added. (1 sachet to 1litre of liquid). Other part used controlled drugs may be disposed of in the following way and placed in a sharps bin as above with a gel vac sachet: Tablets-crush Powders/Sachets- open and add direct Liquids- add direct Ampoules- empty contents and add ampoule Patches- fold Epidurals- empty contents and place giving sets etc. in bin.

Unlicensed Medicines 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.

Clinical Trials Research is an essential part of healthcare because it allows new medications and treatments to be developed. The Trust actively participates and encourages clinical trials in most of the clinical areas. Each research patient that has been consented and randomised has a pink case file. At the front of this file will be an allergy and information sheet. This will detail the trial and contact number of the research nurse involved. Patients without full case notes may carry a trial card, with trial related information. All patients will have an information sheet and consent form in their case file, as well as the contact details for the research nurse co-ordinating the trial or the local principal investigator. Staff need to be sure that they know how to give the drug that is prescribed. That they are aware of the route of administration and if parenteral the length of time over which the drug should be administered and any special lines, pumps or filters required. If not they must contact the research nurse, who will provide advice or come and administer the drug. One of the common fears about giving medication on a drug trial is that the practitioner is unsure states that:„There should be no reason for a registrant to object to taking in that they are not depriving a patient of effective treatment but rather contributing to the evidence base for effective treatment in the future‟. (NMC 2010)

Complementary and Alternative Therapies When a patient comes into hospital 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 in hospital 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.

Patients should always be asked if they are taking any alternative remedies to ensure a full history is being obtained. Advice should be sought from the medical team and ward pharmacists to check that there is no interaction to the medications being prescribed.

Management of Adverse Events (Errors or Incidents) in the Administration of Medicines It is important that any incident involving medications is reported via the Untoward Incident Reporting System. These should be reported within 24 hours of the incident occurring or when the incident came to light. When the incident is reported the following information should be included:- Date and time of incident - Which process was being used - Which drug was involved - Cause of error - Type of error - Was the medication part of a trial? - Dose of medication prescribed / dose actually given - Form of medication / medication actually given - Route of medication / route actually used - Frequency / frequency actually given - When and number of times drug omitted - Allergic reaction? - Serial number of any equipment - Batch number of any medication - Effect of error on patient Near misses should also be recorded as an incident. CD Errors Controlled drug incidents must be reported in the same way as other 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 are correct - Recheck the balance has been calculated correctly - Check stock has not been stored elsewhere - 5% difference acceptable in oral medications - Person in charge of ward must be informed if discrepancy then Ward Manager - If theft is suspected senior management must be informed including the Director of Pharmacy as the Accountable Officer.

Controlled Drugs Controlled drugs (CD‟s) are medications that have additional legal stipulations behind them. The Trust policies in relation to these are:Corp/Proc/302 Controlled Drugs – safer management of controlled drugs Corp/Pol/303 Controlled Drug Policy 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 The Registered Practitioner can delegate control of access (i.e. key holding) to the CD cupboard to another, such as a registered nurse or ODP. 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 and is used solely for the storage of CD‟s. 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 be unique and kept separate to other ward keys. Controlled drug stock checks Two members of staff must check CD stock every 24 hours or at shift change. One must be a registered nurse, Midwife, Doctor, Pharmacist or ODP (Operating Department Practitioner). The 2nd checker may be a Registered Nurse, Midwife, Doctor, Pharmacist, ODP or Student Nurse (UCLAN students only - who have undertaken Controlled Drug Study Day at the end of their second year) willing to undertake the task and knowledgeable about CDs and their accountability. The two checkers must check every drug in the CD cupboard every day and sign on each page of the Controlled drug register that the check has been performed. 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. 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.

Patients own Controlled Drug medication is recorded in a separate CD register. One page per person listing the name form and strength at the top of the page

High dose potassium if stored at ward level usually has its own controlled drug register just because it is classed as a high risk drug.

CD Entries Items arriving from pharmacy should be clearly recorded in the CD register. The arrival time and date as well as requisition number and amount of stock arriving should be documented as received from pharmacy. These entries require two signatures checking drugs out for patient use. An entry made in error must be bracketed and endorse as „error‟ in the margin. This should be signed, dated and for best practice witnessed. All entries must be chronological Every entry must be in black ink All records must be stored for two years from the date of the last entry in the register.

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:Prescribing Audit (Yearly) – to check that prescriptions are legible and all correct standards are being met. Also checking that medication is being given appropriately from these Controlled Drug Audit (3 monthly) - looking at the Controlled Drug Register to check that all balances are correct. Also to ensure that the registers are being filled in correctly and all mandatory sections are being completed. This audit also checks that Potassium is being stored appropriately and the necessary safeguards are in place. Omissions Audit (6 Monthly) - This audit looks at ward compliance with omission codes. The audit looks at whether omission codes have been used on prescriptions when medications have not been able to be given for whatever reason. It also looks at delayed medication. Prescriptions and medical notes are used for this audit. This is to highlight if omission reasons have been recorded in the notes as per Trust policy. Antibiotic Audit (3 monthly) – This audit looks at whether antibiotics have been prescribed correctly in line with the Trust Antibiotic Formulary. It checks that microbiology approval has been given for the high risk antibiotics. It also checks that start and stop dates are clearly recorded on the prescription. Safe and Secure Handling of Medicines Audit (Duthie) (Yearly) – This audit looks at how medications are stored at ward level. It checks that medications are stored securely in a cupboard or in the drugs trolley. It also looks at whether medications are stored in the appropriate environmental conditions for them in relation to heat, light etc. NPSA15 (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. The medications covered are:1. Midazolam 2. Paraffin 3. Injectable Medicines 4. Low Molecular Weight Heparin 5. Oral Bowel Cleansing 6. Oral and other Enteral Routes 7. Anticoagulant Therapy 8. Epidurals 9. Vaccine Cold Storage 10. IV Fluid Solutions 11. Lithium Therapy 12. Opioid Medicines 13. Omitted and Delayed Medicines 14. Medication Loading Doses 15. Hyponatremia

NPSA Alerts Midazolam -

Midazolam 10mg/ 2 mls (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 aware of the contra indications such 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 Medicines Management for Pre-Registration Students 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

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Information Resources Medicines Information internal 3791 (0900-1700) Clinical Pharmacist advice on medicines

Speciality Pharmacists via Bleep These can be contacted in hours via bleep. The bleep numbers are available on the Medicines Management page. Out of hours the on call pharmacist can be contacted via switch board.

Medicines Management Nurse 5685 (weekdays 0845-1700) Offering nursing advice on medicines management issues and professional guidance at ward level. Able to come onto the ward 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. 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. 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 guidehttp://bfwnet/departments/medicines_management/inject.htm UCL Injectable Guide

– Injectable medicines guide in paper form available on ward.

Critical Medicines List

Critical Medicines Quick Reference Guide Although important to administer all medication at the prescribed time, for some medication, serious harm can result from delayed or omitted doses. Doses of critical medicines should not be omitted ( See Appendix 1 for more detailed description) Acetylcysteine Amiodarone Aminophylline Anaesthetics/Sedatives Analgesics Antimicrobials (systemic) antibiotics, antifungals, antivirals and antimalarials Anticoagulants Antidotes Anti-emetics Anti-epileptics Anti-HIV Anti-Parkinsonian agents Anti-platelets & Thrombolytic Beta-blockers Benzodiazepines & parenteral vitamins Biphosphonates parenteral Bronchodilators nebulised Calcium Resonium ; Glucose/Insulin Chemotherapy Corticosteroids Digoxin, Desmopressin Flumazenil Glucose Glucagon Glycopyrronium Insulin Immunosuppressant‟s JIC4CD Just in Case 4 Core Drugs Loading Doses Midazolam s.c. Naloxone Oral Hypoglycaemic agents Opiates Parenteral Electrolyte Replacement Phenytoin Prophylactic agents ( to reduce toxicity) Resuscitation Drugs Warfarin

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. If you have not already done so, please complete the appropriate Mandatory Training Multiple Choice Questionnaires (MCQ) at the end of this workbook 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 Learning and Development 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. What is the annual cost of adverse medication effects? 1. 65 million pounds 2. 900 million pounds 3. 770 million pounds

2. Where can you access the full list of all available medicines outside pharmacy hours? 1. In folders on each ward. 2. In Pharmacy 3. In the on call folder 4. On the intranet shared drive via Pharmacy Medicines 24-7 Location list.

3. How can you gain access to critical medicines out of hours? 1. Code lock on the pharmacy door. 2. You don’t know so just omit the drug. 3. Via the on-call bleep holders 002, 048, 050, on-call pharmacist 4. Fill in a Ward stock request form

4. When completing an untoward incident form that involves a medicine you must include what? 1. The name, dose / rate of the medicine 2. The presentation of the medicine 3. A description of what happened 4. All of the above

5. When completing an untoward incident that involves the administration of a medicine using a medical device what information MUST you include? 1. The type of device and asset number 2. The name, dose / rate of the medicine 3. A clear description of the fault 4. All of the above

6. Which statement best facilitates the safer administration of medicines? 1. The prescription 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. 2. 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. 3. The prescription 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. 4. The prescription 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.

7. What are your main responsibilities when administering medicines to patients? 1. To ensure the patient takes the medicine. 2. To administer the medicine safely and correctly to the patient within my own competencies and knowledge, and to document immediately using the correct code if I have not been able to do so. 3. To ensure that the patient takes the medicine eventually

8. A colleague has asked you to administer a drug that she has reconstituted when you were not present should you1. Administer the medicine and record the administration on the prescription 2. Refuse to administer the medicine and take no further action 3. Inform your colleague that you will reconstitute another dose of the medicine yourself and administer the prescribed dose and document the procedure

9. 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? 1. Maximum temperatures 2. Minimum temperatures 3. Actual temperatures 4. Thermometer reset 5. All of the above

10. Whose responsibility is it to check the loading dose of a medication is correct prior to administration? 1. The prescriber 2. The nurse administering the medication 3. The nurse double checking the medication 4. All of the above

11. The management, storage, security of controlled drugs on the wards is the responsibility of – 1. The Doctors 2. The Directors

3. The Senior Sister / Charge Nurse/ Nurse in charge of the Ward 4. The Nurse administering

12. The stock of controlled drugs must be checked how often? 1. Every week 2. Every time there is a delivery 3. Every month 4. Everyday

13. When discharging patients with medicines, which statement best describes the actions that the discharging nurse must complete? 1. Check the discharge medicines against the prescription; give a full explanation of the purpose, dose, time to be taken and the possible side effects before discharge. 2. Check the discharge medicines against the prescription give a full explanation of the purpose, dose, time to be taken and the possible side effects before discharge and confirm that the patient is able to take / administer them at home. 3. Supply the medicines as dispensed.

14. What is a Patient Group Direction (PGD)? 1. A map of the hospital 2. Specific written instructions for the supply and administration of a named medicine or vaccine in an identified clinical situation 3. A list of medicines that may be supplied without a prescription

15. What does omission code 1 mean? 1. Drug not available 2. Patient Refused 3. Self-Administered

16. Who can second check a bag of Sodium Chloride 0.9% Intravenous? 1. Trainee Assistant Practitioner 2. Assistant Practitioner / 1st year student nurse 3. Assistant practitioner / 2nd year student nurse who has completed medicines management course

Workbook Completion Statement 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 only of this completion statement MUST be sent to the Learning and Development Department 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. 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:Surname: (BLOCK CAPITALS)

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

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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)

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In acknowledgement to all staff who contributed to the production of this work book

Blackpool Teaching Hospitals NHS Foundation Trust

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NHS