Download Policy for the Safe Management of Injectable Medicines

POLICY FOR THE SAFE MANAGEMENT OF INJECTABLE
MEDICINES (ADULTS AND CHILDREN)
Version
4
Name of responsible (ratifying) committee
Formulary and Medicines Committee
Date ratified
20 May 2016
Document Manager (job title)
Director of Pharmacy
Date issued
23 June 2016
Review date
22 June 2018
Electronic location
Clinical policies
Related Procedural Documents
Medicines Management Policy
Key Words (to aid with searching)
Medicines; Prescribing; Administration; Dispensing;
Injection; injectable Drugs; Intravenous;
Intramuscular; Subcutaneous; Prescriptions;
Pharmacy; Label; Preparation; Patients; Children;
Young People; Adults.
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
1
??
2
Sept 2011
New author, incorporation of NPSA recommendations in to Policy
HM
3
June 2014
HM
4
May 2016
Student nursing and student midwife duties and responsibilities
updated. Reference to the UCL guide as to determine which
infusion pumps should be used for various drugs included.
Removal of section on Midwife administration of epidural top ups.
Update to definitions – CDs and PGDs.
5.1.3 Duties and responsibilities updated
5.1.4 Addition of sodium chloride
5.9 Pharmacist duties and responsibilities updated
5.10.2 PSSG changed to G&Q Cttee
5.10.5 Medication Safety Committee duties updated
7.2 Training requirements updated to include requirements for
nurses recruited from the EU.
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
Page 1 of 34
HM
CONTENTS
QUICK REFERENCE GUIDE....................................................................................................... 3
1. INTRODUCTION.......................................................................................................................... 4
2. PURPOSE ................................................................................................................................... 4
3. SCOPE ........................................................................................................................................ 5
4. DEFINITIONS .............................................................................................................................. 5
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 8
6. PROCESS ................................................................................................................................. 14
7. TRAINING REQUIREMENTS .................................................................................................... 15
8. REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 17
9. EQUALITY IMPACT STATEMENT ............................................................................................ 17
10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
18
Appendices:
1.
Trust Standard Operating Procedure for Prescribing, Preparing and Administration of
Injectable Medicines in Clinical Areas…………………………………………………………… 21
2.
Prevention of Over Infusion of Intravenous Fluids and Medicines in Neonates……………….31
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
This policy applies to all healthcare workers who prescribe, handle, supply or administer
INJECTABLE medicines in the course of their duties. This includes, but is not exclusive to, doctors,
dentists, pharmacists, nurses, midwives, operating department practitioners, radiographers,
podiatrists, dental nurses, nursery nurses, dialysis assistants, pharmacy technicians/assistant
technical officers, healthcare support workers, and delivery drivers including taxi drivers delivering
medicines.
The policy covers professional accountability of groups of workers, and the following processes
regarding intravenous medicines:





Risk assessment
Prescribing
Preparation
Administration
Resources required for the safe prescribing, preparation and administration of injectable
medicines
 Procurement
 Training
 Exemptions to medicines legislation in the event of a pandemic
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
Page 3 of 34
1. INTRODUCTION
The use of injectable medication has many health care benefits for patients of all ages. The
complexities associated with prescribing, preparing and administering injectable medicines
means that there are greater potential risks for patients than for other routes of administration.
The risks associated with injectable medicines include:
 Incomplete and/or ambiguous prescriptions which do not include important information.
 Presentations of injectable medicines that may require complex calculation, dilution and
handling procedures before the medicine can be administered.
 Lack of information about injectable medicines available to health care professionals at the
point of use.
 Selection of the wrong medicine or diluent.
 Use of a medicine, diluent or infusion after its expiry time and date.
 Calculation errors made during prescription, preparation, administration of the medicine,
leading to administration of the wrong dose and/or at the wrong concentration or rate.
 Unsafe handling or poor aseptic technique leading to contamination of the injection and
harm to, or infection of the patient.
 Incompatibility between the diluent, infusion, other medicines and administration devices.
 Failure to follow patient identification procedures leading to administration to the wrong
patient.
 Failure to follow administration checking procedures leading to administration via the wrong
route.
 Health and safety risks to the operator or environment.
 Variable levels of knowledge, training and competence amongst health care practitioners.
 Incorrect programming of infusion pumps.
The National Patient Safety Alert 20 “Promoting safer use of injectable medicines,” made six
key recommendations for action to identify and minimise risks associated with the
administration of injectable medicines.
1) Undertake a risk assessment of injectable medicines procedure and products in all clinical
areas to identify high risks, and develop an action plan to minimise them
2) Ensure there are up to date protocols and procedures for prescribing, preparing and
administering injectable medicines in all clinical areas.
3) Ensure essential technical information on injectable medicines is available and accessible to
healthcare staff in clinical areas at the point of use.
4) Implement a ‘purchasing for safety’ policy to promote procurement of injectable medicines
with inherent safety features.
5) Provide training for, and supervision of, all healthcare staff involved in prescribing,
administering and monitoring injectable medicines.
6) As part of the annual medicines management audit programme, healthcare organisations
should include an audit of medication practice with injectable medicines.
This policy documents actions to be undertaken within Portsmouth Hospitals NHS Trust
2. PURPOSE
Ensure compliance with National Patient Safety Agency (NPSA) Patient Safety Alert 20
Promoting Safer Use of Injectable Medicines. To minimise risks associated with the
management and administration of injectable medicines.
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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3. SCOPE
This policy covers the risk assessment, prescribing, preparation, administration of all injectable
medicines to all patients requiring medication via an injectable route.
Injectable routes not covered within this policy are:
 Intrathecal (see PHT Trust Policy for Intrathecal Chemotherapy in Adults – Oncology and
Haematology Departments)
 Epidural (see PHT Trust Policy for Continuous Epidural Infusions)
 Other routes such as intra-arterial, intraventricular, intravitreal, intrapleural and intraocular The Royal Marsden Manual should be used as the default reference, and other specialist
competences and techniques are also used in specific clinical areas. The principles and
basic preparation procedures covered in this policy will generally apply.
It also outlines the required:
 resources for safe prescribing, preparation and administration of injectable medicines,
 procurement
 training.
All staff within Portsmouth Hospitals with responsibility for the procurement, supply,
prescription, preparation, administration and monitoring of injectable medicines are required to
read and apply the recommendations set out below and to ensure that the policy document is
continually available for reference.
Exemptions to medicines legislation in the event of a pandemic
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Administer
To give to a patient a medicinal product, dressing or medical device, either by introduction into
the body, either orally or by injection, etc., or by external application (e.g. application of an
ointment or dressing).
ADR
Adverse Drug Reaction
ATO
Pharmacy assistant technical officer
BNF/BNFc
The British National Formulary (latest edition).
CD
Controlled drug – medicines that are liable to misuse, that are subject to special controls under
the misuse of drugs act 1971.
CIVAS
Centralised Intravenous Additives Services
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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Clinician
A health care professional who is engaged in the direct examination, diagnosis, treatment
and care of patients.
Clinical Support Worker
A clinical support worker is not registered with a professional body. They may be registered
within the Trust. For the purposes of this policy these include:
 Healthcare Support Workers (HCSW)
 Pharmacy Assistant Technical Officers (ATOs)
 Nursery Nurses
 Dental Nurses
 Clinical/ Medical Technicians
 Radiographic Department Assistant
 Assistant/Associate Practitioners
Dispense
To prepare and/or supply a clinically appropriate medicinal product to a patient for self
administration or for administration by another, usually a healthcare professional. Dispensing
must be in response to a legally valid prescription. The act of dispensing should be
accompanied with the provision of advice to the patient on safe and effective use of these
products.
FMG
Formulary and Medicines Group
GMC
General Medical Council
HCSW
Healthcare Support Workers
HPC
Health Professions Council
Healthcare Professional
A registered practitioner in an occupation which requires specialist education and training in
practical skills in health care. The professions concerned are self-regulating and practitioners
are expected to satisfy their profession’s accepted standards of practice and conduct.
For the purposes of this policy, these practitioners are accepted to include:
• Registered nurses or midwives
• Doctors (medical practitioners)
• Dentists
• Dietitians
• Pharmacists
• Radiographers
• Registered Pharmacy Technicians
• Registered Operating Department Practitioners
 Paramedic
• Podiatrists
Injectable medicine
An injectable medicine may be given by one of the following methods:
 Intramuscular injection
 Direct subcutaneous injection
 Subcutaneous infusion
 Intradermal injection
 Intravenously by
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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o Direct injection (bolus) into a vein
o Direct injection into infusion line tubing (bolus)
o Intravenous infusion – either continuous or intermittent
Other injectable routes covered by the NPSA Patient Safety Alert 20, but not covered within this
policy are:
 Intrathecal (see Trust Policy for Intrathecal Chemotherapy in Adults – Oncology and
Haematology Departments)
 Epidural (see Trust Policy for Continuous Epidural Infusions)
Other routes such as intra-arterial, intraventricular, intravitreal, intrapleural and intraocular - The
Royal Marsden Manual should be used as the default reference, and other specialist
competences and techniques are also used in specific clinical areas. The principles and basic
preparation procedures covered in this policy will generally apply.
Medication error
Any preventable event that may cause or lead to inappropriate medication use and/or patient
harm while the medication is in the control of the healthcare professional, patient or carer.
Medicinal product
Any substance or article (not being an instrument, apparatus or appliance) which is
manufactured, sold, supplied, imported or exported for use wholly or mainly in either or both of
the following ways:
(a) use by being administered to one or more human beings for a medicinal purpose
(b) use as an ingredient in the preparation of a substance or article which is to be administered
to one or more human beings for a medicinal purpose
Multi-disciplinary Health Record
Also known as Patient’s Notes, Medical Notes, Casenotes
NHS
National Health Service (UK)
NHSP
NHS Professionals. This is the public sector locum agency for NHS professional staffs. Each
individual practitioner’s professional credentials are vetted by NHSP before admission to the
scheme
NMC
Nursing and Midwifery Council (UK).
NPSA
National Patient Safety Agency (a Special Health Authority of the DoH) This role has now
transferred to the NHS England.
PGD
Patient Group Direction – A specific written instruction for the supply or administration of
medicines to clinical groups of patients who may not be individually identified before
presentation for treatment.
PHT
Portsmouth Hospitals NHS Trust
Prescribe
To order in writing (or electronically) the supply of a medicinal product (within the meaning of
the Medicines Act, 1968, this means a POM) for a named patient (see “Prescription”).
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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Prescriber
A healthcare professional that is legally authorised to prescribe a medicinal product, including
medical and non-medical prescribers.
Prescription
An order for the dispensing of a medicinal product. The order is presented to a professional
who is legally authorised to dispense. The order must be either:
a) in writing in a legally prescribed format and signed by the person authorised by law to
prescribe
b) made, using a Trust-agreed electronic prescribing system, by the person authorised in law to
prescribe medicinal substances, and who has been provided with a secure, individual computer
access password.
Prescription Record Chart
Authorised Drug chart for recording inpatient prescriptions and administration. There are also
“Long Stay” and Mental Health Unit versions.
QAH
The Queen Alexandra Hospital, Cosham, Portsmouth
rINN
Recognised International Name – European Law requires the use of the rINN for medicinal
substances except for adrenaline and noradrenaline which remain the British approved names.
SCIP
South Central Injectables Practice Group
SOPs
Standard Operating Procedures
Treatment
The management and care (including medicines and procedures) of a patient to prevent or cure
disease or to ameliorate suffering and disability.
TTO
To Take Out Medication (Medication the patient is discharged on)
UCL Guide
Injectable Medicines Administration Guide – book on injectable drug administration
5. DUTIES AND RESPONSIBILITIES
The Director Medicines Management and Pharmacy is responsible for the preparation,
implementation and audit of this policy.
All staff must comply with their responsibilities when undertaking their duties involving
injectable medicines both at ward/department level and within pharmacy.
5.1. Nurses
5.1.1. Registered Nurses
Each registered nurse is accountable for her/his own conduct and practice in accordance with
the Nursing and Midwifery Council, The Code: Professional standards of practice and
behaviour for nurses and midwives (2015)and in exercising professional accountability will:

Always act in a manner as to promote and safeguard the interests and well being of patients
and clients
 Ensure that no action or omission on their part, or within their sphere of responsibility, is
detrimental to the interests, condition or safety of patients and clients.
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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

Maintain, update and improve their professional knowledge and competence
Acknowledge any limitations in their knowledge and competence and decline any duties or
responsibilities unless able to perform them in a safe manner.
 Report to a senior person or authority any circumstance in which a safe and acceptable care
for patients and clients cannot be provided.
 Avoid any improper delegation to others, which compromises the interests, wellbeing or
safety of patients and clients.
5.1.2. Ward/Department Managers
Ward/Department managers are responsible for ensuring that their staff meet required
competencies for the administration of medicines. It is every manager’s responsibility to ensure
that all their staff are informed as to which members of the team are competent to accept
delegation of duties.
First level nurses will have established basic competencies in pre-registration education and
competency will be maintained. If evidence cannot be presented, then further training should be
undertaken.
Ward department managers in conjunction with their ward pharmacist are also responsible for
ensuring a risk assessment for injectable medicines is carried out annually for their area (See
Standard Operating Procedure – Risk assessment Process for Injectable Medicines and
Associated Practice in Clinical Areas
5.1.3. NHS Professionals (NHSP) Nurses/bank and framework agencies
Nurses working for NHS Professionals (NHSP) should adhere to the required standards for the
administration of medicines. They should acknowledge any limitations in their knowledge and
competencies, and decline any duties or tasks, unless able to perform them in a safe and
skilled manner.
The nurse in charge of a ward/department where NHSP/bank and framework agency nurses
are deployed, should ensure that all temporary staff receive adequate orientation in relation to
local practices regarding the administration of medicines.
Medication Administration by NHSP/(bank) and Agency Nurses
There is a national framework which is used to supply agency and NHSP (bank) staff where
liability is covered. Only nurses supplied under this framework are able to administer
medications, and there are also additional requirements for specific routes or class of
medications (e.g. IV medications and chemotherapy see below).
1. IV Medications: Only NHSP/framework agency nurses may administer IV medications
if they fulfil all of the following:
 Have been assessed against the PHT IV competency to the required level including
requisite e-learning
 Can provide evidence of theoretical teaching.
Nurses who have left the Trust and return within 1 year in a bank or agency position and
can provide evidence that they have maintained IV competence, can be reassessed
against the PHT IV additives competence, after having achieved the requisite training by
a competent practitioner in clinical practice.
2. Chemotherapy is only given by staff who have completed the
appropriate chemotherapy administration competencies to the required level, as per
PHT Policy for Prescribing, Handling and Administration of Cytotoxic Drugs and
Cytotoxic Oral Chemotherapy Safe Management Policy.
3. Multipost holders who are PHT competent may administer according to their
competency training.
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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Nurses from agencies outside of the framework (e.g. Thornbury are not permitted to
give any medications on PHT wards/ departments.
In any situations where this is thought not to be workable, a full risk assessment must be
carried out and approved by the Director of Nursing.
5.1.4. Student Nurses (other than Student Midwives)
During each practice placement the mentor should assess the student’s proficiency in the
administration of medicines in accordance with the expectations stated in their Assessment of
Practice portfolio. Students must never administer or supply medication without direct
continuous supervision.
Student nurses may observe the administration of medicines and assist in the administration
of medicines by the following routes under the direct and constant supervision of a
qualified nurse, midwife or medical practitioner. NB. This does not apply to student nurses on
Critical Care who cannot prepare or administer any medications.

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oral/ buccal/sublingual
topical medicines (including eye /ear drops)
inhaled / nebulised medicines
subcutaneous (not via infusions)
intramuscular
rectal /vaginal
Students may not participate in the administration of medicines by the following routes:

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intravenous lines (see below for IV fluids)
peripheral lines/ central lines
epidural
medication given by any other route that requires a clinician to undertake further
education and training (e.g. intrathecal).
Final year students or at an equivalent stage (e.g. stage 3 of the Open University 4 year part
time course) can, under the direct and continuous supervision by a competent
registered practitioner assist in the preparation of (but not administration of) intravenous
medicines.
Administration of IV/SC fluid infusions by student nurses.
Student nurses may not participate in the initiation or alteration of administration by the
above routes which involves infusion, mechanical pumps or a patient controlled device. As an
exception, students may administer prescribed pre-prepared standard IV bags of 0.9% sodium
chloride or 5% glucose or sodium chloride 0.18% with glucose 4% via an existing
intravenous or subcutaneous line to adults only. This activity must be carried out only under
the direct and continuous supervision of a qualified nurse, midwife or medical
practitioner. This is the only situation where the student can participate in the administration of
intravenous or subcutaneous fluid
5.2. Midwives
Midwives should adhere to the Nursing and Midwifery Council, The Code: Professional
standards of practice and behaviour for nurses and midwives (2015)
Midwife Exemptions
Midwives working within the Maternity Unit may give, without prior prescription, medicines listed
on the Midwives Exemptions in the course of their professional practice or by an approved
Patient Group Direction. See PHT Midwives’ Exemption Policy.
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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5.2.1. Student Midwives
Administration Under Direct and Constant Supervision
In PHT student midwives can be permitted to administer medication on the midwives
exemption list, (except controlled drugs, epidurals and intravenous medication) only under
the direct and continuous supervision of a registered midwife.
Direct supervision means that the student must be witnessed both visually and audibly, when
administering the medicine, by a registered midwife. Where this is done both the student and
registrant must sign the patient’s medication chart or document in the notes.
The registrant is responsible for delegating to a student, and where it is considered the
student is not yet ready to undertake administration in whatever form, this should be delayed
until such time that the student is ready. Equally a student may decline to undertake a task if
they do not feel confident enough to do so. The relationship between the registrant and the
student is a partnership and the registrant should support the student in gaining competence
in order to prepare for registration.
Under the DIRECT SUPERVISION, student midwives are allowed to:
 Administer medicines on the midwife exemption list or that have been prescribed by a
doctor, except
o
intravenous drugs or
o
epidurals or
o
controlled drugs, unless prescribed on a valid prescription
 Check intravenous fluids against a valid prescription.
 Check prescribed additives, working with registered healthcare professionals against a
valid prescription.
 Discontinue IV infusions/ decannulate.
Student midwives MAY NOT:
 Carry out any medication administration tasks listed above unless they are under the
direct and continuous supervision of a registered midwife.
 Give medicines via the epidural route
 Administer boluses or infusions of any intravenous drugs
 Administer any controlled drugs on the midwives exemption list
5.3 Occupational Health Nurses
Under Occupational Health Schemes or similar e.g. patient group directions, Occupational
Health Nurses can supply and administer certain medicines to patients/clients.
5.4 Paramedics
Paramedics will be registered with the Health and Care Professionals Council.
Paramedics employed by PHT should follow the agreed PHT policies and procedures when
dealing with medicines.
5.5. Registered Operating Department Practitioners (RODPs)

RODPs will be registered with the Health Professions Council.

RODPs should follow the agreed PHT policies and procedures when dealing with
medicines
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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
For detailed guidance on CD’s and RODP’s refer to the PHT Controlled Drugs Policy and
Theatre CD SOP
5.6. Radiographers
Radiographers are allowed to administer medicines such as contrast media to patients, in
accordance with a doctor’s or dentist’s prescription, or in accordance with an authorised PGD
on which they are named.
5.7. Clinical Support Staff
A HCSW, Nursery Nurse, Dental Nurse, Radiographic department assistant, Medical or Clinical
Technician or Assistant/Associate Practitioner who has undertaken suitable training for specific
tasks and has had their competency assessed and recorded, may assist in the
administration of medicines in specific areas, with proper delegation being the responsibility of
the registered nurse, midwife, radiographer or RODP. Whilst their competency is being
assessed, candidates should be under the supervision of the registered nurse, midwife,
radiographer or RODP.
5.8. Doctors
Each doctor is responsible for prescribing and administering medications correctly in
accordance with this policy.
When a doctor is not confident of his/her own competence to prescribe or administer a
particular medicinal product, he/she should not continue until he/she has sufficient working
knowledge of it
Doctors are responsible for:
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Adhering to the Portsmouth District Prescribing Formulary
Ensuring the safe and clinically appropriate use of medicines
Using up-to-date information and guidance on all pharmaceutical aspects of drug therapy
Discussing the aims and side effects of drug treatment with the patient or their
representative, if possible.
Conforming to legal requirements
Ensure the medicines given are appropriate and patient-centred by taking account of their:
age, choices, lifestyle, cultural and religious beliefs, allergies and intolerances, existing
medical conditions and prescriptions, adverse drug reactions and recommended
prescribing regimens.
Documenting patients’ allergy status in patient notes and on patients drug charts including
the type of reaction and source of information.
Documenting the treatment plan, including how the response to drug therapy is to be
monitored, clearly in the patient’s clinical notes.
Checking the patient’s medical record before a new prescription is written
Ensure the prescription is up to date and is reviewed and changed as the patient’s needs or
conditions change.
5.9. Dentists
 Each dentist is responsible for prescribing and administering medications correctly in
accordance with this policy.
 Oral and maxillofacial consultants and registrars are on the GMC register, and therefore
they practice as any other doctor would (rather than as a dentist)
 Junior dental staff who are only dentally qualified, whilst working in the hospital setting can
prescribe from the Dental Practitioners’ Formulary in the current BNF (www.bnf.org)
Medicines – Injectable Medicines Policy
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Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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
When a dentist is not confident of his/her own competence to prescribe a particular
medicinal product, he/she must not prescribe it until he/she has sufficient working
knowledge of it.
5.10. Pharmacists
Each registered pharmacist is accountable for his/her own conduct and practice in accordance
with the General Pharmaceutical Council Guidance and Royal Pharmaceutical Society of Great
Britain’s Code of Ethics.
Pharmacists within Portsmouth Hospitals hold a variety of roles. The list below outlines the key
professional responsibilities of all Pharmacists but the list is not exhaustive:

Optimising therapy with medicines to ensure the safe, clinically appropriate and cost
effective use of pharmaceutical products through involvement at all stages of patient
medicines usage and management (including prescribing).
 Providing up-to-date information and guidance to other healthcare professionals on all
pharmaceutical aspects of drug therapy, pharmaceutical care and medicines management.
 Conforming to legal requirements.
 Advising on the individualisation of patient therapy.
 Advising on patient monitoring of drug effects and side effects.
 Education and consultation with patients, carers and hospital staff on the safe and correct
use of medicinal products.
 Advising on drug-drug and drug-fluid interactions and compatibilities in parenteral
medication.
 Advising on the pharmaceutical requirements and proper undertaking of clinical trials.
 Contribution and advice on governance processes concerning medicines use such as
policy and procedure writing, including the requirements for PGDs and groups of staff such
as non-medical prescribers..
 Advising on and managing medicines audits.
 Ensuring annual risk assessment of injectable medicines is carried out for their area.
The South Central Injectable Practice (SCIP) lead will be responsible for implementing SCIP
action points where appropriate.
5.11. Committees
5.11.1. Trust Board
The Trust Board will receive an annual report/action plan from the Director for Medicines
Management and Pharmacy on all matters of medicines management including the use of
injectables.
5.11.2. Governance and Quality Committee
Will receive an annual report from the Director of Medicines Management and Pharmacy on
all matters of medicines management including injectables and the appropriate risk control
measures to eliminate or reduce and identified risks.
5.11.3. Formulary and Medicines Group
The Formulary and Medicines Group has responsibility for receiving the results of the annual
medicines management audit, sharing it with the divisional/clinical service centre governance
leads and requesting further actions where gaps have been identified.
5.11.4. Divisional/Clinical Service Centre Governance Leads
Responsible for leading on the actions requested by the Formulary and Medicines Group where
gaps have been identified following the annual medicines management audit.
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
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5.11.5. Medication Safety Committee
See NHS England Patient Safety Alert Improving Medication Incident Reporting and Learning
Committee responsibilities include the following:
 Improving reporting and learning of medication error incidents in the organisation.
 Analysing and reviewing incident data, audit and other data to identify, prioritise and
address medication risks to minimise harm to patients.
 Identifying, developing and promoting best practice for medication safety. This will include
supporting the implementation of external patient safety guidance from NHS England,
MHRA, NICE and other organisations –
 Coordinating and supporting education and training support to improve the quality of
medication error incident reports and safe medication practices.
 Assisting in development and review of medication-use policies and procedure.
 Reviewing the results of the annual NHS Protect Security Ward/ Department /medicines
management audit, sharing it with the divisional/clinical service center governance leads
and requesting further actions where gaps have been identified.
 Reviewing and assessing compliance with CQC standards (Health and Social Care Act
2008 (Regulated activities) Regulations 2014: Regulation 12).
6. PROCESS
6.1 Risk Assessment
The PHT Pharmacy Standard Operating Procedure - Risk Assessment Process for Injectable
Medicines and Associated Practice in Clinical Areas (PHPSWI 09:002) should be carried out
annually for each department by the directorate pharmacist and the manager or senior nurse of
the clinical area. The results of the risk assessment should be given to the Medication Safety
Pharmacy Technician.
6.2 Standard Operating Procedure for Prescribing, Preparing and Administering
Injectable Medicines in Clinical Areas
Injectable medicines must be prescribed, prepared and administered according to the Standard
Operating Procedure for Prescribing, Preparing and Administering Injectable Medicines in
Clinical Areas (see Appendix 1) to minimize associated risks.
6.3 Technical information on administration of medicines
The following technical information is available in clinical areas:
o UCL Guide to Administration of Injectable Medicines,
o BNF (and BNFc in paediatric departments) also available on line
o Summary of Product characteristics supplied with the product or available on the internet
on http://www.medicines.org.uk/emc/ and Trust intranet.
o Neonatal Formulary through the pharmacy home page via the medicines information link.
o Further information is available through medicines information (ext. 7700 6632 bleep
1468).
o Standard operating procedures for high risk drugs
o Basiliximab Preparation and Administration Guideline
o Ciclosporin Preparation and Administration Guideline
o Ganciclovir Preparation and Administration Guideline
o Mycophenolate Preparation and Administration Guideline
o Tacrolimus Preparation and Administration Guideline
Further guidance concerning the mixing of drugs in subcutaneous syringe drivers (The syringe
Driver: continuous subcutaneous infusions in palliative care) is being made available to the
Rowans Hospice, F1, F6/F5/F7 and information from this is available through the relevant
departmental pharmacist.
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Date of Review: 22 June 2018 (unless requirements change)
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6.4 Purchasing for Safety Policy
Wherever possible and in line with the NHS Purchasing and Supply Agency (PASA) and South
Central Guidance the pharmacy service will follow the PHT Trust Medicines Purchasing for
Safety Policy to promote the purchase of injectable medicines with inherent safety features.
See: National Patient Safety Agency “Design for patient safety – a guide to the design of
dispensed medicines” (1st Ed 2007).
7. TRAINING REQUIREMENTS
Medication safety should be covered comprehensively in induction programmes for all new
NHS clinical staff (including medical, registered nurses, pharmacy, theatre and any other staff
who handle medicines), and regularly updated through further training and continuing
professional development programmes. In accordance with the essential training matrix, all
clinical staff are required to undertake an annual update of medicines management.
7.1 Prescribing of Injectable Therapy
Medical and dental practitioners cover this requirement during their undergraduate training.
Non-medical prescribers should complete the Non-Medical Prescribing course and its
associated competencies.
7.2 Preparation and Administration of Injectable Therapy.
Nurses, Midwives and other healthcare professionals must have demonstrated their
competence to a minimum of level 2 of the Administration of Medication (excluding intravenous,
intrathecal and epidural routes) competency and are required to complete the PHT process for
Achieving Competency in IV Drug Administration prior to undertaking the administration of
intravenous therapy.
The administration of intravenous medicines and infusions and their maintenance should be
undertaken only by healthcare professionals who have undergone the Trust IV study day which
includes the PHT Administration of IV Medication Training Pack. They must also have
completed the PHT IV drug calculation e-learning pack at www.phtlearningzone/ivstudyday. In
addition, they must have completed the Intravenous Drug Administration –
Adults/Child/Neonate competency. (See also section 6.7.11 of the Trust Medicines
Management Policy, concerning double checking)
Note: new staff who are employed by PHT from other healthcare organizations are not required
to attend the IV study day if they can provide evidence of post registration IV competency
training before employment by PHT and their proficiency can be demonstrated by assessment
in practice. Nurses recruited from the EU with IV administration competence completed as part
of their preregistration course will attend an IV additive update instead of the IV study day as
part of their induction. They will then have their competency assessed in practice and
undertake the requisite E learning.
 Departments may have their own additional competency and training packages that are
required to be completed before injectable medications can be administered. For
example on the Department of Critical Care the following additional training must be
completed:
o Attend a drug lecture provided by the unit
o Complete a drug calculations paper (provided by the unit)
o Complete the Critical Care Units IV competency package.
 Staff administering injectables to children and young people must also have completed
the PHT on-line paediatric medication calculations assessment.
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The above information is summarized in the table below:
Staff group
All nurses and midwives
and other healthcare
professionals
Competency/ Course required
Administration of S/C or IM injections
PHT Level 2 Administration of Medication (excluding
intravenous, intrathecal, epidural routes) competency
Administration of IV medications
All nurses and midwives
and other healthcare
professionals
NHSP Nurses and
Midwives
Agency nurses supplied
by NHSP/bank
framework agencies
Nurses from agencies
outside of the framework
Paediatric nurses
All nurses on DCCQ
Department
Nursing staff required to
give Chemotherapy
1. PHT Level 2 Administration of Medication (excluding
intravenous, intrathecal, epidural routes) competency
2. PHT IV Drug Calculation Online Assessment
(on ESR/ learningzone or moodle)
3. PHT Intravenous Drug Administration Competency Adults/
Child/ Neonate Assessment
4. PHT IV study day (including PHT Administration of IV
Medication Training Pack) NB. attendance on the IV study
day is not required if staff can provide evidence of post
registration IV competency training before employment with
PHT and their proficiency can be demonstrated by
assessment in practice
Multipost holders who are PHT competent may administer
according to their competency training.
May administer by IV route if
 have been assessed against the PHT IV competency to the
required level including requisite e-learning
 Can provide evidence of theoretical teaching.
Nurses who have left the Trust and return within 1 year in a
bank or agency position and can provide evidence that they
have maintained IV competence, can be reassessed against the
PHT IV additives competence, after having achieved the
requisite training by a competent practitioner in clinical practice.
Not permitted to give any medication by any route on PHT
wards/ departments. (e.g. Thornbury)
PHT paediatric medications assessment
Critical Care Competency Training
Critical Care drug lecture
Complete drug calculations test
IV competency package
Completed PHT chemotherapy administration competency as
per PHT Policy for Prescribing, Handling and Administration of
Cytotoxic Drugs
Final year students or at an equivalent stage (e.g. Stage 3 of the Open University 4 year part time
course) can, under the direct and continuous supervision by a competent registered
practitioner assist in the preparation of, but not administration of intravenous medicines.
Medical and dental practitioners cover this requirement during their undergraduate training.
7.3 Administration of Cytotoxic Chemotherapy
Chemotherapy is only given by staff who have completed the appropriate chemotherapy
administration competencies to the required level, as per PHT Policy for Prescribing, Handling
and Administration of Cytotoxic Drugs. The administration of chemotherapy by the intrathecal
route can be undertaken only by medical practitioners who have undergone the PHT training,
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and are certified as competent. See PHT Policy for the Prescribing, Handling and
Administration of Cytotoxic Drugs.
7.4 Administration of Epidural Therapy or Epidural Top-ups
All healthcare professionals who administer epidural analgesia in post-operative situations or
epidural top-ups are required to complete the appropriate PHT competency training. Only
anaesthetists are permitted to initiate epidural therapy.
7.5 Continuing Professional Development
All healthcare staff involved with medicines should undertake continuing professional
development, which is aligned to clinical governance requirements and professional guidance,
to ensure that their knowledge is up to date.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Promoting Safer use of Injectable Medicines, Patient Safety Alert 20: NPSA, March 2007.
www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59812&p=2
PHT Medicines Management Policy
PHT Controlled Drugs Policy
PHT Trust Policy for the Provision and Management of Parenteral Nutrition in Adults in Hospital
PHT Trust Hand Hygiene Policy
PHT Trust Policy for Intrathecal chemotherapy in Adults – Oncology and Haematology
Departments
PHT Policy for the Management of Infusions with Pumps
PHT Central Venous Catheters: Care and Management Policy
PHT Clinical Policy for Peripheral Venous Cannula Insertion and Management (Adults)
PHT Trust Policy for the Safe Handling and Disposal of Sharps
PHT Waste Handling Policy
PHT Patient Identification Policy
PHT Medicines Purchasing for Safety Policy
Mixing of medicines prior to administration in clinical practice – responding to legislative
changes. Supporting guidance for healthcare providers, practitioners and commissioners.
National Prescribing Centre, May 2010.
9 EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
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10 MONITORING COMPLIANCE
PROCEDURAL DOCUMENTS
WITH,
AND
THE
EFFECTIVENESS
OF,
The following points will be carried out/audited by the pharmacy department and compliance
will be reported to the Formulary and Medicines Committee who will take action as required.
Aspect to be monitored
Evidence
Frequency
Review of the PHT Policy for the
Safe Management of Injectable
Medicines
 Copy of PHT Policy for the Safe
Management
of
Injectable
Medicines including approval
dates
 Copy of distribution list for the
Policy for the Safe Management
of Injectable Medicines to be
kept by policy author.
Check Trust intranet
Review and approval every 2
years or earlier if necessary by
current Injectables Policy author
or inheriting pharmacist.
See medicines management audit
Annual medicines management
audit
 Copy of PHT Purchasing for
Safety policy including approval
dates
 Documented ‘purchasing for
safety’ decisions and product
changes to be kept by the
Procurement
and
Regional
Stores Operations Manager.
Review policy every 2 years or
earlier if necessary by policy
author
Evidence
Prescribers:
 Medical
prescribers
and
dentists: Evidence of completion
of
undergraduate
medical
training/registration.
 Non-medical
prescribers
–
evidence of completion of
independent prescribing course
and associated competencies.
Healthcare
professionals
preparing and administering IV
drugs:
 Copy of IV study day training
curriculum,
 Copy of training/assessment
materials,
 Dates of training sessions,
 Records of staff who have
received training.
 Evidence of completion of postregistration IV training.
 Evidence of completion of
relevant competencies
Pharmacy
Manufacturing
Technical Staff preparing CIVAS
and Parenteral Nutrition
Evidence
of
completion
of
appropriate stages of the Aseptic
Medicines – Injectable Medicines Policy
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Frequency
Clinical areas to compile training
record at staff induction/ on
completion of relevant training.
Availability of the PHT Policy for
the
Safe
Management
of
Injectable Medicines on the trust
intranet
Availability of UCL guide and PHT
Drug Therapy guidelines in clinical
areas
Review PHT Purchasing for
Safety policy to ensure it
incorporates
procurement
of
injectable medicines with inherent
safety features
Monitor adherence to the policy
Aspect to be monitored
Ensure all staff who prescribe,
prepare, administer and monitor
injectable
medicines
have
received training and have the
necessary work competencies to
undertake their duties safely
Annual spot check by IV policy
author.
Review
annually
by
PHT
Formulary and Medicines Group
Pharmacy
(Injectables
policy
author to delegate as appropriate)
to review staff register in relation
to area training record annually.
Pharmacy Manufacturing Unit
manager to audit training files for
each member of Pharmacy
Manufacturing Unit staff
Page 18 of 34
All clinical areas to have a
documented risk assessment of
injectable
products
and
procedures.
All clinical areas to introduce risk
reduction methods as result of risk
assessment
Review of patient safety incident
data
involving
injectable
medicines
Preparation Training programme
and 3 Broth test validations.
 Documented Risk assessment
as per policy,
 Number of high risk injectable
products and procedures
 Number of high risk injectable
products and procedures
following the introduction of risk
reduction methods
 Number of incident reports
involving injectable medicines
per division.
 Clinical outcome
 Type of report
 Type of incident
 Top 10 incidents/themes
 High risk injectable medicines
added to trust risk register
 Record of actions taken to
decrease
incidents/risk
associated
with
injectable
medicines
Medicines – Injectable Medicines Policy
Version: 4
Date of Issue: 23 June 2016
Date of Review: 22 June 2018 (unless requirements change)
Annually by Directorate
Pharmacist and ward manager.
Departments that do not have
directorate pharmacists will have
the risk assessment delegated to
a pharmacist as deemed
appropriate.
Annually by Risk Management
Pharmacist
Page 19 of 34
Appendix 1: Standard Operating Procedure for Prescribing, Preparing and Administering
Injectable Medicines in Clinical Areas
Introduction
The use of injectable medication has many healthcare benefits for patients. The complexities associated with the
prescription, preparation and administration of injectable medicines means that there are greater potential risks
for patients than for other routes of administration. Weak operating systems increase the potential risk of harm,
and safe systems of work are needed to minimise these risks.
The prescription of intravenous drugs, infusions, transfusion and their preparation, administration and
maintenance should only be undertaken by healthcare professionals who have undergone specific training in this
skill and have demonstrated their competence to do so. They should work within the Portsmouth Hospitals NHS
Trust Medicines Management Policy.
The healthcare professional should also:
 be aware of their legal and professional responsibilities;
 be accountable for their actions or omissions;
 know the mechanism for reporting adverse reactions of prescribing or administering errors and how to
manage them;
Departmental managers are responsible for ensuring that the system of training, recording and documentation is
properly maintained.
Supply and storage of Injectable Medicines
 A risk assessment of all injectable medicines (see PHT Pharmacy Standard Operating Procedure – Risk
Assessment Process for Injectable Medicines and Associated Practice in Clinical Areas PHPSWI 09:002) must
be undertaken in all clinical areas annually by the directorate pharmacist and ward manager or senior nurse to
determine the safest presentation and location for storage and preparation. The resulting assessment
documentation will be kept by the Medication Safety Pharmacy Technician.
 Injectable cytotoxics and parenteral nutrition must be supplied to clinical areas only as ready-to administer
products.
 Ready-to-administer or ready-to-use products should be stocked in all clinical areas in preference to those
needing preparation before use, or those which are classified as high-risk. Concentrates should only be
supplied where safer alternatives are not available.
 Multiple use of an unpreserved injectable medicine should be eliminated. Most injectable medicines are
licensed for ‘once-only’ use. Unless the manufacturer’s label specifically indicates that the injection contains a
preservative, the container should only be used to prepare a single dose for a single patient on one occasion.
Any departments that have reasons not to comply with this guidance must seek approval from the Formulary
and Medicines Committee/Medications Safety Committee and a record of the medication and situation in which
it is to be used more than once should be made on the risk register.
 Epidural solutions should be stored separately from those intended for intravenous use.
 See PHT Controlled drugs policy for storage of high strength opiates and controlled drugs
 See the Trust Policy for Intrathecal chemotherapy in Adults – Oncology and Haematology Departments for
information on storage of intrathecals.
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Step 1: Prescribing of Injectable Medicines
Medicines should be given by injection only when the practicality and appropriateness of other routes of
administration have been excluded. The use of this route should be regularly reviewed in favour of switching
to oral administration as soon as clinically appropriate.
 It is the responsibility of all prescribers to:
o ensure that the medicines prescribed are appropriate for the injectable route and for the vehicle of
administration, taking account of stability and incompatibility information.
o provide a legal, legible, signed prescription as stated below to enable the drug to be administered
safely and correctly (note: if medicines are to be mixed i.e. in a syringe/bag or administered through a
single line, the instruction to mix must be in writing by the prescriber see section 2.9 Mixing of
Medicines).
o ensure that the patient has appropriate intravenous access for intravenous medicines prescribed so
that they can be administered.
o be aware of agreed departmental protocols and the role of designated health care professionals in
administration of Injectable drugs
o ensure that no drug is added directly to any blood product.
o if in doubt, prescribers should seek information from the pharmacy department.

1.1 All prescriptions for injectable medicines (including injectables on TTO’s) should be written in capital letters
and must specify the following:
 Patient’s name, date of birth, NHS number and weight;
 Prescriber’s signature and bleep number;
 The approved medicine name;
 The dose and frequency of administration;
 The date and route of administration;
 The allergy status of the patient.
1.2 Where relevant, the prescription must specify the following:
 Brand name and formulation of the medicine;
 Concentration or total quantity of medicine in the final infusion container or syringe;
 Name and volume of diluent and/or infusion fluid;
 Rate and duration of administration;
 Stability information to determine the expiry date of the final product;
 Type of rate-control pump or device(s) to be used;
 The age and weight of any patient under 16 years of age, where relevant;
 Date on which treatment should be reviewed;
 Arrangements for fluid balance or clinical monitoring should be made on an individual patient basis
and according to local protocol and clinical need.
 If medicines are to be mixed, the instruction to mix must be in writing by the prescriber if the
combination is not covered in the PHT Trust mixing guideline (see section 2.9 Mixing of Medicines)
1.3 When two or more prescription charts are in use, it is essential that they are cross referenced so that
practitioners are aware of all prescribed medicines (e.g. extra drug charts, insulin, heparin, fluid epidural
charts).
NOTE: inpatient injectable medicines should be prescribed on the inpatient drug chart not the IV fluid chart.
1.4 Some injectable medicines may be administered under a PGD (see Medicines Policy) or Midwife Exemption
(see Medicines Policy)
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Step 2: Preparation of Injectable Medicines
The preparation and administration of intravenous medicines, infusions, transfusions and their maintenance
should be undertaken only by healthcare professionals who have undergone the training detailed in section 7
(Training requirements) and meet requirements stated in Section 5 (Duties and Responsibilites) of the Policy
for the Safe Management of Injectable Medicines (Adults and Children)
 Preparation should only take place if: there is a prescription; a patient group directive or other written
instruction; and essential information is available about the product(s) and processes needed for safe
preparation and administration. (see section 6.3 for reference resources).
 Aseptic (non-touch) technique should be used during preparation and administration. Injectable medicines
prepared in clinical areas should always be administered immediately after preparation. They should not be
stored for a period of time before use. Administration of infusions prepared in clinical areas should be
completed within 24 hours of preparation. In exceptional circumstances where an infusion from a single
container is intended to continue for more than 24 hours, a risk assessment should be undertaken to
determine the safest course of action. Every effort should be made to use a ready-to-administer product.
 Parenteral nutrition – Each bag of parenteral nutrition may be administered for up to 48 hours. See the PHT
Trust Policy for the Provision and Management of Parenteral Nutrition in Adults in Hospital for further
information on parenteral nutrition administration.
 All syringes, including flushes and infusions, must be immediately identifiable at all stages after preparation
by the person who prepared them (see 2.7). ‘Flag labelling’ should be used to ensure that volume
graduations on small syringes are not obscured. The only exception to this is in situations where preparation
and bolus (push) administration is one uninterrupted process and the unlabelled product does not leave the
hands of the person who prepared it. Only one unidentifiable medicine must be handled at one time.
 Medical devices with luer connectors must be used only for preparation and administration of injections.
 Risk assessment will have identified those products representing the highest risk to patients at the time of
preparation. Consideration must be given to the use of safer products and systems, for example, doublechecking.
 Neonatal infusions: see Appendix 2 for additional information on infusions of IV fluids and medicines for
neonates

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2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.1.7
2.1.8
2.1.9
2.1.10
2.1.11
2.1.12
2.1.13
2.1.14
2.1.15
2.2
2.2.1
2.2.2
2.2.3
General
Read all prescription details carefully and confirm that they relate to the patient to be treated.
Ensure that the area in which the medicine is to be prepared is as clean, uncluttered and free from
interruption and distraction as possible. Ideally, preparation should take place in an area dedicated to
this process.
Assemble all materials and equipment: sharps bin for waste disposal, medicine ampoules/vials, diluent,
syringes, needles, alcohol and chlorhexidine wipes, disposable protective gloves, clean re-usable plastic
tray.
Check the following:
 Expiry dates;
 Damage to containers, vials or packaging;
 That medicines were stored as recommended, e.g. in the refrigerator.
Beware of the risk of confusion between similar looking medicine packs, names and strengths. Read all
labels carefully.
Check that:
 The formulation, dose, diluent, infusion fluid and rate of administration correspond to the prescription
and the product information;
 The drug is compatible with the diluent and infusion fluids
 The patient has no known allergy to the medicine
 You understand the method of preparation.
A second healthcare professional is required to check all agents for intravenous administration. This
check must incorporate the whole preparation and administration process i.e. valid prescription, product
accuracy, correct patient, check of infusion rate programmed into the appropriate device.
Calculate the volume of medicine solution needed to give the prescribed dose. Write the calculation
down and obtain an independent check by another qualified healthcare professional.
 If the calculations do not correspond they must be repeated independently. If there is still a
discrepancy between the two calculations, assistance should be sought from a third authorised
person, doctor or pharmacist.
 If there is any doubt, or if the dose seems to require the administration of the contents of more than
4 ampoules of a stock medicine, contact pharmacy to check this is correct.
Displacement values: where the dose of a medicine is less than a complete vial and the vial requires
reconstitution, e.g. for paediatrics, it is necessary to take into account the displacement value of the
medicine (see PHT Trust guideline: Reconstitution of Dry Powder Antibiotics for Paediatrics; the UCL
Injectable Medicines Administration Guide and package inserts for information on displacement values
NOTE: there can be variation in displacement values between brands therefore always ensure you refer
to the correct information.)
Prepare the label for the prepared medicine (see section 2.7 of this policy)
Cleanse your hands according to the PHT Hand Hygiene Policy.
Put on a pair of disposable protective gloves.
Use a detergent spray or wipe or soap and water to disinfect the surface of the plastic tray.
Assemble the syringe(s) and needle(s). Peel open wrappers carefully and arrange all ampoules/vials,
syringes and needles neatly in the tray.
Use a ‘non-touch’ technique, i.e. avoid touching areas where bacterial contamination may be introduced,
e.g. syringe-tips, needles, vial tops. Never put down a syringe attached to an unsheathed needle.
Prepare the injection by following the manufacturer’s product information/UCL guide or local guidelines,
and the relevant guidance in standards 2.2 to 2.7.
Withdrawing solution from an ampoule (glass or plastic) into a syringe
Tap the ampoule gently to dislodge any medicine in the neck.
If the ampoule contains a suspension rather than solution, it should be gently swirled to mix the contents
immediately before they are drawn into the syringe.
Clean the ampoule with an alcohol and chlorhexidine wipe before opening.
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2.2.4
2.2.5
2.2.6
2.2.7
2.2.8
2.2.9
Snap open the neck of glass ampoules, using an ampoule snapper if required.
Attach a filter needle to a syringe and draw the required volume of solution into the syringe. Tilt the
ampoule if necessary.
Invert the syringe and tap lightly to aggregate the air bubbles at the needle end. Expel the air carefully.
Ensure the syringe is identifiable (see standard 2.7)
Keep the ampoule and any unused medicine until administration to the patient is complete to enable
further checking procedures to be undertaken.
The neck of some plastic ampoules is designed to connect directly to a syringe without the use of a
needle, after the top of the ampoule has been twisted off.
2.3
2.3.1
Withdrawing a solution or suspension from a vial into a syringe
Remove the tamper-evident seal from the vial and wipe the rubber septum with an alcohol and
chlorhexidine wipe. Allow to dry for at least 30 seconds.
2.3.2 With the filter needle sheathed, draw into the syringe a volume of air equivalent to the required volume of
solution to be drawn up.
2.3.3 Remove the filter needle cover and insert the needle into the vial through the rubber septum.
2.3.4 Invert the vial. Keep the needle in the solution and slowly depress the plunger to push air into the vial.
2.3.5 Release the plunger so that solution flows back into the syringe.
2.3.6 If a large volume of solution is to be withdrawn, use a push-pull technique. Repeatedly inject small
volumes of air and draw up an equal volume of solution until the required total is reached. This
‘equilibrium method’ helps to minimise the build-up of pressure in the vial.
2.3.7 Alternatively, the rubber septum may be pierced with a second needle to let air into the vial as solution is
withdrawn. The tip of the vent must always be kept above the solution to prevent leakage.
2.3.8 With the vial still attached, invert the syringe. With the needle and vial uppermost, tap the syringe lightly
to aggregate the air bubbles at the needle end. Push the air back into the vial.
2.3.9 Fill the syringe with the required volume of solution then draw in a small volume of air. Withdraw the
needle from the vial.
2.3.10 Expel excess air from the syringe. Remove the needle and exchange it for a new needle or a sterile blind
hub.
2.3.11 The vial(s) and any unused medicine should be kept until administration to the patient is complete.
2.2.12 If the vial contains a suspension rather than solution, it should be gently swirled to mix the contents,
immediately before they are drawn into the syringe.
2.4
2.4.1
2.4.2
2.4.3
2.4.4
2.4.5
2.4.6
2.4.7
2.5
2.5.1
Reconstituting powder in a vial and drawing the resulting solution or suspension into a syringe
Remove the tamper-evident seal from the vial and wipe the rubber septum with an alcohol and
chlorhexidine wipe. Allow to dry for at least 30 seconds.
Use the procedure in 2.2 above to withdraw the required volume of diluent (e.g. water for injection or
sodium chloride 0.9%) from ampoule(s) into the syringe.
Inject the diluent into the vial. Keeping the tip of the needle above the level of the solution in the vial,
release the plunger. The syringe will fill with the air which has been displaced by the solution (if the
contents of the vial were packed under a vacuum, solution will be drawn into the vial and no air will be
displaced). If a large volume of diluent is to be added, use a push-pull technique (see above).
With the syringe and needle still in place, gently swirl the vial(s) to dissolve all the powder, unless
otherwise indicated by the product information. This may take several minutes.
Follow the relevant steps in 2.3 above to withdraw the require volume of solution from the vial into the
syringe.
Alternatively, the rubber septum may be pierced with a second needle to let air into the vial as solution is
withdrawn. The tip of the vent needle must always be kept above the solution to prevent leakage.
If a purpose-designed reconstitution device is used, the manufacturer’s instructions should be read
carefully and followed closely.
Adding a medicine to an infusion
Prepare the medicine in a syringe using one of the methods described in 2.2 to 2.4 above.
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2.5.2
2.5.3
Check the outer wrapper of the infusion container is undamaged.
Remove the wrapper and check the infusion container itself in good light. It should be intact and free of
cracks, punctures/leaks.
2.5.4 Check the infusion solution, which should be free of haziness, particles and discolouration.
2.5.5 Where necessary, remove the tamper-evident seal on the additive port according to the manufacturer’s
instructions or wipe the rubber septum on the infusion container with an alcohol and chlorhexidine wipe
and allow to dry for at least 30 seconds. (Note: there is no need to clean the additive port if the bag has
just been taken out of its sterile packaging.
2.5.6 If the volume of medicine solution to be added is more than 10% of the initial contents of the infusion
container (more than 50ml to a 500ml or 100ml to a 1litre infusion), an equivalent volume must first be
removed with a syringe and needle.
2.5.7 Inject the medicine into the infusion container through the centre of the injection port, taking care to keep
the tip of the needle away from the side of the infusion container. Withdraw the needle and invert the
container at least five times to ensure thorough mixing before starting the infusion.
2.5.8 Do not add anything to any infusion container other than a burette when it is hanging on the infusion
stand since this makes adequate mixing impossible.
2.5.9 Before adding a medicine to a hanging burette, administration must be stopped. After the addition has
been made and before administration is re-started, the contents of the burette must be carefully swirled
to ensure complete mixing of the contents.
2.5.10 Check the appearance of the final infusion for absence of particles, cloudiness or discolouration.
2.5.11 Label the infusion (see standard 2.7)
2.6
2.6.1
2.6.2
2.6.3
2.6.4
2.6.5
2.6.6
2.6.7
2.6.8
2.7
2.7.1
2.7.2
Diluting a medicine in a syringe for use in a pump or syringe-driver
Prepare the medicine in a syringe using one of the methods described above.
Draw the diluent into the syringe to be used for administration by the pump or syringe-driver. Draw in
some air (slightly more than the volume of medicine needed) and remove the needle.
Stand the diluent syringe upright. Insert the needle of the syringe containing the medicine into the top of
the diluent (administration) syringe and add the medicine to it. Alternatively, a disposable sterile
connector may be used to connect two syringes together directly.
Check the following:
 The total volume of injection solution in the syringe is as specified in the prescription and that the
infusion can be delivered at the prescribed rate by the administration device chosen;
 The rate of administration is set correctly on the administration device and according to the
manufacturer’s instructions and the BBraun drug library if applicable.
Fit a blind hub to the administration syringe and invert several times to mix the contents.
Remove the blind hub. Tap the syringe lightly to aggregate the air bubbles at the needle end. Expel the
air and refit the blind hub.
Carefully check the syringe for cracks and leaks and then label it (see standard 2.7) especially noting the
requirements specific to syringe drivers.
Check that the rate of administration is set correctly on the device before fitting the syringe, priming the
administration set and starting the infusion device.
Labelling injection and infusion containers
All injections should be immediately identifiable at all stages after preparation, except for syringes
intended for immediate push (bolus) administration by the person who prepared them. Under no
circumstances should an operator be in possession of more than one unidentifiable syringe at any one
time, nor must an unlabelled syringe be fitted to a syringe driver or similar device.
Labels used on injectable medicines prepared in clinical areas should contain the following information:
 Name of the medicine;
 Dose/quantity of drug in the syringe/bag ;
 Route of administration;
 Diluent and final volume;
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 Patient’s name;
 Expiry date and time;
 Batch number of the medicine;
 Name of the practitioners preparing and checking the medicine.
2.7.3
2.7.4
Inotropes and vasopressors should be labelled with a purple infusion label as above. Pre-printed purple
labels are available for noradrenaline, dobutamine and adrenaline, these pre-printed labels should be
used in preference to plain purple labels for these particular drugs.
Place the final syringe or infusion and the empty ampoule(s)/vial(s) in a clean plastic tray with the
prescription for taking to the patient for administration.
2.8
2.8.1
Multiple use of injectable medicine
Multiple use of an unpreserved injectable medicine should be eliminated. Most injectable medicines are
licensed for ‘once-only’ use. Unless the manufacturer’s label specifically indicates that the injection
contains a preservative, the container should only be used to prepare a single dose for a single patient
on one occasion. Any departments that have reasons not to comply with this guidance must seek
approval from the PHT Formulary and Medicines Committee/Medications Safety committee and a record
of the medication and situation in which it is to be used more than once should be made on the
departmental risk register.
2.9
2.9.1
Mixing of medicines
In some settings it will be in the patient’s best interests for medicines to be mixed, for instance
administration through a SC syringe driver or single line. Mixing of medicines should:
 Only be undertaken in the best interests of the patient e.g. to avoid multiple injections or only one
access point is available.
 Be avoided where possible
 Only be done by a person competent and willing to do so
 Take place in a pharmacy, where possible.
The Department of Health has recommended that:
 Doctors, dentists, nurse and pharmacist independent prescribers who can mix medicines themselves,
can direct others to mix.
 Supplementary prescribers can mix medicines themselves and direct others to mix, only where that
preparation forms part of the clinical management plan for an individual patient.
Prescribers should seek advice from a pharmacist in deciding whether there are alternatives to
administering mixed medicines for individual patients, or if not possible refer to the PHT Trust Mixing
Guideline for a list of drugs authorized to be mixed in the Trust.
If the guideline does not provide information on a particular combination of drugs then Prescribers should
seek advice from a pharmacist in determining which substances can be mixed and in what
concentrations.
If the required combination of drugs is found to be compatible in an alternative reference source the
instruction/direction to mix must be in writing by the prescriber on the drug chart or in the patients notes.
The prescriber must take responsibility for satisfying him/herself that the clinical governance
arrangements are in place to ensure that the “mixer” is competent to undertake the task safely and
effectively.
The person mixing the medicines must be competent to administer the injectable medication.
No-one should be obliged to mix and administer medicines if they do not feel competent of content to do
so.
2.9.2
2.9.3
2.9.4
2.9.5
2.9.6
2.9.7
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Step 3: Administration of an injectable medicines
 The preparation and administration of injectable medicines, infusions, transfusions and their maintenance
should be undertaken only by healthcare professionals who have undergone the training detailed in section 7
(Training requirements) and meet requirements stated in Section 5 (Duties and Responsibilities) of the Policy
for the Safe Management of Injectable Medicines (Adults and Children)
 Before administration, the following should be available: a current prescription, a patient group direction,
essential technical information and a prepared and labelled injectable medicine. The patient’s identity and
details should be confirmed according to The Patient Identification Policy.
 The person administering the medicine should personally make a record of administration as soon as
possible after the event. This is extremely important in circumstances such as theatres, where the person
administering the medicines may also be the prescriber and there may be no written prescription.
 Risk assessment will have identified those products representing the highest risk to patients at the time of
administration.
 The UCL Hospitals Injectable Medicines Administration Guide should be used to determine if a drug should
be administered using an infusion pump and which type of pump should be used.
 If the UCL guide states that a drug should be given by infusion but does not specify which type of infusion
device should be used, the administering practitioners discretion should be used when deciding whether to
use an electronic pump or not, but they must ensure that the drug is given at an appropriate rate regardless
of the method used.
 Drugs that should be administered intravenously via a syringe driver should be given via an intravenous B
Braun smart pump syringe driver. (See Trust Policy for the Management of Infusions with Pumps)
 Infusions of noradrenaline, dobutamine or adrenaline should be administered via B Braun volumetric smart
pumps using the drug library. All other drugs requiring a volumetric infusion pump should be administered
using a Grasby volumetric infusion pump. (See Trust Policy for the Management of Infusions with Pumps)
 Fluids should always be given via a graseby volumetric pump
 Drugs that are administered via subcutaneous infusion should be administered via a McKinley T34 syringe
driver.
 The patient should be observed throughout intravenous treatment for any change in condition/ adverse
reactions.
 Infusions should be monitored according to the UCL Injectable Medicines Administration Guide, relevant
product information and any relevant Drug Therapy Guidelines and clinical policies to ensure safe
administration of prescribed treatment.
 Neonatal infusions: see Appendix 2 for additional information on infusions of IV fluids and medicines for
neonates
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3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.1.7
3.2
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.6
3.2.7
3.2.8
3.2.9
3.3
3.3.1
3.3.2
3.3.3
Before administering any injection
Check all the following:
 Patient’s name, hospital/NHS number or date of birth or address with the patient and their wrist band;
 Prescriber’s signature;
 The approved medicine name;
 The dose and frequency of administration (remember to consider patient weight where appropriate e.g.
paracetamol IV, enoxaparin etc);
 The date and route of administration (including whether the drug should be given via a central line or
peripherally);
 The allergy status of the patient.
Also check, where relevant:
 Brand name and formulation of the medicine;
 Concentration or total quantity of medicine in the final infusion container or syringe;
 Name and volume of diluent and/or infusion fluid;
 Rate and duration of administration;
 Type of rate-control pump or device(s) to be used;
 The age and weight of any patient under 16 years of age, where relevant;
 Date on which treatment should be reviewed.
Check that the medicine is due for administration at that time and has not already been given.
Assemble everything you need including any flushing solution(s) needed, and ensure that any drugs
necessary for dealing with reactions are available.
Explain and discuss the procedure with the patient.
Check any infusion already in progress. It should be free of haziness, particles and discolouration.
Check that an appropriate access device is in place and is patent. Health care professionals should only
inject into an established intravenous access point. Flush it immediately before and after administration
of a medicine, and between doses of different medicines administered consecutively. Also check the
administration site for signs of leakage, infection or inflammation.
Administration of injections – general
Check infusions. They should be free of haziness, particles and discolouration.
Use aseptic (non-touch) technique at all times.
Attach administration sets to infusion containers carefully, on a flat surface and using the technique
appropriate to the type of container.
Prime the access device immediately before starting and infusion.
Before adding a medicine to a hanging burette, administration must be stopped. After the addition has
been made and before re-commencement, the contents of the burette must be carefully swirled to
ensure complete mixing.
Ensure the giving sets are changed in accordance with the trust guidelines.
All drugs that can be given peripherally can be given by a central line.
A second healthcare professional is required to check all agents for intravenous administration. This
check must incorporate the whole administration process i.e. valid prescription, product accuracy, correct
patient, check of infusion rate programmed into the appropriate device
For information on mixing medicines see section 2.9 Mixing of medicines.
After administration
After completion of an intermittent infusion, flush the access device according to (standard 4).
Ask the patient to report promptly any soreness at the injection site or discomfort of any sort.
Make a detailed record of administration.
 Discard the empty ampoule(s)/vial(s) from which the injection was prepared and any unused medicine
according to the PHT Trust Waste Handling Policy. Ampoules or vials should never be used to prepare
more than one injection unless specifically labelled by the manufacturer for ‘multi-dose’ use.
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3.3.4
3.3.5
4
Re-check the administration site for signs of leakage, infection or inflammation and continue to monitor
the patient, contents of the infusion container and the rate of infusion.
Check that arrangements for monitoring fluid balance or clinical parameters have been made. Ensure
that relevant documentation is made available for subsequent regular monitoring to take place.
Flushing
IV access devices should be flushed daily (as per the PHT Clinical Policy for Peripheral Venous Cannula
Insertion and Management and the PHT Central Venous Catheters: Care and Management Policy) to
maintain the patency and immediately before and after administration of a medicine, and between doses
of different medicines administered consecutively.
Flushes to maintain the patency of the line should be prescribed on the prescription chart stating the
flush to be used, volume and times of administration.
Flushes administered pre and post drug administration are an integral part of the intravenous drug
administration process. Therefore an appropriate flush should be administered as standard pre and post
drug administration, these will not be prescribed.
Any suitably trained person authorised by the Trust to cannulate patients as part of their role, can
administer 1 – 2ml of sodium chloride 0.9% to establish initial patency of a peripheral intravenous
cannula. Document this administration in the Cannula Insertion and Management Form. See the PHT
Clinical Policy for peripheral venous cannula insertion and management.
5
Cannula Management
Refer to the PHT Clinical Policy for Peripheral Venous Cannula Insertion and Management (Adults) and
the PHT Central Venous Catheters: Care and Management Policy
6
7
Reactions to intravenous drugs
Anaphylaxis
Refer to: PHT Cardiopulmonary Resuscitation Policy (Including Anaphylaxis and Defibrillation
Adverse reactions
a patient exhibits any adverse reaction receiving an injectable medicine it must be stopped and the
prescriber/medical/dental officer notified. It should only be continued on his/her decision.
 The prescriber/medical/dental officer should take a full clinical history. List signs, temperature, all
medicines and the times and batch number of any infusions given.
 Update the adverse medicine reaction box on the front of the patient’s medicine chart with the causative
drug and the type of reaction that occurred.
 If a defect in an infusion is suspected take specimens for blood culture from another vein and inform
pharmacy.
 Watch any other patients having medication of the same batch. The order of use of the containers
concerned should be noted. When the administration of the medication has been completed the
containers should be retained for a period of 24 hours to ensure that they can be examined should any
reaction follow.
 All suspect containers and accessories should be labelled and kept in case they are needed for
investigation.
 The senior nurse and senior pharmacist on duty (or the on-call pharmacist) should be informed
immediately.
 See PHT Policy for the management of adverse event and near misses
 If any incident relates to an infusion then the pump should be isolated so that the information settings
can be down loaded by medical electronics.
 If
8
Extravasation
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Extravasation is the accidental infiltration in intravenous fluids/medicines into the subcutaneous tissue
see the Central Venous Catheters: Care and Management Policy and fill in an incident form.
9
In-line Intravenous filters
The current guidelines on the use of 0.2 micron in-line intravenous filters are:
 There is no need for the routine use of these filters.
 Individual clinical areas are free to develop their own policy if required, for example clinical needs to reduce
particulate contamination or to increase cannula life. It is recommended that these should be discussed
with microbiology and directorate pharmacist.
 Specific drugs require the use of these filters, so these must be stocked in clinical areas where these drugs
are used, (obtain through supplies)
 Current examples:
 Phenytoin infusion
 Infliximab infusion
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Appendix 2: Prevention of Over Infusion of Intravenous Fluids and Medicines in
Neonates.
Prior to commencing any infusion

Do not use any syringe pump/volumetric pump unless you are competent to do so and have signed the
Group Competency Statement for Registered NICU staff within the last 2 years.

Two nurses must double check the IV prescription chart against the current NICU local formulary (route
of administration & working weight of baby needs to be on prescription chart). If the prescription differs
from the formulary, the reason why needs to be documented in the baby’s notes.

Clearly identify the baby for who the fluids are intended by double checking name bands against
prescription chart.

When using a syringe pump to administer IV fluids, a bag of fluids must not be left connected to the
syringe (excluding blood, see NICU blood transfusion guideline).

Ensure all administration equipment is correctly loaded onto the infusion pump before connecting to the
infant and the clamps are in the off closed position.

The infusion rate and the total volume to be infused will be double checked by another Registered Nurse
and against the prescription. (This will also apply if any changes are made to the rate once the infusion is
commenced)
.
During Each Infusion

Check and document the infusion rate, total volume infused and pressure indicator hourly on the fluid
chart.

If the rate is changed, double check the rate and total volume against the prescription.

Continuously monitor the baby and record observations hourly and more frequently if required. Set
pressure alarm on volumetric pumps at 30 mmHg above the venous pressure reading. Set pressure
alarm at 1 bar (≡ 75 mmHg) on B Braun pumps.

If a burette is used, place only 4 hours volume of fluid plus 10 mls in the chamber. To prevent over
infusion and prevent chamber from emptying, set the volume to be infused at a volume equivalent to 4
hours infusion.

If the baby deteriorates, consider the possibility of fluid overload along side other potential causes.

Check blood sugar level within an hour of starting any glucose infusion and then 4-6 hourly (frequency
may vary depending on clinical needs, this should be confirmed with medical team and documented).
Any blood sugar level results outside normal limits should be reported to the medical team.

Close all clamps prior to the removal of an administration set from the infusion device.
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At handover

Double check the infusion rate and total volume to be infused with the registered nurse (or nursery nurse
with competencies in medicines management) taking over care.

For babies receiving a glucose infusion, check that the most recent blood sugar level is within acceptable
limits in accordance with the clinical management plan.

Ensure all discontinued infusions are clamped off and have been disconnected from the baby.

Ensure octopus clamps are slid to their full extent to ensure effectiveness of clamp

Using the Neonatal Vascular IV Care Bundle double check and document observation of all cannula
sites.
References
Neonatal Intensive Care Nursing Care Plan August 2011,
National Patient Safety Agency August 2010 Reference 1264 August 2010,
PHT Policy for the Management of Infusions with Pumps, Issue 1. 19.07.2005 V2
PHT Policy for the Safe Management of Injectable Medicines (adults and Children) Version1 16.09.10
Appendix 2 is managed by: Kim Edwards and Susi Hill Practice Educators and Nicola Hill Women’s and
Children’s Divisional Pharmacist
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Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval for service and policy changes/amendments.
Stage 1 - Screening
Title of Procedural Document: Policy For The Safe Management Of Injectable Medicines (Adults
And Children)
Date of Assessment
10.5.16
Responsible
Department
Pharmacy
Name of person
completing
assessment
H McHale
Job Title
CHAT Pharmacist
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
No
 Disability
No
Comments
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
 Ethnic Origin (including gypsies and travellers)
No
 Gender reassignment
No
 Pregnancy or Maternity
No
 Race
No
 Sex
No
 Religion and Belief
No
 Sexual Orientation
No
If the answer to all of the above questions is NO,
the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
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Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Mitigating Actions
(what needs to be done to minimise /
remove the impact)
Responsible
Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document:
Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
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