Download existing registered practitioners where medicines management is

Mandatory Competency Assessment for Medicines
Management (Not Injectable Medicines) for
Registered Practitioners
‘IN HOSPITAL’
Document Author
Written by: Lead Pharmacist/Lead
Technician
Medicines Use and Safety Team,
Pharmacy Department
Authorised Signature
Authorised by: Head of Practice Education
and Development
Date: September 2015
Effective Date: October 2015
Date: September 2015
Review Date: October 2017
Approval at: Clinical Competency Group
and Mandatory Training Group
Date Approved: September 2015
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DOCUMENT HISTORY
(Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g.
1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when
writing a procedural document for the first time – the initial draft will be version 0.1)
Date of Issue
Version
No.
Date
Approved
October 2015
1.0
September
2015
March 2016
1.1
Person Responsible for
Change
Nature of
Change
Ratification /
Approval
Clinical
Competency
Group/Mandatory
Training Group
Donna Baker
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Frequency
amended to
reflect the annual
assessment
component of the
Medicines Policy
Version 1.1
‘Nursing staff in the best interests of their patients must know the therapeutic uses of the
medicine to be administered, normal dosage, side effects, precautions and contraindications.
They must have considered the dosage, method of administration, route and timing of the
administration in context of the patient’s condition, co-existing therapies and meals’ (NMC,
Standards for Medicines Management 2010).
The core mandatory assessment requirements for Medicines Management ‘IN HOSPITAL’
are applicable to the following practitioners:
NEW REGISTERED PRACTITIONERS OR EXISTING PRACTITIONERS WHERE MEDICINES
MANAGEMENT IS NEW TO THEIR ROLE ARE TO COMPLETE ALL THE REQUIRED ELEMENTS
BELOW PRIOR TO UNDERTAKING MEDICINES MANAGEMENT UNSUPERVISED.
EXISTING REGISTERED PRACTITIONERS WHERE MEDICINES MANAGEMENT IS PART OF
THEIR ROLE ARE TO COMPLETE THE REQUIRED ELEMENTS EVERY TWO YEARS ENSURING
THAT A DIFFERENT ELEMENT IS COMPLETED ON AN ANNUAL BASIS.
REQUIRED ELEMENTS:
1. Ward based ‘IN HOSPITAL’ Competency Assessment for Medicines Management
(this document)
2. E Learning Training Tracker Module for Medicines Management
a) Clinical Medicines Scenarios – 100%
b) Maths and Medicines Calculations - 100%
IF REQUIRED
3. Electronic Prescribing and Medicines Administration system (EPMA) training
commonly referred to as “JAC” Medicines Management system, if in use on the
ward.
4. Electronic Medicines Storage Cabinet training (e.g. Omnicell and MDG Cabinet) if the
electronic medicines storage cabinet is in use on the ward.
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Learning outcome 1
Safely & Effectively Administer Medicines (not injectable
medicines)
Observed administration of medicines (not injectable
medicines)
1.1 Using the electronic or paper drug chart the RP must satisfy
the assessor that:
Registered practitioners (RP) to be observed
undertaking administration of medicines to 4 different
patients covering a minimum of 4 different
formulations
1.
1
patient
2
3
4
Assessed as
competent
Signature
1
patient
2
3
4
Assessed as
competent
Signature
1
patient
2
3
4
Assessed as
competent
Signature


the correct drug chart is being used for the correct patient
the whole drug chart has been checked (to identify prn, stat
doses & range of doses) e.g.to check if once only doses
have, or have not been administered e.g. methotrexate, or
to ensure that prn medicines e.g. paracetamol, are
administered within recommended maximum dose/dose
range
 the patient’s allergies have been considered
 the patient’s weight has been considered (if necessary)
 identify if other drug /recording charts are being used for
that patient e.g. warfarin, insulin
 identify which medicines are to administered at that time
1.2 The assessor witnesses the RP with the patient:




asks the patient to confirm identity (wrist band and
verbally) full name & DOB (or according to Patient
Identification policy)
asks the patient about allergies or sensitivities
explains details of medicines to be administered
obtains patient consent
1.3 The assessor witnesses the RP selecting the medicine for
administration (the medicine label must correspond to the
prescription)
 the correct medicine
 the correct strength and dose
 the correct formulation
 the correct frequency/time
 the correct route
 the medicine has a valid expiry date
Assessed as
competent
Signature
1.4 RP is able to demonstrate /explain where to obtain
information about a medicine e.g. dose, contraindications,
side effects, how to prepare the medicine, route, drug
interactions and obtaining stock RP to include the following:
 Intranet- Medusa & Electronic Medicines Compendium
(EMC)
 medicine pack insert
 in date BNF/ web BNF
 JAC clinical information on
 ward pharmacy team
 on call pharmacist (out of hours)
 bed manager (out of hours)
1.5 RP is able to demonstrate completion of administration of
medicine/s :



observes the patient taking/using the medication
documents administration on JAC/Paper prescription
4
orders a specific medicine using ‘resupply orders’
1
patient
Medicines Use and Safety Team Pharmacy Department 2015
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3
4
Assessed as
competent
Signature

can explain process when delaying or omitting a prescribed
medicine
 demonstrates disposal of equipment/waste medicines
1.6 RP is witnessed administering a selection of formulations
during assessment; tick preparations/routes assessed
*mandatory
 Oral tablet
 Dispersible tablets*
 Liquid- oral syringe/spoon/medicine measure*
 Inhalers*
 Cream/ointment
 Eye drops/ointment*
 Rectal – suppositories
 Vaginal - pessaries
 patch
 Nebules*
 Sublingual
 Others please state:
1.7 RP to explain what action to take if they are unable to
administer a prescribed medicine to include:




demonstrates ability to select appropriate equipment with
rationale for us

prepares the medicine for injection appropriately

identifies correct patient, explains procedure, checks any
contraindications, potential side effects and obtains valid
consent
demonstrates ability to ensure correct administration
technique of the medicine via the subcutaneous route in the
prescribed site
demonstrates understanding of the anatomy and
physiology of sites used for injection technique
1.9 RP is witnessed administering an intramuscular injection



3
4
Assessed as
competent
Signature
Assessed as
competent
Signature
nurse unable to give by prescribed route (contact prescriber
without delay)


2
if a patient is unable to swallow (determine reason e.g. size
of table, refer for SALT assessment, refer to doctor for
review form of medication)
if a medicine is not available(contact pharmacy, bed
manager- out of hours ,prescriber) there should be NO
delay, especially with critical medicines)
patient unable to tolerate
1.8 RP is witnessed administering a subcutaneous injection (tick
boxes 1.1 – 1.8)

1
patient
1
patient
2
3
4
Assessed as
competent
Signature
1
patient
2
3
4
Assessed as
competent
Signature
demonstrates ability to select appropriate equipment with
rationale for use
prepares the medicine for injection appropriately
identifies correct patient, explains procedure, checks any
contraindications, potential side effects and obtains valid
consent
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

demonstrates ability to ensure correct administration
technique of a medicine via the intramuscular route in the
prescribed site safely
 demonstrates understanding of the anatomy and
physiology of sites used for injection technique
1.10 RP to demonstrate the correct procedure for administering
Controlled Drugs ( including appropriate record keeping)
Assessed as
competent
Signature

preparation and administration (must be carried out by two
RPs )
 how to ensure security of the CD cupboard
 how to complete a stock balance
 use of electronic medicines storage cabinet for
‘supplementary restock’ and ‘cycle counts’( if in use on
ward)
1.11 RP to demonstrate correct process to follow when
administering and documenting Oxygen therapy

flow rate and duration


appropriate percentage according to patient’s saturation
rate
appropriate device used

correct documentation
1
patient
2
3
4
Assessed as
competent
Signature

what action to take if oxygen not prescribed and patient
requires oxygen
1.12 RP to demonstrate/explain how to prescribe/administer
Homely Remedies on JAC or paper prescription chart


which medicines can be given( paracetamol, Gaviscon
Advance, simple linctus, senna, lactulose and aqueous
cream)
check for contraindications

correct procedure for administering medicines
Assessed as
competent
Signature

length of time these medicines can be administered before
review (24hours)
1.14 RP to explain the use of a Patient Group Direction (PGD) and
records required

explains when are they used

explains who can use them

explains appropriate recording/documentation
Assessed as
competent
Signature
Assessed as
competent
Signature
1.15 RP to explain the process to initiate and monitor a patient on
the Self Administration of Medicines Scheme (SAM) the
following should be mentioned:
 patient assessment

SAM levels

consent

only medicines reconciled(checked by pharmacy)can be
used
medicines not suitable to self-administer

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
key security

Medicines Information Card/JAC administration chart

where to store medicines

nurse responsibility for monitoring patient (mention
deteriorating patient and withdrawal from scheme)
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Learning outcome 2
Medicines Safety
2.0 Medication errors and patient safety
2.1 RP to define the following:
Assessed as
competent
Signature

Medication errors: are incidents in which there has been
an error in prescribing, dispensing, preparing, administering
or monitoring, regardless of whether harm has occurred
 Near miss: are incidents that did not cause harm but which
are judged to have had the potential to cause harm
2.2 RP to explain what process to follow upon discovery of a
medication error (including near miss)
 complete incident on electronic incident report ‘Datix’

the ‘Management of medication related incidents’ protocol
(see Intranet)must be followed
2.3 RP to explain how they would manage the following:



Assessed as
competent
Signature
Adverse drug reaction(preventable and nonpreventable)(MHRA- Yellow Card Scheme)
a missed dose

a patient sensitive to prescribed medicine (e.g. upset
stomach)
no stock of the first dose antibiotic

incorrect stock balance of a Controlled Drug


a patient has been given two doses of Paracetamol within 1
hour by a colleague
a discovery of a ‘near miss’

you have given a medicine to the wrong patient
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Learning outcome 3
Order, Receive, Store, Transfer and Dispose of Medicines
3.1 RP is able to demonstrate/explain the process for ordering,
receiving and storage of urgent medicines used on the ward
including : cardiac arrest, anaphylaxis, intubation boxes.
 which packs are stocked on your ward?
 when are they used?
 where are they stored?
 how are they ordered?
3.2 RP can demonstrate/explain the correct process for ordering,
receiving and storage of ward stock medicines
Assessed as
competent
Signature
Assessed as
competent
Signature

urgent medicines for cardiac arrest , anaphylaxis,
extravasation, intubation and neonatal resuscitation boxes
 order a ward stock item for Top Up and Non Top up wards (
use stock item request form or green stock profile order
folder)
 request a new stock item by using the ‘New Stock Request’
form
 receiving medicines on to a ward including signing
transportation of medicines register
 ‘returning’, ‘supplementary re -stock ‘and ‘cycle count’ for
medicines using the electronic medicines storage cabinet, if in
use on ward
 storage of the following ward stock:
Intravenous fluids - should be stored off the floor in their
original containers in a designated area/electronic medicines
storage cabinet
medicines for internal use
medicines for external use
diagnostic reagents
medical gases
3.3 RP to explain the correct storage and documentation
requirements for refrigerated medicines:



Assessed as
competent
Signature
demonstrate/explain daily temperature monitoring and
recording (using an electronic max/min thermometer to
maintain temp between 2-8 0C or electronic display on
automated fridges) or web monitoring (electronic medicines
storage cabinet)
action to be taken following disconnection of electrical supply
or refrigerator breakdown
action following the discovery of medicines that have not
been stored in recommended conditions
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3.4 RP can demonstrate the process for ordering, receiving and
storage of named patient medicines
Assessed as
competent
Signature


ordering medicines for named patients
receiving medicines in secure green pharmacy bag, checking
and signing transportation of medicines register
 storage of the following:
insulin
unopened eye drops
dosette box (patient’s own medicines)
oral tablets
3.5 RP can demonstrate/explain correct procedures for dealing with
the following:

Expired medicines

Lost/missing medicines

Returns to pharmacy

Disposal of medicines (see Trust Waste Policy)

Medicines on death of a patient
Assessed as
competent
Signature
3.6 RP can demonstrate the process for ordering, receiving,
returning and storage of Controlled Drugs to include:

ordering a Controlled Drug for stock

receiving stock Controlled Drugs

storing and stock checking process for Controlled Drugs

returning Controlled drugs to Pharmacy including
documentation
how to obtain supplies of Controlled drugs out of hours





Assessed as
competent
Signature
explain the process for dealing with discrepancies in ward
stock levels of Controlled Drugs
why a Controlled Drugs record book needs to be used on the
ward (include requirements for documentation)
how to manage patient’s own Controlled Drugs brought into
the hospital
process for managing Controlled Drugs when a ward or
clinical area is closed or transferred to another clinical area
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Learning outcome 4
Managing Discharge and Transfer of Medicines
4.1 Registered practitioners can explain the procedure for
managing medicines for discharge (TTOs)including
timescales
 check the medicines: right drug, right patient, right
strength, right route, right time (including any
medicines stored in the fridge or electronic medicine
storage cabinet or Controlled Drugs cupboard)and
sufficient quantity(14 days)
 patient assessed on knowledge and ability to selfmedicate on discharge
 patient receives appropriate information (e.g. copy of
discharge summary, treatment cards) regarding their
discharge medicines
 patient given follow up appointments for monitoring of
high risk medicines (e.g. warfarin)
 appropriate discharge paperwork is completed
Assessed as
competent
Signature

RP can explain how to arrange discharge medicines for
a patient out of hours
4.2 Registered practitioners can demonstrate/explain the
procedure for patients being discharged on Controlled
Drugs. (the following should be mentioned)
 CD prescription sent to Pharmacy


Assessed as
competent
Signature
sign out of the CD record book any medicines belonging
to patient to be used for discharge
patient counselled on discharge medicines

If discharge is to be delayed then CDs should be entered
into the CD register and locked in electronic medicine
storage cabinet or CD cupboard as appropriate, until
patient is discharged e.g. overnight
4.3 Registered practitioners can demonstrate/ explain the
procedure for the transfer of patient’s medicines to
another ward area
 check and place all patient medicines from patient’s
own lockable bedside cabinet into a ‘My Medicines’
Green bag
 check for medicines stored elsewhere e.g. in fridge or
electronic medicine storage cabinet or CD cupboard that
are needed for patient on next ward
Assessed as
competent
Signature
4.4 Registered practitioners can demonstrate the process for
issuing TTO packs from wards and clinics (see also section
1.3)
 after checking the patient’s identity, date of birth and
address, assemble appropriate TTO medicines pack/s
according to the (electronic) prescription

Assessed as
competent
Signature
insert patient name in the space provided on the label
and complete date of issue (if using an ‘over the
counter’ pack this step can be omitted)
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
insert administration instructions if not already present
on the label according to the prescription

obtain second check from another RP

complete appropriate paperwork

complete identity checks, sensitivities and allergies
before issuing the medicine

Give the patient full verbal instructions on taking the
medicine and make patient aware of information leaflet
inside the pack.

If paper prescription is used, place the pink copy of the
triplicate form with GP’s letter and give to the patient.

Send completed paper prescription to Pharmacy for
filing
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Assessment Outcome – Please sign in relevant box
Rating
Outcome
Actions
Assessor Signature and
date
Initial Assessment
Green
Pass - All essential
competencies evidenced.
Red
Refer - One or more
competencies not evidenced.
No action required. Review
annually at appraisal. Revisit
any development learning
points listed below as
recommended by assessor.
Clinical practice in relation to
the specific competency not
evidenced is to be supervised
and reassessed within 2
weeks.
Assessor Signature and
date
2nd Assessment
Learning points to revisit following successful competency assessment:
First Assessors Signature:
Registered Practitioners Signature:
Date:
Inform [email protected] of PASS outcome to update individuals Mandatory Training Profile
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Assessor Signature and
date
3rd Assessment
Action Plan following referral at FIRST assessment. To be completed following this assessment in preparation for second assessment.
PART 1
First assessor to tick, initial and date once completed
 Outcome of assessment and feedback given to registered practitioner
Initial:
Date:
 Line manager informed of referral at first assessment
Initial:
Date:
 Registered Practitioner signposted to further underpinning knowledge/ Competency Lead
Initial:
Date:
First Assessors Signature:
Registered Practitioners Signature:
ACTION PLAN
PART 2
Individual Learning Plan between line manager and Registered Practitioner.
assessment.
To be completed following this assessment in preparation for second
Date for re-assessment:
Line Managers Signature:
Registered Practitioners Signature:
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Action Plan following referral at SECOND assessment. To be completed following this assessment in preparation for final assessment.
PART 1
Second Assessor to tick, initial and date once completed
 Outcome of assessment and feedback given to registered practitioner
Initial:
Date:
 Line manager informed of referral at first assessment
Initial:
Date:
 Registered Practitioner signposted to further underpinning knowledge / competency Lead
Initial:
Date:
Second Assessors Signature:
Registered Practitioners Signature:
ACTION PLAN
PART 2
Individual Learning Plan between line manager and Registered Practitioner.
assessment
To be completed following this assessment in preparation for final
Date for Reassessment:
Line Managers Signature:
Registered Practitioners Signature:
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Managing a referral at Summative Assessment
Referral following Initial Assessment
 The first assessor provides feedback to the candidate; documents the outcome and completes PART 1 of the action plan.
 The assessor will refer the outcome to the candidate‘s line manager.
 The line manager will complete an individual learning plan in preparation for the second re-assessment. A different assessor will be identified for the second assessment.
 The line manager will consider invoking informal capability.
Referral following Second Assessment
 The second assessor provides feedback to the candidate; documents the outcome and completes PART 2 of the action plan.
 The assessor will refer the outcome to the candidate‘s line manager.
 The line manager will complete an individual learning plan and arrange for the candidate to undertake further simulated / supervised practice in preparation for the final reassessment.
 The line manager will consider invoking formal capability.
Referral following Final Assessment
Referral at the final attempt may lead to further performance management in line with Trust policy. This will be discussed in confidence with the candidate and their line manager.
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