Download Medication Management Policy and Procedure Manual

PINN
CLE
POLICY STATEMENT
COMMUNITY SERVICES
1MEDICATION
MANAGEMENT POLICY
AND PROCEDURE MANUAL
POLICY ADOPTED:
Date
15/1/2015
Policy Objective:
This policy outlines Pinnacle Community Services strict guidelines on the management/ administration
of consumer medication in the community setting.
Responsibilities:
The Manager of Pinnacle Community Services, Temora Shire Council is responsible for the
implementation of this policy.
Case Managers, Coordinators, all other employees and volunteers engaged by Pinnacle
Community Services are required to comply with this policy.
Policy Statement:
Pinnacle Community Services promote duty of care principles which require staff to maintain a level
of competency when reminding, supervising or administering medication. Medications will only be
administered by Pinnacle Community Services staff with the appropriate education and assessed
skill level required.
Staff will administer all medications correctly as prescribed, through practices that comply with
Legislation and this Medication Management Policy and Procedure Manual. Pinnacle Community
services will take every step to ensure a safe, efficient and effective management of medications.
This includes ensuring that:
 all state and territory legislative requirements are met;
 staff are aware of and adhere to their scope of practice and individual role in medication
management;
 staff use professional judgment (within scope of practice) in deciding when a medication
should or should not be given and they are required to report to the Manager / Case
Manager / Coordinator with any concerns;
 consumers are assessed appropriately and where appropriate, their medication
management plan developed;
 staff administer or supervise medication safely and correctly according to regulatory
guidelines;
 medications are stored correctly;
 the reporting and recording of reactions to the medications occurs and that an initiation of
required interventions in consultation with the Medical Practitioner and Pharmacist is
attended;
 the monitoring and evaluation of the use of medicines occurs when required;
 consumer's rights are respected and they are consulted in relation to their medication
management.
Medication Management Community Care Policy and Procedure Manual (Baptist Community
Services – NSW &ACT, September 2012)
1
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
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Any medication supervision, prompt or assistance can only be by staff who have been assessed as
competent to do so. If a staff member has not been so assessed they are not allowed to partake in
any activity related to medication.
Definitions
Definitions taken from the Community Care Medication Management Community Care Policy and
Procedure Manual (Baptist Community Services – NSW & ACT, September 2012). Refer to
Attachment 1.
Abbreviations
PRN – as required
RN- Registered Nurse
CW – Care Worker
EN – Enrolled Nurse
DAA - Dose Administration Aids
AHPRA – Australian Health Practitioner Regulation Agency
ANMC – Australian and Nurses Midwives Council
CI – Continuous Improvement
APAC – Australian Pharmaceutical Advisory Council
Refer also to Attachment 1.
Reference
This document is based on information taken from the Community Care Medication Management
Community Care Policy and Procedure Manual (Baptist Community Services – NSW &ACT,
September 2012).
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Introduction
This Medication Management Policy and Procedure Manual sets clear procedures on assessment,
ordering, supply, storage and security of medicines in community care services at Pinnacle
Community Services.
It clearly addresses the duty of care and roles of those accountable and responsible for medication
management and ways to manage the system to ensure it remains a safe and secure means of
managing a consumer's medications.
It must be acknowledged that no policy or procedure can ever cover all eventualities or replace
sound clinical judgment.
The manual commences with the Community Care Medication Management Policy Statement. It is
followed by:
 Contents List;
 Recommended Practice ;
 Roles of other key players;
 Comprehensive procedures that make up a medication management system;
 Recognition of Continuous Improvement through avenues such as internal auditing and
incident management;
 Attachments that include scope of practice, abbreviations, resources, references and
related forms;
 Section within the attachments for local documents such as local work instructions, training
competencies and guiding documents.
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Contents
Recommended Practice ...............................................................................................................................5
Scope Of Practice ..........................................................................................................................................6
Roles In Medication Management – Consumer .....................................................................................6
Roles In Medication Management - Person Responsible – E.G. Carer/Advocate ........................6
Procedures ......................................................................................................................................................7
Assessment: All Consumers ......................................................................................................................7
Assessment: Consumer Self Adminstration ..........................................................................................8
Prescribing: Medication Chart .................................................................................................................10
Administration: Consent ...........................................................................................................................11
Administration Of Medication ..................................................................................................................13
Administration: Altering And Crushing Medications .........................................................................15
Administration: During An Outing And On Leave ..............................................................................16
Administration: Alternate/Herbal/Aromatherapy Oils/Over The Counter (Otc) Medications...17
Administering Rectal And Vaginal Medications ..................................................................................18
Administering Medication Via A Peg Tube ...........................................................................................20
Administering Medication Via A Nasogastric Tube ............................................................................22
Administering Insulin Via Preloaded Syringe Or Pens ......................................................................24
Administration: Standing Orders ............................................................................................................26
Schedule 8 – Administration And Registering.....................................................................................27
Labelling: Medication .................................................................................................................................30
Storage And Security: Responsibilities ................................................................................................31
Storage And Security: Medication – Day Centres And Respite ......................................................32
Storage And Security: Disposal Of Medication ...................................................................................33
Continuous Improvement ..........................................................................................................................34
Continuous Improvement: Incidents And Errors ................................................................................35
Continuous Improvement: Medication Review ....................................................................................36
Continuous Improvement: Competencies And Ongoing Training Procedures For Staff ........37
Attachment 1 Definition And Abbreviations .........................................................................................39
Attachment 2 Scope Of Practice..............................................................................................................45
Attachment 3 Medication Self Administration Assessment .............................................................55
Attachment 4 Medication Assistance And Administration Plan .....................................................58
Attachment 5 Consumer Risk Assessment Forms.............................................................................60
Attachment 6 Consent For Administration Of Medication ...............................................................70
Attachment 7 Incident / Hazard Report Form .......................................................................................72
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Recommended Practice
1. It is the responsibility of Pinnacle Community Services Manager to ensure that a copy of
this document is available to all staff.
2. Staff must ensure that they have read and understood the policy and consider themselves
competent to act in accordance with it. If staff are unsure about any part of the policy they
MUST clarify the issue or seek further training.
3. Any failure to adhere to this policy, if deemed to have been health or life threatening,
jeopardised safety or had other serious consequences, could lead to investigation,
retraining and, on occasion, to disciplinary action.
4. Pinnacle Community Services is responsible for ensuring that appropriate training and
supervision is made available to staff.
5. Staff and volunteers are not authorised to make any decisions about consumer medication
and should contact the Manager/ Coordinator/ Case Manager if they have any concerns
about the way a consumer is managing their own medication regime.
6. The Manager/ Coordinator/ Case Manager will make referrals to other services such as the
General Practitioner or Health service if the consumer is not managing their own
medication administration.
7. In the case of an emergency, staff/volunteers are required to administer adequate first aid
measures which may require the administering of medication / or as advised by relevant
medical professionals (refer Accident and Incident Policy).
8. In the case of an emergency where staff/ volunteers are required to administer medication,
they are not to deviate from the instructions that have been prearranged as part of the care
plan or are an instruction from emergency services.
9. Staff and volunteers are required to maintain a current first aid certificate which includes the
emergency management of asthma, diabetes, anaphylaxis etc.
10. Where a consumer has a known illness in which they may need physical assistance with
medication in case of an emergency, such as asthma, allergies, diabetics etc., their care
plan will include directions on how to manage medication assistance and staff will be
provided with training on how to administer the specific medication/treatment in accordance
with the care plan.
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Scope of Practice
Refer to Attachment 2.
Roles in Medication Management – Consumer
Consumers Rights in Pinnacle Community Service Community Care Include:
1. To consent or refuse consent to medication management.
2. To receive medication(s) at the time indicated as per the Medical Practitioner’s order
according to relevant funded program guidelines and the consumer's plan of care.
3. To manage their own medicine regime if assessed as competent to do so.
4. To confidentiality in relation to their medicine regime.
5. To a medication system that promotes the safe use of medications and the consumer’s
privacy.
6. Advice and support on medicine use from health professional's including Registered
Nurses, Pharmacists. Dentists and Medical Practitioners depending on relevant program
guidelines.
7. Encouragement and support to maintain independence in the administration of medicines in
a safe and effective way.
Consumer Assessment
1. All consumers will be assessed on their ability to manage their medications on admission,
annually and as care needs change, in accordance with relevant program guidelines.
2. Consumers will be consulted during the assessment process and the results will be
documented on the consumer's own medication management plan. Inclusion of medication
management assessments will be dependent on relevant program guidelines.
Consumers who self - medicate
1. Consumers will be assessed for their ability to self - medicate on admission to a community
program and at regular intervals as per relevant program guidelines or when there is a
change in physical or cognitive abilities.
2. Consumers will follow the directions on the label as dispensed by the pharmacy.
3. Dose Administration Aids (DAA) such as Webster or Blister packs are recommended as
best practice for community care consumers and Pinnacle Community Service consumers
are encouraged to use DAA.
4. Consumers ensure that their medications are stored safely. It is recommended medications
are stored in a cool, dry and secure place. There may be some medications requiring
refrigeration and directions on the Product Information Sheets should be adhered to
5. Consumers ensure their medications are kept out of reach of children who may be
residents or visitors of the home.
6. Consumers supply their own scripts to the pharmacy and arrange delivery where possible.
Roles in Medication Management - Person Responsible – e.g. Carer/Advocate
Person Responsible ensures that:
1. They participate and are involved in the consultation/assessment of a consumer's
medication management where appropriate and indicated at initial consultation.
2. They advocate on the consumer's behalf.
3. They may consent to medication management if the consumer has impaired capacity.
4. They may consent to the use of generic medication if the consumer has impaired capacity.
5. They have provided full current contact details with Pinnacle Community Service.
6. If the consumer is under the age of 18 years and requires medication management that all
required documentation is completed.
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PROCEDURES
ASSESSMENT: ALL CONSUMERS
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. A Coordinator may undertake a medication assessment in consultation with the consumer
and/or person responsible and the consumer's treating Medical Practitioner.
2. The initial assessment and any review is documented on the Medication Assistance Plan,
the Care Plan and the consumers file (Refer to Assessment Policy).
3. The assessment will Involve the following:
 Encouraging the consumer's physical and cognitive independence.
 Level of assistance and safety requirements.
 Type of staff who will administer the medication(s).
 Special requirements (i.e. enteral feeding, nasogastric)
 Ability of the consumer to swallow medications and determine if medications should
be crushed cut in half and/or altered in any way.
 Allergies, drug sensitivities or adverse reactions.
 Ability to self-medicate (refer to procedure on assessing consumers for Assistance:
Self Medication).
 Whether there are any behavioral, social, and psychological barriers that may affect
compliance with medication administration.
 Consumer limitations such as cognitive, coordination, physical, dexterity, vision that
may impact on their ability to take their medications.
 Pain management and use of analgesia.
Medication Assistance and Administration Plan
1. The assessment information is to be entered on the Medication Assistance and
Administration Plan and the consumer reassessed as per program guidelines and as
identified needs change.
2. The consumer Medication Assistance and Administration Plan is kept in the consumer file
and a copy left in the home if medication management is part of the Care Plan.
Forms
 Medication Self Administration Assessment
 Medication Assistance and Administration Plan
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ASSESSMENT: CONSUMER SELF ADMINSTRATION
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
The Assessment
1. The Coordinator will ensure that:
 depending on program guidelines, consumers are assessed on their ability to manage
their medications on admission and as care needs change.
 the results of the assessment will be documented and a Medication Assistance and
Administration Plan developed in consultation with the consumer/person responsible.
 the consumer’s ability to self-administer medication will be assessed annually using the
Medication Self Administration Assessment Form and reviewed as per program
guidelines or as care needs change. The results will be recorded on the Medication
Assistance Plan.
 the consumer is assessed to determine if they can self-administer medications. The
consumer may require assistance with some medications but manage others
independently.
 the assessment is discussed with the Medical Practitioner (MP) and consumer /person
responsible. Consumers are encouraged to maintain independence in this area for as
long as possible, including managing their own medications in a safe and effective way.
 where required a current list of medications is made available by the consumer at
assessment depending on relevant program guidelines.
 the consumer is encouraged to have their medications checked regularly by the MP.
 any review must be documented, signed and dated on the existing Self Administration
Assessment form.
2. Where a consumer is self-medicating the Coordinator will monitor that the consumer is able
to:
 responsibly administer their own prescribed medications and follow the pharmacy
directions.
 store their medications safely.
 order and take receipt of the medications from the pharmacy.
 inform the staff of any difficulty they may encounter while self-administering.
 ensure that they have a sufficient supply of their own medications.
 inform staff if they are taking any over the counter/alternative medicines if this is
relevant to their funded program guidelines.
3. When a consumer's right to self-administer conflicts with the Coordinator assessment of the
consumer to self-administer medication the Coordinator will:
 discuss the safety concerns with the consumer/person responsible and MP.
 if the consumer wishes to self-administer and the practice is identified as unsafe by the
Coordinator the consumer /person responsible will complete a Consumer Risk
Assessment Form.
 Control measures to monitor the consumer's ability to self-medicate should be
documented in the ‘Consumer Risk Assessment Form’ and the progress notes.
 The Coordinator will continue to monitor the consumer and document in the progress
notes any changes or strategies.
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Forms



Consumer Risk Assessment Form
Medication Assistance and Administration Plan
Medication Self Administration Assessment
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PRESCRIBING: MEDICATION CHART
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Definitions
Medication
signing sheet
Medication
chart
Method used to record the administration of medication
Used by MPs to record medication and treatment orders, and by
nursing staff to record and monitor the administration of such
medications and treatment.(Guiding principles for medication
management in the community. APAC 2006).
Procedure
Use of Medication Signing Sheets
1. Medication that is to be administered to a consumer by Pinnacle Community Services staff
should be in Dose Administration Aid e.g. Webster Pack when the medication is in tablet
form.
2.
Medication Signing Sheets should only be required when the consumer or person
responsible is not able to manage their own medication and program guidelines indicate
assistance needs to be given.
3. Where indicated as appropriate and necessary, a Medication Signing Sheet is provided by
the pharmacist responsible for packaging.
4. Under no circumstances is a Pinnacle Community Services staff member permitted to
transcribe onto a Medication Signing Sheet.
5. If it has been determined that a consumer requires assistance with, or administration of,
some medication they must have a Medication Signing Sheet.
Forms

Medication Signing Sheet (Webster Pack)
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ADMINISTRATION: CONSENT
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. A consumer's ability to consent to treatment including administration of medications is
assessed on admission to Pinnacle Community Services
2. When is Consent valid - In order for the consent to be valid the consumer must:
 be able to understand the treatment/activity proposed and understand the risks
associated.
 be aware of alternative treatments/activities
 understand the impact of undertaking no treatment/activity.
 agree to the proposed treatment/activity.
3. Where written consent is required and a consumer is not able to comprehend or is unable
to communicate their choice, a lawful substitute consent must be obtained. This is
mandatory when a child is a consumer of a community service.
4. The consumer has the right to:
 refuse treatment/activities.
 withhold or withdraw consent at any time. This can be in writing, verbally or through
their actions.
Staff have a duty of care to explain the implications of refusal (Refer to Duty of Care
and Dignity of Risk Policy).
5. Refusal of a consumer to take their medication:
 It is the responsibility of the person administering/assisting with medication to inform the
Coordinator and to document the refusal of medication in the consumers file.
 An Incident / Hazard Report must be completed.
 The treating Medical Practitioner (MP) will need to be notified once the Coordinator
determines the risk of this refusal. The consumer needs to be consulted before the MP
is informed.
6. Obtaining written consent (when the consumer has a person responsible)
 A person responsible is identified as a person who is known to the Pinnacle Community
Services and can act as a substitute decision maker in the event that the consumer is
unable to make their own decisions.
 Where a child is receiving services the family/person responsible should administer
medications. Where this is not possible the policy and procedures for administration are
adhered to and the Consent for Medication Administration is signed by the child's
person responsible.
7. Obtaining written consent (when the consumer has no person responsible)
 If the consumer is incapacitated, assessed as not competent and does not have a
person responsible application may need to be made to the Guardianship Tribunal to
appoint a substitute decision maker.
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Forms


Consent for Administration of Medication
Incident/Hazard Report Form
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ADMINISTRATION OF MEDICATION
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. Where required by program guidelines the Coordinator ensures:
 the safe management of medications in Pinnacle Community Services.
 that following assessment, all consumers receive medications as prescribed by the
Medical Practitioner (MP) and administered by an appropriate individual.
 that where Pinnacle Community Services are involved appropriately trained staff
administer medications.
 that persons responsible / family members are involved in the management of
medication where appropriate and possible.
2. According to their scope of practice the coordinator/care worker ensures:
 they refer directly to the MPs instructions.
 only medications ordered by a Medical Practitioner (MP) are to be administered.
 they follow a strict protocol for checking the identity of the consumer on each occasion.
 the consumer's allergies and any previous adverse drug reactions are checked before
administration.
 that the same person who selects a consumer's medication should administer that
medication.
 the medication administration is recorded at the time the medication is administered.
 medications are administered directly from the dose aid/container supplied from the
pharmacy.
 they read the pharmacy label on any dose administration aid/container and check the
correlation with the dose aid (i.e. they are one and the same); e.g. eye/ear drops,
topical creams, nasal sprays, patches, inhalers.
 that if they are unsure of the medication order, the appropriateness of the medication or
any other query, they need to contact the Coordinator before the medication(s) are
administered.
 they remain with the consumer until the consumer has swallowed the medication(s).
 that any suspected adverse drug reactions to prescription medicines, over the counter
medicines or complementary medicines should be reported to the coordinator, Medical
Practitioner, and consumer/person responsible and documented in the consumer file
and complete an Incident/Hazard Report Form.
 where a consumer has cognitive impairment or there are children residing in the home
medications need to be stored in a safe place.
 medication orders are not to be transcribed by staff administering medication.
Placing Medication in Food or Fluids for Administration
1. Medications are not to be placed in a food/beverage for others to administer unless the
medication is ordered as a medication that needs to be dissolved in water e.g. Metamucil.
2. Medications are not to be placed in beverages or plates of liquid/semi liquid food e.g. cups
of tea, cereal.
3. Medications may only be placed in foods/beverages if the consumer has been assessed as
having swallowing difficulties and the consumers MP is aware. In this circumstance the
following choices are preferable for administration:
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




the fruit is pureed or is jam - it is preferable to use portion size serves if possible;
placement of the medication in the fruit/jam is not contraindicated;
staff spoon the medication into the consumer's mouth;
staff witness the consumer swallowing the medications;
staff remains with the consumer until all the medications have been taken.
4. If a consumer experiences difficulty swallowing this is to be referred to the Coordinator for
an assessment and appropriate measures put in place, i.e. referral to the Medical
Practitioner, an allied health professional, Refer to Nutrition and Swallowing Policy and
Procedures – ADHC.
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ADMINISTRATION: ALTERING AND CRUSHING MEDICATIONS
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
The Pharmacy
1. The pharmacy must indicate if a medicine cannot be crushed or altered. If required, this can
be ascertained by the Coordinator contacting the pharmacy if a consumer requires
medicines to be crushed.
Assessment
1. Depending on program guidelines consumers who are admitted into Pinnacle Community
Services must have an initial assessment which includes an assessment of physical care
needs (e.g. swallowing).
2. If the consumer has been assessed as requiring medications to be crushed or altered,
reference is to be made to 'Commonly Used Medications that shall not be crushed' list to
ensure medications can be altered. This list can be obtained from the consumer's
Pharmacist.
3. This list must be available to all involved in a consumer's care provision including family or
unpaid carers.
4. The Product Information Sheets provided with medications should be referenced for
additional information regarding crushing.
Administration
1. If medications are to be crushed this must be clearly marked on the Medication Signing
Sheet and indicated on the Medication Assistance and Administration Plan.
2. If using a glass mortar and pestle to crush tablets - use a paper patty pan in the mortar to
avoid cross contamination and clean after every use.
3. Tablets should be crushed prior to adding capsule contents.
4. Capsules may be opened and the contents added to the crushed tablets.
5. Do not sprinkle medications on meals.
6. Mix crushed medications in a medicine cup, preferably with pureed fruit or jam. Avoid using
yoghurt - some medications should not be mixed with milk.
7. Whenever possible the consumer should be upright when taking their medication.
Medications should be administered immediately after crushing/altering.
8. Administer with sufficient water or other suitable liquid.
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ADMINISTRATION: DURING AN OUTING AND ON LEAVE
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. Where Pinnacle Community Services is responsible for a consumer’s medication
administration and the consumer is on an outing, the Coordinator will ensure that the
medication is administered.
2. The staff member administering the medications on an outing must be appropriately
trained.
3. If a dose of medication is required while a consumer is out, the pharmacy packed dose
administration aid (i.e. Webster Pack) will be taken on the outing.
4. The Coordinator should take every step to ensure the consumers medications are
administered as required. This may include (but is not limited to) the following:
 The Medical Practitioner is contacted regarding changing the medication regime;
and
 Where possible the timing of the outing is changed to suite the consumer's
medication regime.
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ADMINISTRATION: ALTERNATE/HERBAL/AROMATHERAPY OILS/OVER THE COUNTER
(OTC) MEDICATIONS
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Definitions
Alternate/Over the counter
These Include herbal, aromatherapy oils and those over the
counter, medications purchased at the pharmacy
Procedure
1. Where Pinnacle Community Services is responsible for medication administration a list of
current medicines including alternative and over the counter medicines is to be obtained
from the consumer/person responsible at the time of the consumer's admission to a
community program.
2. Where medication management is necessary, the Medical Practitioner (MP) is to be made
aware of and confirms the consumers use of alternative and over the counter medicines at
the time of admission.
3. Staff must not initiate, supply or give alternative (particularly aromatherapy oils) or over the
counter medications unless the treating MP has approved them in writing.
4. If the advice from the MP or Pharmacist is that continuation of alternative and/or over the
counter medicine should be reconsidered by the consumer/person responsible in the light
of possible adverse health outcomes, such advice should be discussed with the
consumer/person responsible and entered into the consumer file.
5. If the consumer/person responsible wishes to continue with the alternative or over the
counter medicine this action should be documented in the consumer file and a Consumer
Risk Assessment form completed.
6. All alternative and or over the counter medicines should be kept in a secure storage area
with all other medicines.
7. The consumer's needs and preferences regarding the type of approved therapy will be
documented in the consumers Medication Assistance and Administration Plan and if
applicable their plan of care.
Forms
 Consumer Risk Assessment Form
 Medication Assistance and Administration Plan
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ADMINISTERING RECTAL AND VAGINAL MEDICATIONS
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. Collect all the equipment including the consumers prescribed medication, gloves, lubricant,
waterproof under sheet, tissue or toilet roll and a bag for rubbish.
2. Check that the following information is correct:
 Right consumer;
 Right medication;
 Right date and time;
 Right route;
 Right amount.
3. Explain the procedure to the consumer and obtain verbal consent. Ensure the area you are
using is private and the consumer’s dignity is maintained. Attach a "do not disturb" to the
door if in an environment with other people.
4. Ask the consumer to void prior to administering the medication.
5. Wash hands as per the Infection Control Policy.
6. Ask the consumer to lie on the bed. Where able, place the bed at a height that is
comfortable for the administration of the medication.
7. Follow the steps listed below for administering the vaginal and rectal medications.
8. Ensure the consumer has access to assistance.
9. Return equipment to appropriate storage places once the medication has been
administered e.g. rectal and vaginal medications are returned to their original storage site.
10. Sign the Medication Signing Sheet after medication has been administered. Report any
concerns to the Coordinator / / Manager and document in the consumer's file.
11. Document the result if the rectal medication was an aperient.
Administering a Rectal Medication
1. Place the waterproof under sheet on the bed and ask the consumer to lie on their left hand
side.
2. Put gloves on and other PPE (personal protective clothing) if applicable.
3. Remove the rectal medication from the wrapper and lubricate.
4. Ask the consumer to take deep breaths to relax the buttocks.
5. Retract the consumer’s buttocks with non-dominant hand.
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6. Perform a gentle rectal examination of the bowel with a lubricated finger to assess the
condition of the bowel and to check for the presence, and consistency, of faeces if
applicable.
7. Insert the rectal medication gently through the anus, past the rectal sphincter and against
the rectal wall (5 - 10cms).
8. Withdraw finger and gently wipe anal area.
9. Dispose of gloves by removing, leaving inside out, and place with other used equipment
into a yellow contaminated waste bag if available. Place the rubbish into a plastic bag; i.e.
the ends together and place into the usual rubbish bin when in a consumer's home or
community setting (Refer to Infection Control Policy – Waste Management for further
guidance).
10. Wash and dry hands.
11. Ask the consumer to remain lying on the bed for at least 15 minutes to allow the medication
to dissolve. The full effect of the medication will occur within 30 minutes.
Forms
 Incident / Hazard Report Form
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ADMINISTERING MEDICATION VIA A PEG TUBE
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Definitions
PEG
Stands for percutaneous endoscopic gastrostomy, a surgical procedure for
placing a feeding tube into the stomach. The aim of a PEG is to feed those
who cannot swallow. It is also used for administering medications.
Procedure
1. Prior to administering medication a valid medication order is required.
2. The equipment required prior to undertaking the procedure may include:
 Prescribed medications
 Medication Container
 Pill crusher (if required)
 60ml catheter tipped syringe (for flush and administration of drugs)
 Cool tap water in appropriate container
 Covered container for syringes and caps
 Gloves-and other PPE if appropriate.
Administration
1. Wash hands as per the Infection Control Policy.
2. Check the medication against the 5 x rights:
 right consumer
 right medication
 right date and time
 right route
 right amount
3. Let the consumer know what you are doing as you undertake the procedure and ensure
their privacy and dignity is maintained.
4. Take all equipment to the bedside or an appropriate location convenient to the consumer.
5. Ensure the consumer is comfortable at a 30 degree or greater angle.
6. Place appropriate protection over the abdomen and expose the PEG tube.
7. Apply gloves and PPE as required.
8. If the consumer has a pump for the delivery of nutrients turn it off prior to administering
medications and back on at the end of the procedure.
9. Check the tube is in the correct position prior to commencing the procedure. Tube should
be rotated 360 degrees on a daily basis. Refer also to Policy and Procedure Enteral
Nutrition Support.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
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10. Flush the PEG tube gradually with 30 ml of water prior to commencing the administration of
medication, (if the tube becomes blocked refer to the Policy and Procedure Enteral Nutrition
Support for management).
11. Introduce the first medication, diluted with drinking water, by connecting the syringe to the
medication port. If a medication port is not available connect the syringe to the end of the
tube. Gradually push in the medication.
12. Where possible, medication for administration via the PEG tube should be ordered in its
solution or dispersible form. Suspensions or syrups can also be used although care must
be taken as these may block the tube.
13. Medications can be dissolved with drinking water or crushed finely and mixed with drinking
water prior to administration if approved by the consumer’s Medical Practitioner.
Dissolve/crush all medications individually and do not mix medications unless pharmacy
advice indicates mixing the medications is acceptable.
 Tablets should be diluted with 10-15mls of drinking water.
 Soluble drugs should be diluted as per manufactures instructions.
 Viscous liquids should be diluted with equal amounts of drinking water.
14. Flush the tube with 30ml of drinking water following administration of each medication.
15. Re-clamp the tube. Position the tube upright from the stoma.
16. Ensure the consumer is comfortable at a 30 degree angle (in bed) or upright in a chair, and
replace clothing/blankets appropriately.
17. Tidy away all equipment and wipe up any spillage.
18. Wash any containers, syringes in mild detergent, rinse and dry thoroughly. Cover all
equipment in storage.
19. Record the medications given on the medication /signing sheet.
20. Notify the Coordinator/Case Manager/ Manager of any concerns and document
appropriately.
Forms
 Enteral Feeding Support Plan
 Incident / Hazard Report Form
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 21 of 74
ADMINISTERING MEDICATION VIA A NASOGASTRIC TUBE
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Definitions
Nasogastric tube
(NGtube)
A tube that is passed through the nose and down through the nasopharynx
and oesophagus into the stomach. Abbreviated NG tube. It is a flexible tube
made of rubber or plastic, and it has bidirectional potential. It can be used to
remove the contents of the stomach, including air, to decompress the stomach,
or to remove small solid objects and fluid, such as poison, from the stomach.
An NG tube can also be used to put substances into the stomach
such as medication or food.
Procedure
1. The equipment required prior to undertaking the procedure may include:
 Ordered Medications
 50-100 ml drinking water
 Kidney dish
 50 cc syringe (for aspirating the tube and introducing medication) Blue litmus paper.
2. Wash hands as per the Infection Control Policy.
3. Check the medication against the 5 x rights:
 right consumer
 right medication
 right date and time
 right route
 right amount
4. Medications given via a NG tube will be in a liquid form in most circumstances. If the
medication is in a tablet form, crush well (after checking this medication is crushable with
the pharmacist and MP) and mix with drinking water.
5. Let the consumer know what you are doing as you undertake the procedure and ensure
their privacy and dignity is maintained.
6. Position the consumer with the upper body raised to at least 45 degrees.
7. Apply gloves and other PPE if appropriate.
8. Remove the spigot from the NG tube. Use a 50ml syringe to aspirate the tube to check the
correct positioning of the tube.
9. Test the aspirate with litmus paper to ensure it is positioned in the stomach. If there is no
aspirate check the markings on the tube near the nose and the length of the tube that is
visible. The tube may need to be reinserted by the Medical Practitioner if there are doubts
regarding its' position.
10. Ensure the medication is in a liquid form, either mixed well with drinking water or in its
original liquid state.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 22 of 74
11. Insert each medication, individually, into the NG tube using a 50ml syringe.
12. Follow all medication with 50ml of drinking water to flush the tube.
13. Ensure the consumer remains sitting upright, on their back or side, after the medication is
administered.
14. Once the medication is given and the consumer is comfortable, remove the equipment
used and clean the area.
15. Report any concerns to the Coordinator / Case Manager / Manager.
16. Sign the Medication Signing Sheet after the medication has been administered.
Forms

Incident / Hazard Report Form
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 23 of 74
ADMINISTERING INSULIN VIA PRELOADED SYRINGE OR PENS
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Definitions
Insulin
Lipohypertrophy
Insulin is necessary for normal carbohydrate, protein, and fat
metabolism.
People with diabetes mellitus do not produce enough of this
hormone to sustain life and therefore depend on insulin
administration for survival.
Term that refers to a lump under the skin caused by accumulation
of extra fat at the site of many subcutaneous injections of insulin.
It may be unsightly, mildly painful, and may change the timing or
completeness of insulin action. It is a common, minor, chronic
complication of diabetes mellitus. Typical injection site
hypertrophy is several cm across, smoothly rounded, and
somewhat firmer than ordinary subcutaneous fat.
Procedure
RNs and employees assessed as competent to administer Insulin will ensure:
 that they review the medical order prior to administering insulin, paying particular attention
to sliding scale orders;
 the consumers Diabetic Support Plan /Care Plan is checked;
 consumers are made comfortable and have adequate privacy prior to the administration of
insulin;
 their full attention is given to the administering of insulin and ensure there are no
distractions such as the telephone and other environmental distractions;
 each consumer has been assessed to determine the safest equipment options and this
information has been documented on the consumer's Medication Management/Assistance
and Administration Plan and/or consumer file;
 needles are applied and removed in line with each manufacturer's instructions paying
particular attention to the avoidance of needle stick injury;
 used needles are disposed of in an appropriately labelled sharps container;
 each insulin pen is either labelled with the consumer’s name or identified as the consumers
own by themselves (i.e. the consumer in their own home). The label is not to cover the
name of the insulin;
 each consumer's insulin pen is stored in an individual container with the consumers details;
 all insulin is checked by a second employee where possible. The second employee will stay
with the consumer and the person administering throughout the procedure where possible.
Both employees are to check the 5 rights.
 right consumer
 right medication
 right date and time
 right route
 right amount
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 24 of 74
Administration Procedure
1. Wash hands prior to the procedure in accordance with the Infection Control Policy
guidelines.
2. Collect a clean container and the insulin pen (with needle) and take to the consumer.
3. Put on disposable gloves (PPE).
4. Roll the insulin pen between your hands a few times and then invert the pen at least 10
times to mix the insulin.
5. Dial the pen to 2 units, hold upright and gently tap with your finger a few times. Push the
button fully and expel a small amount of insulin to remove air bubbles. Ensure the dial
returns to zero. Ensure fluid is seen at the tip of the needle, if not, repeat be process.
6. Select the prescribed dose by dialing again.
7. Check the injection site prior to injection and change site if there are signs of
lipohypertrophy, inflammation, oedema or infection.
8. If there is risk of the injection becoming Intramuscular due to limited subcutaneous tissue,
gently grasp a 2 - 2.5 cm fold of skin where the insulin will be injected. Rotate the actual
injection site to avoid the formation of fatty lumps under the skin. The stomach, 'a nonexercised area', is the preferred site although arms and legs can also be used.
9. Insert the needle at 90 degrees into the subcutaneous tissue.
10. Press the push button down fully to ensure all insulin is injected.
11. Count to at least 10 slowly and then remove the needle from the skin. Counting past 10
may be necessary for higher insulin doses.
12. Apply gentle pressure to the injection site but do not rub.
13. Check that the dosage selector has returned to 0. If the whole dose has not been delivered,
the remaining number of units to be injected will be displayed in the dosage indicator
window.
14. Make sure the consumer is comfortable.
15. Store the pen in the marked container - opened insulin is not to be stored in the
refrigerator.
16. Once given, the medication is to be signed for on the medication signing sheet.
Forms
 Diabetes Care Support Plan
 Medication Assistance and Administration Plan
 Incident / Hazard Report Form
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 25 of 74
ADMINISTRATION: STANDING ORDERS
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. A standing order provides legal written instructions for the administration of medicines by
an authorised person. It is to be used in situations where a prompt response using a
standard procedure will improve consumer care and where medicine is part of this
procedure. This is not a PRN (as required' medication) order.
2. Whilst standing orders are discouraged in Pinnacle Community Services there may be
exceptional circumstances where this is required e.g. Epipen.
3. The use of a standing order is for a specific condition that must be clearly documented in a
consumer's initial assessment and Plan of Care with the date and name of medicine.
4. All consumers who have standing orders are required to provide an emergency contact for
their Medical Practitioner (MP).
Standing orders will:
 be supported by appropriate MP clinical assessment;
 clearly state conditions for administration;
 be clearly written with the date, name of the medicine, dosage, route and frequency;
 note any special observations or care which may be required prior to, or subsequent to
the administration;
 be signed with the name of the authorised prescriber clearly legible;
 be time limited and subject to regular review;
 be current within the time limit; and
 identify who can administer
The preferred administrator of standing orders is the emergency service (Ambulance Officer) or the
MP. Pinnacle Community Services staff are only permitted to administer if the above are not
available and they are trained appropriately.
If a consumer is assessed as needing the administration of a standing order an ambulance should
be called and all details given to the emergency service or the consumers MP if available. If not
available, the medication should be administered and the ambulance or MP advised.
Forms
 Ascia - Action Plan for Allergic Reactions
 Ascia - Action Plan for Anaphylaxis – Epipen
 Ascia - Action Plan for Anaphylaxis – Anapen
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
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SCHEDULE 8 – ADMINISTRATION AND REGISTERING
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
Designation
Registered
Nurse
Webster Packed
S8 administration
√ Can administer Webster packed √ Can administer PRN and
S8 medication which have been
emergency medications e.g.
ordered as the consumer's regular Epipen
dose of medication by the
consumers Medical Practitioner
and labelled and dispensed by the
pharmacist for the consumer.
Register requirements
X As medication is the property of
the consumer and is for
administration in the home a
register Is not required.
Enrolled Nurse
NSW (with
appropriate
Nursing and
Midwifery Board
Registration)
PRN and Emergency
S8 administration
X Cannot administer
S8 medications in any form.
√ Can act as a witness (it trained
and competent) to S8
administration.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Register
Requirements
X As medication is the
property of the consumer and is for
administration in the home a
register Is not required
X Cannot administer
S3 medications in any
form.
√ Can act as a witness (if trained
and competent) to S8
administration.
Page 27 of 74
Designation
Webster Packed
S8 administration
PRN & Emergency
S8 administration
Enrolled Nurse
MedicationsACT with
appropriate
Nursing and
Midwifery Board
registration)
Can give out S8
medication
√ Can administer Webster packed
S8 medication which have been
ordered as the consumer's regular
dose of medication by the
consumers Medical Practitioner.
Must be in a Unit Dose 7 Webster
pack.
√ Can administer PRN emergency
medication e.g. Epipen
Coordinatorwithout
professional
medication
qualifications
√ Can administer Webster packed
S8 medication which has been
ordered as the consumers regular
dose of medication by the
consumers Medical Practitioner.
May be a Unit Dose 7 Webster
pack [if under the delegation of an
RN) OR a Multidose Webster pack.
X Cannot administer PRN S8
medications.
Care WorkerCert IV
√ Can administer Webster packed
S8 medication which has been
ordered as the consumer's regular
dose of medication by the
consumer's Medical Practitioner.
May be a Unit Dose 7 Webster
pack (if under the delegation of an
RN) OR a Multidose Webster pack
X Do not have to be registered in a
drug register.
X Cannot administer PRN
medications in any form.
Register requirements
X As medication is the property of
the consumer and is for
Register requirements
administration in the home a
X Do not have to be registered in a register is not required.
drug register.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
√ Can act as a witness (if trained)
to S8 administration.
√ Can act as a witness (if trained)
to S8 administration.
Page 28 of 74
Designation
Care WorkerCert111
Webster Packed
S8 administration
√ Can administer Webster packed
S8 medication which has been
ordered as the consumers regular
dose of medication by the
consumer Medical Practitioner.
Maybe a Unit Dose 7 Webster pack
(if under the delegation of an RN)
OR a Multidose Webster pack.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
PRN and Emergency
S8 administration
√ Cannot administer PRN S8
medications.
X Can act as a witness (if trained)
to S8 administration.
Page 29 of 74
LABELLING: MEDICATION
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. When medication administration is an identified service the Coordinator, Case Manager
and Care Worker is responsible for ensuring that:
 all medications dispensed by the pharmacy have a label;
 only a Pharmacist has placed a medication label on the medication container;
 inappropriately labelled medications are returned to the pharmacy;
 where a medication is incorrectly labelled an Incident / Hazard Report is completed
and the Manager is informed;
 pharmacy medication labels are not altered, modified or marked in any way;
 if a label is found to have been modified an Incident / Hazard Report Is completed
and the Manager Is notified;
 medication labels and/or medications are not transferred to other containers or
tampered with in anyway, and
 when medication orders change, the pharmacist is notified so that the medication
can be labelled correctly.
2. Medication label should contain the following details:
 The name and address of the pharmacy;
 The name, strength and quantity of the medication;
 Directions for use;
 The consumers name;
 If the brand supplied by the Pharmacist ;s a generic alternative and the medication
on the pharmacy label is different to the Medical Practitioner (MP) order, the
medication ordered is to appear in brackets on the pharmacy label;
 The dosage and frequency of administration;
 The route of administration;
 The name of the consumers treating MP;
 Date of supply;
 Date of expiry.
Forms
 Incident / Hazard Report Form
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 30 of 74
STORAGE AND SECURITY: RESPONSIBILITIES
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. The Coordinator ensures that:
 All Pinnacle Community Service consumers who are using medication are encouraged
to store their medications in a manner that maintains the quality of the medicine and
safeguards to consumers, their family and visitors.
2. The Coordinator ensures:
 a risk assessment Is undertaken when it is identified that the security and storage of
medications presents a potential risk to the consumer/care worker or organisation;
 following the risk assessment appropriate action is to be taken. This may include the
provision of a lockable place that is not accessible to the consumer or changes to the
methods of administration e.g. family may administer;
 keys to medication storage are to be held separately from other keys in order to ensure
that access to medications is by authorised persons only;
 a service specific local work instruction is to be developed to ensure the security of the
medication keys;
 medications that are supplied in Dose Administration Aids are required to remain in the
Dose Administration Aids until they are administered to the consumer;
 medications are stored according to manufacturer or Pharmacist instructions;
 in the event of a consumer's death or transfer, unused medications are to be returned to
the consumers family or Pharmacist;
 details of storage arrangements are clearly documented in the Care Plan and in
consumer file.
Forms
 Incident / Hazard Report Form
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 31 of 74
STORAGE AND SECURITY: MEDICATION – DAY CENTRES AND RESPITE
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. The Coordinator is responsible for:
 the day to day storage of all medications in their Day Centre or Respite Services;
 the safety and security for the keys to all medication storage areas.
2. Storage and Security of Medications:
 medications are required to be stored in a locked cupboard;
 the cupboard is to be kept locked when not in immediate use;
 no other goods, including keys, cash, or documents are to be kept in the medication
storage area;
 all medications labelled for individual consumers are to be stored in the cupboard.
3. Storage of Medications (Other Than Vaccines) in Refrigerators:
 Medication stored in Pinnacle Community Services refrigerators is required to be kept in
a container, separate from food, and preferably on a dedicated shelf for medication.
 The temperature of the fridge is to be monitored and documented on a daily basis.
Medication fridges are to be maintained between 2 to 8 degrees.
 If the temperature is recorded outside of 2 to 8 degrees medications are moved to
another suitable fridge and the fridge is repaired or replaced.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 32 of 74
STORAGE AND SECURITY: DISPOSAL OF MEDICATION
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual.
Procedure
1. Medication that is no longer in use for the consumer for whom it was dispensed must not be
kept for administration to another consumer.
2. Arrangements should be made with the consumer/person responsible for the return of
general prescription only medications and nonprescription medicines to the pharmacy for
appropriate disposal via a pharmaceutical waste system.
3. The Return of Unwanted Medicines program provides for appropriate disposal of unwanted
medicines via any community pharmacy at any time.
4. Medications that have explicit expiry dates (e.g. eye drops, ointments, anginine, insulin)
should be discarded one month after opening. The date the container was opened must be
recorded on the packaging.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 33 of 74
CONTINUOUS IMPROVEMENT
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual and
Quality Management Policy.
Procedure
1. It Is the responsibility of the Coordinator to:
 ensure that regular medication audits are conducted in order to monitor all aspects
of the service's medication management system. These would only be required for
consumers who have medication management as part of their Care Plan;
 ensure that every consumer's medication needs are assessed at least every twelve
(12) months;
 promote Home Medicine Reviews and report number of reviews initiated and
completed by each service;
 collate medication incident/errors, near misses and trends. Report outcomes to the
Manager/Coordinator/Case Manager and staff meetings;
 ensure that all new staff are aware of medication management policy and
procedures according to their scope of practice;
 ensure that all staff involved in medication administration completes a yearly
competency assessment in medication administration;
 ensure risk assessments are conducted and documented as per Risk Management
and Work Health and Safety policy and procedures;
 conduct staff counselling, education or disciplinary action resulting from noncompliance in relation to the Medication Management Policy.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 34 of 74
CONTINUOUS IMPROVEMENT: INCIDENTS AND ERRORS
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual and
Quality Management Policy.
Procedure
1. All staff that have a role In medication management have a responsibility to:
 report any medication incident / error or 'near misses' on the Pinnacle Community
Services Incident / Hazard Report and advise their supervisor;
 attend education and / or counselling meetings pending the results of investigation
of a medication incident / error;
 document the incident in the consumer's file.
2. The Coordinator is responsible for the following:
 Reporting (if appropriate) the incident to the Medical Practitioner (MP), the
Pharmacist, the consumer or the person responsible.
 That staff are aware that in the case of medication being given or taken by the
wrong consumer or the incorrect dose being given or taken, the incident is reported
immediately to the Coordinator who will inform the consumer’s MP and person
responsible. This may for instance occur if there are two consumers residing and
receiving care in one home or on a field trip.
 Ensuring that the incident / error is fully investigated and documented on the
Incident / Hazard Report and recorded in the consumer’s notes.
 Investigating all medication incidents / errors / near misses. An action plan is to be
implemented to reduce the possibility of recurrence.
 An analysis report of medication incident/errors is reported to the appropriate
meeting such as staff meetings. Trends are identified and actions implemented.
 Contacting the pharmacy immediately if the incident/error relates to faulty
medications, faulty packaging or incorrect labels.
 All medication packs that are found to be packed or labelled incorrectly are to be
removed and returned to the Pharmacist for repacking. An Incident / Hazard Report
is completed.
Forms
 Incident / Hazard Report Form
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 35 of 74
CONTINUOUS IMPROVEMENT: MEDICATION REVIEW
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual and
Quality Management Policy.
Procedure
1. It is recommended consumers be encouraged to have their medications reviewed by the
Medical Practitioner.
2. Review by Medical Practitioner is encouraged for consumers who have an identified
assessed need; dependent on the relevant program guidelines.
3. The medication review must involve consultation with the consumer or person responsible.
Evidence of any consultation must be documented in the consumers file.
4. The review should involve collaboration between the Medical Practitioner, the Pharmacist,
other health professionals and the consumer / person responsible.
5. When required the review team should include other professionals such as speech
pathologists and physiotherapists to provide expertise in specific situations.
6. The reviews are to be read by the Coordinator / Manager and in consultation with
staff involved in medication, e.g. allied hearth, if required.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 36 of 74
CONTINUOUS IMPROVEMENT: COMPETENCIES AND ONGOING TRAINING PROCEDURES
FOR STAFF
Policy
Refer to Policy Statement within the Medication Management Policy and Procedure Manual and
Quality Management Policy.
Procedure
1. Staff are required to complete annual competencies related to their level of qualification in
administration of medications.
2. Practical competencies will be completed by all staff with a registered trainer within TAFE
NSW.
3. A record of all staff training will be kept in Pinnacle Community Services office (Refer to
Information Management Policy).
4. A data base of records is kept for all staff that is competent in administration of medications
and a competency expiry date is recorded.
5. Refresher training will be arranged by the Manager / Coordinator and all staff must attend.
6. Only staff that is deemed competent will remain on the list to assist with administration of
medications.
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 37 of 74
Authorisation:
Status
Current
Owner
General Manager
Superceded Policy
Date of Adoption/
Amendment
Revision Number
Review Date
15/1/2015
0
October, 2016
Related Council Policy / Procedure
Accident and Incident Policy
Information Management Policy
Temora Shire Council Work, Health and Safety Policy
Consumer Care Plan Policy
Quality Management Policy
Consent Policy
Duty of Care Policy
Infection Control Policy
Enteral Nutrition Support Policy and Procedure
Injection Safety Policy
Clinical Procedure Manual
Procedure on assessing consumers for Assistance: Self Medication
Nutrition and Swallowing Policy and Procedures – ADHC
Temora Shire Council Training Policies
Temora Shire Council Infectious Diseases Policy
Temora Shire Council Incident and Hazard Reporting Procedures
Temora Shire Council Hazard Identification Risk Assessment and Control Procedure
Temora Shire Council Personal Protective Clothing and Equipment Procedure
Medication Management Policy and Procedure Manual
Pinnacle Community Services auspiced by Temora Shire Council
Page 38 of 74
Attachment 1
Definition and Abbreviations
Accountability - One who has ultimate responsibility for ensuring effective completion of tasks
through appropriate delegation. Person must be able to demonstrate processes to ensure overall
control.
Administration of medications - The giving of the medication orally, by injection, per rectum, or
other routes.
Adverse drug reaction - "Is any unintended or undesired response to a drug”. This can occur as
predictable, unpredictable, as a consequence of long term use or delayed effects.
Allergy - A hypersensitivity reaction in which the body's immune system overreacts to innocuous
antigens called allergens.
Altering a medication - Means the crushing or cutting of tablets and the opening capsules.
Alternative/Herbal Medications and Aromatherapy - Includes herbal medicines, homeopathy,
nutritional therapy and aromatherapy and health food supplements.
Capacity - The ability to make your own decisions is called 'capacity'. When a person has capacity
they can make decisions about things that happen in their life. Capacity is not an all or nothing
concept. It is possible to have capacity intact in some domains (e.g. the capacity to consent to
medical treatment), while lacking capacity in other domains (e.g. the capacity to manage finances).
Under the law the patient is assumed to have capacity, unless there is evidence to the contrary.
The core of a capacity assessment involves continuing that the patient: understands the question,
understands all the options including the option to do nothing, understands the reasonably
foreseeable consequences of each of these options and has not made their decision based on
delusional thinking.
Coordinator - Is a staff member responsible for coordinating one or more services or programs to a
number of consumers Iiving in the community.
Care Worker (CW) - Is an unlicensed worker whose previous title could include Assistant in
Nursing, Personal Care Assistant or Recreational Activities Officer.
Certificate IV in Aged Care Work - Is a national qualification endorsed by the Vocational Education
and Training Accreditation Board (VETAB).
Certificate IV in Aged Care Trainee - Is a student undergoing the Certificate IV qualification and
can administer medications under the supervision of a Registered Nurse (RN) once they have
achieved competency in medication administration.
Certificate IV in Nursing (Enrolled Nurse) Trainee - Is a student undergoing the Enrolled Nurse
program and can administer medications under the supervision of a Registered Nurse (RN).
Consent - Is the voluntary agreement of one who has sufficient mental capacity to make an
intelligent choice to do something proposed by another person. It can be either informed or implied.
A person has the right to consent and the right to refuse consent to a medicine.
Cytotoxic medications - Is any drug that has a toxic effect on cells; commonly used in
chemotherapy to inhibit the proliferation of cancerous cells.
Dispensing - Supplying the medication or poison m accordance with a prescription duly provided
by a Medical Practitioner or Dentist.
Direct Supervision - Is provided when the Registered Nurse is actually present, observes, works
with, guides and directs the person who is being supervised. (ANMC Council).
Dose Administration Aids - Are compartmentalised blister pack- type devices used to aid the
administration of solid, oral medications (APAC Guidelines page 34).
Enrolled Nurse (EN) - Is a licensed worker that has successfully completed a recognised
accredited course and is registered with the Australian Health Practitioner Regulation Agency.
Error - Is a mistake or a wrong action attributable to bad judgment or ignorance or inattention.
Guardian Order - Is an order made by the Guardianship Board that gives a person ('the guardian')
the legal right to make decisions in health and lifestyle matters for another person ('the protected
person'). If the Guardianship Board is satisfied that a person has a mental capacity that affects his
or her ability to make independent decisions, it can appoint a guardian who has powers and
responsibilities to exercise on behalf of and for the benefit of that person.
Incident - Any event which is not part of the standard operation of a service and which causes, or
may cause, an interruption to, or a reduction in, the quality of that service.
Indirect supervision - When the RN works in the same care centre or service as the supervised
person, but does not constantly observe their activities. The RN must be available for reasonable
access. What is reasonable access will depend on the context, the needs of the Consumers and
the needs of the person being supervised (ANMC).
Labelling - Is the written Identification of all relevant Information regarding the medication.
Medications - Are substances taken to prevent or treat illness. They can be anything from herbal
extracts and vitamins to synthetic chemicals. They come in many forms and may be ingested,
inhaled, inserted or applied.
Medical Practitioner - Is an individual who is registered with the NSW or ACT Medical Board to
practise as a Medical Practitioner. Can also be referred to as a Doctor or Local Medical Officer.
Medication chart - Is a document that records the medication order as written by the consumer’s
Medical Practitioner. It is a requirement of all services within Pinnacle Community Services that all
consumers have a current medication chart.
Medication review - Is an analysis of a consumer's medication regime by an accredited
Pharmacist.
Mental incapacity - The inability of a person to look after his or her own health, safety or welfare or
to manage his or her affairs as a result of any damage to or any illness, disorder, imperfect or
delayed development, impairment or deterioration, of the brain or mind; or any physical illness or
condition that renders the person unable to communicate his or her intentions or wishes in any
manner whatsoever.
Near miss - Is an unplanned event that did not result in injury, illness, or damage - but had the
potential to do so.
Non packed - In the context of this Policy and Procedure non packed medication refers to any
other medication that is not packed in a Webster Unit Dose 7 or Webster Multidose. Thus bottles,
boxes, nebulisers, ointments, creams etc. are all examples of non-packed medications.
Packed Medication - In the context of this Policy and Procedure packed medication refers to
medication packed in a Webster Unit Dose 7 or Webster Multidose. Webster packed medications
are a type of individual 'blister’ pack dose medication system which are heat sealed and tamper
evident.
Person Responsible - Is a person who can make decisions for children and adults who have a
disability and who are incapable of consenting to treatment. If the patient is an adult, the person
responsible in priority order is either:




a guardian (including an enduring guardian) who has the power to consent to health care,
which includes tie power to refuse or withdraw consent to treatment
a spouse - including a de-facto spouse
an unpaid carer who Is now providing domestic services or support to the patient, or who
provided these services and support before the patient entered a residential facility
a relative or friend who has both a close personal relationship and a personal interest in the
patient's welfare.
Pharmacist - Is a licensed health care practitioner who is registered with either the NSW or ACT
Pharmacy Board.
Policy Statement - Is a course of action adopted by the organisation.
Prescription - The granting of a right to receive a substance to prevent or treat illness of a particular
person by a Medical Practitioner, Nurse Practitioner, Dentist, Veterinary Surgeon.
Procedure - Is a particular course of action intended to achieve a result. Usually set out in a set
sequence of steps.
PRN (when required) medication - Are those medications which are ordered by a Medical
Practitioner for a specific consumer on that consumer's medication chart and which the Registered
Nurse, using clinical judgement, initiates, or delegates to an authorised Endorsed Enrolled
Nurse/Care Supervisor when necessary.
Registered Nurse - Is a nurse who is currently registered with the appropriate licensing
body in Australia.
Responsibility - One whose role it is to manage the system/task and who ensures that functions
are delivered.
Schedule 2 medicines - Over the counter medicines sold supermarkets and in pharmacies.
Schedule 3 medicines - Medicines sold in pharmacies only: labelled pharmacy medicine.
Schedule 4 medicines (Restricted Substances – labelled prescription only drug') - Substances for
therapeutic use that in the public interest should be supplied only upon the written prescription of a
Medical Practitioner, Nurse Practitioner, Dentist or Veterinary Surgeon.
Schedule 4 D medicines - (labelled 'prescription only drug') - These are Schedule 4 medicines
listed in the Poisons and Therapeutic Good Regulations 1994 due to their abuse potential (e.g.
benzodiazepines, ephedrine, ketamine, anabolic androgenic steroids); labelled Prescription Only
Medicine. Special separate storage requirements apply to these drugs.
Schedule 8 medicines (Drugs of Addiction – labelled 'controlled drug') - Substances that have
therapeutic use in controlled circumstances but which are addiction producing or potentially
addiction producing. Schedule 8 drugs require a prescription plus special storage and a Drug
Register.
Scope of Practice - Is a terminology used by state licensing boards for various professions that
define the procedures, actions, and processes that are permitted for the licensed Individual. The
scope of practice is limited to that which the law allows for specific education and experience, and
specific demonstrated competency. Each state has laws, licensing bodies, and regulations that
describe requirements for education and training, and define Scope of Practice.
Supervision of staff - This includes both direct overseeing of staff and indirect through telephone
contact.
Webster System - Medication management system of packaging medications via single dose or
multi dose blister packs, labelling, ordering, colour coding and alert cards, medication charts,
signing sheets and administration records.
Webster Pak-Multi Dose - Is a dose administration aide. The pack is arranged in 4 columns across
for the dose times of the day and seven rows down representing the seven days of the week. The
packed blister sheet may be placed in a reusable plastic folder or may be used as a disposable
blister sheet. Each blister may contain multiple solid medications prescribed for that time of the
day.
Webster Pak-Unit Dose 7 - Is a dose administration aide. Each drug is in an individual blister,
up to four different drugs per blister sheet. Directions and MIMs descriptions can be included on
blister packs and colour coding for each dosage time.
Witness - Someone who sees an event and reports what happened. Must be a person who is fully
familiar with the procedure and who understands their legal responsibility in the role. Staff mat act
as a witness in medication management must be suitably assessed and trained to do so.
Abbreviations: Pinnacle Community Services Medication Chart
Approved Abbreviations for Medication Charts (reasons that medications are not taken) must be
circled on medication charts and signing sheets when used.
Abbreviation
Meaning
Abbreviation
Meaning
A
Absent
N
Nil Stock
D
Doctors Instructions
0
Outing medication
sent with consumer
F
Fasting
R
Refused
H
Hospital
S
Self-Administered
L
Social Leave
w
Withheld
M
Refer to progress
notes
Some Frequently Used Approved Abbreviations
Abbreviation
Meaning
Abbreviation
Meaning
AC
before meals
DC
discontinue
PC
after meals
FBS
fasting blood sugar
PRN
as required
Gtts
drops
Mane
morning
Hr
hour
Nocte
night
Liq
liquid
subcutaneous
Injection
twice a day
meds
SCI
BD
6/24
every 6 hours
NGT.
QID
4 times per day
NSAID
medications
non-steroidal antiinflammatory drug
nasogastric tube
02
oxygen
3 times per day
PEG
percutaneous
endoscopic
gastronomy (gastric
lube)
PR
per rectum
Q2H
every two hours
Stat
Immediately
Q3H
every three hours
Am
morning
Rx
prescription
amt
amount
tabs
tablets
with
tbsp
tablespoon
Capsules
tsp
teaspoon
TDS
C
Caps
Reference:
Webster Care Resident Identification Sheet
Attachment 2
Scope of Practice
Care Worker with/without Certificate111
Care Worker Certificate 1V
Coordinator
Registered Nurse (RN)
Enrolled Nurse (EN) - Community Care - NSW
Care Worker with/without Certificate 111 - May administer the following medication after
completing relevant competencies.


CHC30208 Certificate 111 in Aged Care.
CHC30308 Certificate 111 in Home and
Community Care
These courses include the following units:
 CHCS305A Assist with Medication
 HLTAP301A Recognise healthy body
systems
Tier 1 competency includes the
administration of the following:
 Pharmacy packed dose administration
aid (e.g.
 Webster Pack)
 Patches
 Creams
Tier 2 competency includes administration
of the following additional items:
 Oral liquid non - prescription
 Nebuliser
 Inhaler
 Eye drops/ointments
 Eardrops/ointments
Tier 3 competency includes further
additional Items that are administered after
competency training.
 Epipen
Any requirements for Medication not listed
above will be discussed with the consumer’s
Coordinator prior to administration by a Pinnacle
Community Services staff member.
Care Workers are responsible for the safe assistance in medication administration by:
 Complying with this Medication Policy.
 Meeting medication competency standards prior to being able to participate in the
administration of medication.
 Assist with administering oral medications via pharmacy packed dose administration aids
e.g. Webster Packs.
 Using Five Rights (as a minimum) when checking and signing with administration of
medications from a dose administration aid - right consumer, right date and time and the
right number of medications, right route.
 Using the Five rights when assisting with medication administration of non-packed
medication right consumer, right date and time, right medication, right route and right
amount, e.g. eye drops, topical creams, inhalers, etc.
 Supervising and observing the consumer taking the medications and confirming with the
consumer their ingestion or completion.
 Signing the designated medication signing sheet as evidence that the medication has been
ingested by the consumer.
 Recognising circumstances when appropriate action is to report observed consumer health
condition rather than proceeding with administration of medication and seek the advice of
the Coordinator.
 Promptly reporting to the Coordinator any inconsistencies observed with medication or
changes in consumer condition prior to or following medication administration.
 Using approved Pinnacle Community Services abbreviations if required on the signing
sheets and providing further information in the consumer file e.g. refusal of medication - do
not leave signature box empty.



Never crushing medication unless it is approved and documented by the Medical
Practitioner/pharmacist on the medication plan /chart.
Offering support and education on the safe use and storage of medicines.
Not promoting, purchasing or administering any "over the counter" medication unless
directed by the consumer’s Coordinator.
Care Workers will:
 Report immediately to the Coordinator any incidents, inconsistencies or errors that have
arisen from medication administration and complete an Incident / Hazard Report ; and
 Report any suspected changes in the consumer’s health condition to the Coordinator that
may be a result of medication administration.
The Care Workers role In Continuous Improvement:
 May participate in Continuous Improvement activities that include medication audits;
 May participate in medication audits and related surveys; and
 Reports and documents medication incidents and errors.
Care Worker Certificate 1V - May administer the following medication after completing relevant
competencies.
 CHC40108 Certificate IV in Aged Care
 CHC40208 Certificate 1V in Home and
Community care
Courses include the following unite:
 CHCCS305A-Assist With Medication
 CCCC424A Administer and monitor
medications
 HLTAP301A Recognise' healthy body
systems
Tiers 1 - 3 after competency assessment
Dose Administration Aid (e.g. Webster Pack)
Patches (schedule 8 under direct/indirect
supervision of an RN):
 Creams
 Oral liquid non - prescription
 Nebuliser Inhaler
 Eye drops/ointments
 Eardrops/ointments
 Suppositories
 Enemas
 Some emergency medications e.g.,
epipen,
Any requirements for Medication not listed
above will be discussed with the consumer’s
Coordinator prior to administration by a Pinnacle
Community Services staff member.
Pinnacle Community Services staff that are enrolled in the above qualifications and have been
deemed competent in the above mentioned medication competency units can administer
medication.
The Care Worker is responsible for safe administration of medications by:
 Administering medications according to relevant legislation and policy;
 Administering medications to consumer in the community and in Pinnacle Community
Services Care Centre’s e.g. Respite and Day Program;
 Administering medications from a valid medication order - i.e. one that has been ordered by
a Medical Practitioner or Dentist;
 Administering medications via the Five Rights in medication management (consumer, drug,
dosage, route and time) then signing the medication signing sheet immediately following
the administration;
 Not signing medication sheets prior to administration of the medication.
 Immediately reporting to the coordinator/community manager any medication incident
and/or error;
 Completing an Incident / Hazard Report if involved in or subsequently discover an
incident/error;
 Ensuring that medications are not set out in containers or spoons (pre-dispensing).
 Ensuring that medication is stored safely and appropriately.
The Care Workers role in Continuous Improvement
 Reports the side effects that the consumer may suffer as a result of taking medication;
 Participates in Continuous Improvement activities that may include medication audits; and
 Reports and documents medication incidents and errors.
Scope of Practice:
Coordinator – May administer the following medication after completing relevant competencies.
A Coordinator may have the following
qualifications or have completed other
relevant qualifications.
 CHC40108 Certificate IV in Aged Care
 CHC40208 Certificate IV in Home and
Community Care
Courses include the following units:
 CHCCS305A-Assist With Medication
 CCCC424A Administer and monitor
medications
 HLTAP301A Recognise healthy body
systems
Coordinators with qualifications may
administer the following medication in Tiers
1 - 3 after competency assessment:
 Dose Administration Aid (e.g. Webster
Pack)
 Patches (schedule 8 under direct/indirect
supervision of and RN)
 Creams
 Oral liquid non – prescription
 Nebuliser
 Inhaler
 Eye drops/ointments
 Ear drops/ointments
 Suppositories
 Enemas
Some emergency medications e.g. epipen,
Pinnacle Community Services staff member.
Any requirement a consumer has with
medication that is not listed above is discussed
with the Service Manager.
Role of the Coordinator in medication management
The Coordinator ensures:
 consumers are assessed and reviewed as to their medication support needs where
relevant;
 that staff comply with the medication management policy;
 compliance with relevant legislation is undertaken;
 staff who administer medications undergo appropriate training and annual competencies.
 staff who administer medications maintain contemporary knowledge and skills in relation to
pharmacology and health assessment;
 medication incidents are investigated and actions implemented;
 there is adequate delegation and supervision of medication administration.
 they liaise with the consumers Medical Practitioner and Pharmacy, where required, to
ensure adherence with Medication Management Policy;
 management of disciplinary procedures if required, when staff do not comply with the
Pinnacle Community Services Medication Policy (e.g. in the event of a medication error).
 there is a current list of 'medication competent’ staff available;
A Coordinator administers medications if:
 They have undergone an annual Pinnacle Community Services competency assessment in
medication administration.
 A Pinnacle Community Services competency assessment is included in the individual staff
personnel records.
 Their name is documented in a current list of 'medication competent’ staff.
The Coordinator, with relevant qualifications, is responsible for safe administration of
medications by:
 Administering medications according to relevant legislation and policy;
 Administering medications to consumers receiving Community Care;






Administering medications from a valid medication order - i.e. one that has been ordered by
a Medical Practitioner or Dentist;
Administering medications via the Five Rights in medication management: (consumer,
drug, dosage, route and time) then signing the medication signing sheet immediately
following the administration;
Not signing medication sheets prior to administration of the medication.
Immediately reporting to the Manager any medication incident and/or error;
Completing Incident / Hazard Report if involved in or subsequently discover an
incident/error;
Ensuring that medication is stored safely and appropriately.
The Coordinator role in Continuous Improvement
 Reports the side effects that the consumer may suffer as a result of taking medication;
 Participates in Continuous Improvement activities that may include medication audits; and
 Reports and documents medication incidents and errors.
Scope of Practice:
Registered Nurse (RN)
Education Requirements
Current Authority to Practice
May administer the following after
completing relevant competencies:
Administer medications via all routes
(Routes of administration that are exceptional to routine
practice require in service training and support prior to and
during administration e.g. the administrator, of intravenous
medication and administration of cytotoxic medications)
Administration of Schedule 8 medications
Delegation and Supervision
The Registered Nurse provides a level of supervision after considering the health status of
the consumer and the skills of the care worker to whom the administration is to be
delegated.
An RN may administer medications in Community Services if:
1. They hold a current Authority to Practice;
2. They have undergone a Pinnacle Community Service competency assessment in
medication administration including Schedule 8 medications;
3. Their name is documented in a current List of 'medication competent’ staff;
4. A Pinnacle Community Service competency assessment is included in the individual staff
personnel records.
The RN is responsible for safe medication administration by:
1. Administering medications according to relevant legislation and Pinnacle Community
Service Medication Policy.
2. Administering medication using the Five Rights in medication management (right
consumer, drug, dosage, route and time).
3. Administration of medication from a valid medication order, i.e. that has been ordered by a
Medical Practitioner or dentist
4. Administering of Scheduled 8 medications, intramuscular, intravenous, and subcutaneous
medications.
5. Ordering medications from the pharmacist in some circumstances.
6. Understanding the pharmacokinetics and pharmacodynamics of medications that are being
administered.
7. Advising on the safe and appropriate storage of medication/s including all forms of
Schedule 8 medications and injections.
8. Investigating and reporting medication incidents to the Coordinator.
9. Reporting any medication side effects or adverse reactions.
10. Consulting with the Medical Practitioner and Pharmacy to report medication side effects,
contraindications and adverse reactions.
11. Signing medication signing sheets/medication charts immediately following the
administration of medications.
12. Ensuring safe storage of medication in day centers and respite.
13. Ensuring that medication trolleys, cupboards, rooms and draws are locked when not in use
or that medication is stored safely in a consumer's home.
14. Checking pharmacy delivery against the consumer's prescribed medication list where
applicable.
15. Being willing to maintain contemporary knowledge and skills in relation to pharmacology
and health assessment.
The RN role in Continuous Improvement
 Reports the side effects that the consumer may suffer as a result of taking medication;
 Participates in Continuous Improvement activities that may include medication audits; and
 Reports and documents medication incidents and errors.
Scope of Practice:
Enrolled Nurse (EN) Community Care - NSW
Education Requirements
Pre 2008
Enrolled Nurse (EN) who has
completed a Nursing and
Midwifery Board of Australia
medication endorsed
accredited course such as:
■ Analyse health information
(HLTAP501A)
■ Administer and monitor
medications in the work
environment (HLTEN507A)
■ Elective course;
Administer and monitor
intravenous medication in the
nursing environment
(HLTEN519A)
■ (ENs who are not yet
qualified to administer
medicines will have a
notation against their name
that will read
"Does not hold Board
approved qualifications in the
administration of medicines'
until the EN can provide
evidence of a Board approved
administration of medicines
unit
Post 2008
Diploma of Nursing (Enrolled) (HLT51607)
and have an Authority
to Practice Certificate
in NSW
May administer the following
after completing relevant
competencies:
> Schedule 4 oral medications
> Capsules
> Eardrops
> Eye drops
> Inhalants
> Liquid
> Lotions and creams
> Nose drops
> Patches
> Powder
> Insulin using pre-loaded
syringes or pens
> Intra Muscular Injections (NB –
see below)
> Tablets
> Wafers
> Suppositories (ensure
competence achieved)
> Pessaries (ensure competence
achieved)
EN in NSW cannot
administer Schedule 8
medications.
An EN may administer medications in Community Care If:
1. They hold a current Authority to Practice Certificate and they do not have a notation on the
Board register against their name reading “Does not hold Board-approved qualifications in
administration of medicines."
2. They have undergone an annual Pinnacle Community Service competency assessment in
medication administration.
3. Their name is documented in a current list of 'medication competent staff.
The EN is responsible for safe administration of medications by:
1. Administering medications according to relevant legislation and policy.
2. Administering medications from a valid medication order - i.e. one that has been ordered by
a Medical Practitioner or Dentist.
3. Administering medications via the Five Rights in medication management (consumer, drug,
dosage, route and time) then signing the medication signing sheet immediately following
the administration.
4. Only administering herbal medicines if they have been ordered by a Medical Practitioner.
5. Not signing medication sheets prior to administration of the medication.
6. Reporting to the Coordinator or community manager immediately in the event of a
medication incident and/or error.
7. Undergoing annual competency assessment and maintaining current pharmacological
knowledge.
The ENs role in Continuous Improvement
1. Reports the side effects that the consumer may suffer as a result of taking medication.
2. Participates in Continuous Improvement activities that include medication audits if
requested.
3. Participates in medication related audits and surveys if requested.
Attachment 3
Medication Self Administration Assessment
Attachment 4
Medication Assistance and Administration Plan
Attachment 5
Consumer Risk Assessment Forms
Attachment 6
Consent for Administration of Medication
Attachment 7
Incident / Hazard Report Form