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NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
NUH MEDICINES POLICY: CODE OF PRACTICE
ADMINISTRATION OF MEDICINES POLICY (EXCLUDING IV
ADMINISTRATION)
Reference
CL/MM/008
Approving Body
Senior Management Team
Date Approved
5 February 2016
Implementation Date
5 February 2016
Version
7
Summary of Changes from
Clarification on two practitioner checks for
Previous Version
medicines administration, which drugs must
be second checked
New appendices, appendix 1 Flowchart for
nurses to follow if patients unable to
swallow tablets, appendix 4 and 5
Update to pre-op fasting-wording taken
from NUH guideline
All IV policy information taken out and
inserted into new IV administration policy.
New section 6.5.3, using the patient as a
second checker
New reference for drug administration via
infiltration and irrigation.
Supersedes
Version 6 (July 2012)
Consultation Undertaken
Medicines Management Committee
Medicines Safety Group
Nursing and Midwifery Strategy group
Date of Completion of
Equality Impact Assessment
Date of Completion of We
Are Here for You
Assessment
Date of Environmental
Impact Assessment (if
applicable)
Legal and/or Accreditation
Implications
Target Audience
2nd Aug 2015
2nd Aug 2015
2nd Aug 2015
Multiple- see section 10 of this policy
All staff administering medicines at NUH,
and NUH staff working on behalf of NUH at
affiliated hospitals, clinics or in the
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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community.
Review Date
July 2017
Lead Executive
Medical Director
Author/Lead Manager
Mo Rahman
Head of Pharmacy, Clinical Director of
Medicines Management,
Chair, Medicines Management Committee
Ext: 61199
Sonia Gilmore
Secretary to Medicines Management
Committee
Ext 59374
Further
Guidance/Information
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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CONTENTS
Paragraph
Title
1.
2.
3.
4.
5.
6.
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
6.14
Introduction
Executive Summary
Policy Statement
Definitions (including Glossary as needed)
Roles and Responsibilities
Policy and/or Procedural Requirements
Professional conduct
Authorisation to administer medicines
Staff authorised to administer medicines at NUH
Timeliness of administration and critical drugs list
Two-person checking (also called second-checking)
Process for drug administration
Oral administration of medicines
Parenteral administration of medicines
Enteral route administration of medicines
Rectal or bladder administration of medicines
Spinal (intrathecal) administration of medicines
Local anaesthetic and epidural administration
Transdermal and topical administration of medicines
Infiltration or Irrigation route for administration of
medicines
6.15
Process for recording administration of medicines
6.16
Administration of medicines to patients who are preop fasting
6.17
Non-administration of medicines
6.18
Vomiting of medicines
6.19
Covert administration of medicines
6.20
Specific administration requirements for medicines
identified in current and previous national medicines
alerts
7.
Training, Implementation and Resources
8.
Impact Assessments
9.
Monitoring Matrix
10.
Relevant Legislation, National Guidance and
Associated NUH Documents
Appendix 1 Flowchart for nurses to follow if patients unable to
swallow solid dosage forms (tablet or capsule)
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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5
5
5
5
6
7
22
22
24
25
27
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Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Flowchart- medicines administration by the oral
route
Flowchart-medicines administered as a parenteral
direct injection or as a parenteral infusion
Midwives rules at NUH- available from MMC
professional secretary
What involvement students can have in medication
preparation and administration’ available from MMC
professional secretary
Equality Impact Assessment
Environmental Impact Assessment
Here For You Assessment
Certification Of Employee Awareness
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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29
31
31
32
34
36
28
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1.0
Introduction
1.1
This policy is applicable to all practitioners involved in the
administration of medicines to patients at NUH.
2.0
Executive Summary
2.1
This policy applies to all practitioners working at NUH or working in
affiliated hospitals or in the community on behalf of NUH who are
involved in administering medicines.
When practitioners employed by other Trusts come into NUH to
practice they must comply with all NUH policies, procedures and
guidelines for medicines.
3.0
Policy Statement
3.1
Practitioners administering medicines should act within their sphere
of competence at all times.
Practitioners are accountable for their practice in accordance with the
standards of their professional body and with the requirements of the
NUH medicines policy.
4.0
Definitions
4.1
4.1.1 Healthcare professional: A registered member of staff,
including nurses, operating department practitioners, doctors,
dentists and radiographers. This also includes individuals employed
by a third party person to work within NUH.
4.1.2 Non-registered clinical staff: Non-registered staff employed
as band 2, 3 or 4. This group will include phlebotomists, Clinical
Support Workers (CSW)/ Healthcare Assistants (HCA)/ Healthcare
Support Workers, physiotherapy assistants, dietetic technicians,
nuclear medicine technicians, cardiology technicians.
4.1.3 Competence: Is defined as demonstrating the knowledge and
skills to perform the task to NUH standards, consistently and without
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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supervision.
4.1.4 Two person check procedure (also known as second
checking): At NUH the accepted standard is to have two registered
health care practitioners both check specific medicines before
administration. This is usually two registered nurses/ midwives. All
steps of the process are checked from drug selection and preparation
to administration. Where a calculation is involved, both practitioners
must perform an independent calculation and then share their
individual calculation result to confirm accuracy. See 6.5 of this
policy.
4.1.5 Preceptorship nurse: A newly qualified nurse who upon
commencing post undergoes a programme of supported learning in
their practice environment. Supported learning programmes are
available for other newly appointed nurses to the Trust where this is
deemed essential to their role.
5.0
Roles and Responsibilities
5.1
Committees
5.1.1 Nursing and Midwifery Board
Responsible for ensuring that this policy reflects best practice and
legislation for nursing.
5.1.2 Medicines Management Committee (MMC)
Responsible for approving the policy, managing the monitoring
arrangements for the policy and to address barriers to
implementation of the policy.
5.2
Individual Officers
5.2.1 The Chief Nurse is responsible for implementation of this
policy by nurses at NUH.
5.2.2 The Head of Pharmacy/Clinical Director for medicines
management is responsible for ensuring the content of this policy
aligns with the necessary legislation and accreditation standards
through the Medicines Management Committee.
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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5.2.1 Clinical Leads and Heads of department are responsible for
ensuring that necessary measures are in place to support the safe
implementation and monitoring of the use of the policy in practice.
They will need to take measures where practice has been deemed
potentially unsafe.
5.2.3 Matrons and department managers are responsible for
ensuring that all staff accountable to them are aware of and adhere
to this policy. It is the manager’s responsibility to investigate and
rectify any discrepancies identified.
5.2.4 Ward sister/ charge nurse/ department leader will act as
excellent role models and are responsible and accountable for the
policy implementation among staff in practice, and the monitoring of
standards and best practice associated with it. They will ensure that
all staff in the sphere of their responsibility have access to training to
develop the skills and competence.
5.2.5 All registered healthcare professionals have a duty of care
to their patients. This is a legal and professional requirement of state
registration that cannot be delegated.
5.2.6 Pharmacists are responsible for monitoring both the
prescribing and overseeing the administration of medicinal therapies
and alerting prescribers and other health care professionals to
potential or actual problems in line with NUH pharmacy procedures
and Royal Pharmaceutical Society standards.
6.0
6.1
Policy and/or Procedural Requirements
Professional conduct
All registered healthcare professionals administering and
checking medicines must be competent to do so.
The practitioners who administer and check the medication must
understand the prescription and have knowledge of the common
indications, side-effects and dosages of the medicine prescribed
and the reason that it has been prescribed for that patient.
If the practitioner is not familiar with the medicine they must check
that both medicine and dose are appropriate, referring to the
current BNF, BNF for children, or other appropriate up to date
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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reference source. If there is any doubt, they must confirm the
prescription with the original prescriber or a pharmacist. If they
are still in doubt, they must not administer the medicine and must
inform the prescriber.
6.2
6.3
6.3.1
Authorisation to administer medicines
Medicines may be administered to the patient under the
authorisation of a :
 Prescription by an authorised prescriber
 Patient-specific written direction e.g. administration of eye
drops in a clinic
 Patient Group Direction (see CL/MM/007 PGDs policy)
 Verbal Order (in exceptional circumstances- see
CL/MM/006 prescribing policy)
 Transcribed prescription or verbal order written by a
pharmacist under the authorisation of a doctor (in
accordance with a pharmacy local agreement)
In addition, midwives are legally permitted to supply and
administer some medicines without the prescription of a doctor,
under legislation known as ‘midwives exemptions’ – see 6.3.3 and
appendix 4.
Staff authorised to administer medicines at NUH
The following practitioners are permitted to administer
medicines, providing they have the relevant underpinning
knowledge and competencies to do so (also see 7.0 Training) :
 Registered nurses and midwives, including student
midwives who are also registered nurses working within the
scope of their professional practice.
 Agency nursing and midwifery staff (including NHS
professionals and other external Agency organisations). The
nurse must ensure that they have sufficient knowledge of
the patient to which they are administering medicines, and
that they are working within their sphere of competence.
 Registered doctors, including Foundation year doctors, and
locum doctors.
 Other registered practitioners, e.g. physiotherapists,
radiographers. (These practitioners require a local
agreement approved by MMC in order to sign for
administration).
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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 ODPs- see administration in theatres section of the
Medicines Policy CL/MM/014
 Student nurses, or student midwives who are not registered
nurses, medical students/MAST students, and any other
practitioner in training whose role explicitly involves
medicines administration, may only administer under the
direct supervision of a Designated Practitioner. This
Designated Practitioner is responsible for the correct
administration and documentation of medicines
administered. See Appendix 5 for ‘What involvement
students can have in medication preparation and
administration’.
If a named individual or staff group not listed above needs to
administer medicines there must be a current local agreement
ratified by MMC in place.
6.3.2
Administration by non-registered staff:
Non-registered clinical staff (e.g. Clinical Support Worker (CSW)/
Healthcare Assistants (HCA), physiotherapy assistant, dietetic
technician, nuclear medicine technician, cardiology technician
etc.) may assist the patient to apply a limited range of topically
applied medicines/dressings which are prescribed.
A registered nurse (or registered practitioner authorised to
administer) must check and sign the prescription, hand the
product to the non-registered staff and be accountable for the
delegation of the task.
In addition, areas may have a local agreement in place, ratified by
MMC, to allow specified groups of non-registered staff who have
signed the local agreement to administer specific drugs within
limited criteria.
6.3.3
e.g. Clinical support workers may administer 0.9% sodium
chloride flushes providing they have successfully completed the
NUH cannulation pack and the flush is prescribed.
Administration of medicines by midwives at NUH:
Midwives rules and standards
Midwives are legally permitted to supply and administer some
medicines without the prescription of a doctor. The legislation
known as “midwives exemptions” includes medicines such as
sedatives, opioids and oxytocics, as well as specific neonatal
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medicines.
Midwives must comply with legislation as listed in section 10 of
this policy.
When independent midwives or midwives employed by other
Trusts come into NUH to practice they must comply with the
Trust’s policies, procedures and guidelines for medicines. These
midwives must use the medicines stocked by the hospital rather
than their own supply.
When midwives employed by NUH practice in the community they
must adhere to the current NUH practice.
6.3.4
6.3.5
6.3.6
6.4
6.5
See Appendix 4 for how Midwives rules applies at NUH.
Administration of medicines in operating theatres
For arrangements and regulations specifically applied to operating
theatres refer to CL/MM/014 of the Medicines Policy: Code of
Practice.
Administration of medicines in radiology and diagnostics
For arrangements and regulations specifically applied to radiology
and diagnostics refer to CL/MM/015 of the Medicines Policy: Code
of Practice.
Administration of medicines by patients or carers
A patient or carer may administer medicines, where SelfAdministration procedures are in place and where the patient or
carer has been assessed as competent by a nurse (refer to
CL/MM/005 of the Medicines policy: Code of Practice). On
children's wards, patients and carers may participate in medicine
administration where the ward staff consider them competent to do
so.
Timeliness of administration and critical drugs list
It is important that all medicines are given as close to their
prescribed time as possible. This is especially important for some
drugs. At NUH the categories of drugs are detailed on the NUH
critical drugs list, see MMC website.
If staff, particularly on admissions units are aware of critical
medicines that patients require before they have been clerked,
they should alert medical staff to prescribe the drugs.
Two-person checking (also called second-checking)
The majority of oral and topical medicines may be administered at
NUH by a single practitioner with no need for a two-person check.
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6.5.1
Where a two-person check is required both practitioners are
equally responsible for the administration.
Medicines requiring a two-person check
 All injectable medicines (except prophylactic doses of
enoxaparin) including IV fluids- refer to separate IV policy
 Irrigation fluids
 All medicines administered to children under 18years (or
16years if nursed on a non-paediatric ward), unless in the
approved lists of non-IV medicines exempted from this (see
MMC website)
 All controlled drugs- refer to CL/MM/012 of the Medicines
policy: Code of Practice (includes high risk drugs identified
locally and nationally at increased risk of causing harm to
patients, and which are not CDs but are treated as such at
NUH)
 All cytotoxic drugs administered via any route
It is best practice to seek a second check for any other medicines
that require a calculation where the nurse is not confident e.g. if
using liquid oral medicines. See section 6.6.2 below.
6.5.2
A nurse may seek a second check at any time for any other
medicine if they wish from an appropriate practitioner. See section
6.5.2 below.
Staff who may act as the second checker for non-IV
medicines (for IVs refer to separate IV policy)
 A doctor
 A nurse
 A pharmacist
 Any practitioner permitted to administer that medication
which is being second checked
If the second checker is not a nurse, that practitioner must follow
the same process that the nurse would when checking.
Practitioners must work within their sphere of competence at all
times.
A local agreement ratified by MMC is required to allow any other
practitioner to administer or act as the second checker.
Student nurses:
A second year student nurse who has successfully completed
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theoretical and practical training within the Division of Nursing
may act as an independent second checker for injections given
the Intramuscular or subcutaneous routes.
A third year student nurse who has successfully completed
theoretical and practical training within the Division of Nursing
may act as the independent second checker for oral controlled
drugs.
6.5.3
Use of the patient as a second checker
A nurse may use a patient as a second checker where
appropriate in the following circumstances:
 For a SC injection that the patient usually administers to
themselves at home, e.g. insulin, epoetin injections,
therapeutic enoxaparin. Patient must have capacity at that
time.
 For adult haemodialysis patients administering IV drugs see
local procedures.
 For administration of drugs in the community where there is
only a single nurse (where this is an IV drug refer to NUH IV
policy), a local agreement ratified by MMC is required.
The patient must confirm:
 That they are the correct patient (name and date of birth),
i.e. Positive patient identification
 That they are expecting the drug intended
 They are not allergic to the drug being administered
If the patient does not have capacity at that time a second
practitioner must be used. For practitioners administering in the
community, if the patient lacks capacity the administration will
have a single person check.
6.6
A diagonal line should be drawn across the administration box,
and initials of one nurse AND ‘pt’ or ‘patient’ should be
documented.
Process for drug administration
Before administration or checking a medicine, the practitioner
must ensure they:
 Understand the prescription
 Have knowledge of the common side-effects and doses of
the medicine prescribed, referring to the BNF, CBNF or
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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other reference if necessary. If in doubt refer back to the
prescriber or a doctor responsible for that patient, or a
pharmacist.
6.6.1
The following processes must be followed for administration of all
medicines. The steps may occur in a different order to that listed if
necessary, ensuring patient safety at all times:
 Right patient and right medication chart (follow positive
patient identification policy)
 Right day and time (check all sections of all charts)
 Confirm allergy box completed (if not completed and signed,
do not administer)
 Right drug, right indication (use reference source if
necessary)
 Right route
 Right dose (use reference source if necessary. Complete
calculations if necessary)
 Right dosage form (e.g. tablet, liquid, topical, injection)
 Right strength
 Right expiry
 Get a two person check from a second practitioner if the
drug requires it (see section 6.5 of this policy)
 Recheck right patient
 Administer to the patient and watch patient take the
medication (this must not be delegated to healthcare
workers or clinical support staff)
 Do not leave prepared medicines unattended; administer
straight away
 Sign chart immediately
 Ensure stock present or ordered for when next dose due
 Ensure all medication prescribed for an individual by one
route is completed before moving on administer medication
by any other route (to minimise chance of wrong route
errors)
See appendix 2 and 3 for full summary of steps.
 For all IV administration information refer to separate NUH
IV policy.
 It is best practice to discuss medicines with their patient or
carer at the point of administration in order to ensure their
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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understanding and aid compliance.
 It is best practice for the same person who has prescribed a
drug not to administer it, unless in an emergency (separate
arrangements in place for theatres).
6.6.2
Calculations
Calculations must be done independently and any discrepancies
must be re-calculated. If necessary seek advice from a
pharmacist.
If calculations need to be checked (e.g. if the administering nurse
is not confident), they must ask a second practitioner for a second
check. A nurse may ask for this at any time for any medicine.
6.7
6.7.1
Calculations for IV medicines MUST be second checked- refer to
NUH IV policy.
Oral administration of medicines
Nurse must follow all points in 6.6.1 of this policy
Also see appendix 2 for flow chart of oral administration
Splitting of tablets
Occasionally a dose of a medicine is prescribed that requires the
tablet to be cut in half. Before doing this the nurse should follow
the process below:
 Contact Pharmacy to see if a lower strength tablet or liquid
preparation can be provided to administer the dose.
 If the tablet is scored down the middle it should be halved
using a tablet cutter device, and the remaining portion
discarded.
 Use tweezers or forceps to put the tablet into the medicine
pot for the patient to take.
 If a tablet is not scored but needs cutting, or if a quarter of a
tablet is needed then contact Pharmacy to cut the tablets
(see separate Pharmacy procedures). The cut tablets will be
provided to the ward or clinical area for that named patient
only, and will state “these tablets have been
halved/quartered and each half/quarter contains___mg”.
Out of hours the on-call pharmacist may authorise a one-off
dose to be cut by ward staff.
 Cytotoxic medicines must never be cut in half by ward staff
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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6.7.2
and must only be done by the patient. They may be issued
with a tablet cutter for their use only. Contact Pharmacy for
further advice before doing this on the ward or clinical area.
Patients unable to swallow solid dosage forms
If there are concerns about a patient’s ability to swallow solid
dosage forms, seek advice from Pharmacy and SALT team.
The administration of medication via enteral feeding tubes is likely
to be outside of the licensed indications and route of
administration in the product’s summary of product
characteristics. The crushing of tablets and opening of capsules
will also place the medicine outside of its product licence. When a
medicine is unlicensed or used in an unlicensed way any
untoward event becomes the responsibility of the prescriber and
therefore the Trust.
6.8
6.9
See appendix 1 for process to follow to find alternative routes of
administration.
Parenteral administration of medicines
Refer to separate NUH IV administration policy
Enteral route administration of medicines
Refer to separate Trust Policy and Procedures for the Use of
Syringes to administer medication feeds and flushes by the enteral
route (Adult policy CL/CGP/016, Paediatric policy CL/CGP/016).
Parenteral (Luer lock or Luer tip) syringes must not be used for
the purpose of administering medicines via the oral, enteral or
rectal route.
6.9.1
6.10
6.11
Purple enteral syringes, measuring pots or 5ml medicine spoons
are the only permitted ways to measure and administer oral liquid
medicines.
Enteral feeding tubes
Enteral syringes are the only permitted way to administer
medicines via enteral feeding tubes, e.g. NG, PEG tubes. Oral
syringes may be used to measure the dose accurately.
Rectal or bladder administration of medicines
If a medicine for rectal administration is not supplied with an
administration device, a bladder syringe and rectal tube must be
used to administer it.
Spinal (intrathecal) administration of medicines
In line with part A of the NPSA Alert on Safer spinal (intrathecal),
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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epidural and regional devices, all procedures which access the
CSF space should use the new spinal needles introduced 1st
March 2012. This includes procedures to introduce medication
into the spinal space.
This guidance is clarified and strengthened by the subsequent
non-Luer spinal intrathecal devices for chemotherapy NHS
England alert (ref NHS/PSA/D/2014/002)
This Trust will only use Non-Luer Lock needles/connectors of
‘Surety®’ type. The Surety® needle is a new design and will not
allow a standard Luer syringe to attach to the spinal needle.
A future non-Luer device is planned as an international standard
(ISO) and the Trust position will be reviewed when new
equipment is available.
All spinal (intrathecal) bolus doses should be prepared in Surety®
yellow syringes e.g. intrathecal chemotherapy and where possible
should be supplied to clinical areas in a ‘ready to administer’ form.
There are some patients who have their drugs administered via
other devices into the spinal space. This was addressed under
part B of the NPSA Alert on Safer spinal (intrathecal), epidural
and regional devices, April 2013.
New products, especially infusion products, are still awaited from
the manufacturers.
Until compliant equipment is available from the manufacturers,
the following drugs should continue to be manufactured by
Pharmacy in syringes with a Luer Lock Connector:
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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



intrathecal vancomycin
intrathecal gentamicin
intrathecal morphine
any other drugs which are being administered via an
EXTERNAL VENTRICULAR DRAINAGE (EVD) set.
Subarachnoid blockade with appropriate local anaesthetic and
opioid should be drawn up and delivered in Surety® syringes.
This should be done by appropriately trained clinicians.
Only appropriately trained doctors or nurses with current and
relevant training, approved by the Head of Service, and assessed
as competent in the administration of intrathecal medication may
administer such medication.
6.12
6.13
6.14
6.15
Refer to CL/MM/013 of the Medicines Policy: Code of Practice for
policy regarding cytotoxic intrathecal medication.
Local anaesthetic and epidural administration
For a registered nurse or midwife to administer epidural medicines
to patient at NUH they must have been assessed as competent by
completing the Trust package. For epidural top up administration,
nurses or midwives must attend regular update sessions.
Refer to CL/MM/029 of the Medicines Policy: Code of Practice
(Local anaesthetics including epidural administration)
Transdermal and topical administration of medicines
When applying transdermal patches the nurse must ensure that
the old patch is removed before applying new patch. The patient
may be wearing more than 1 strength of patch or may have
different types of patch.
Infiltration or Irrigation route for administration of medicines
Infiltration is the deposition of a solution (e.g. local anaesthetic)
directly into tissue often during surgical procedures. Due to the
associated risks the same process as for IV preparation and
administration should apply. Refer to NUH IV administration
policy.
Irrigation is the washing or filling of an organ, body cavity or
wound by a stream of fluid. Due to the associated risks the same
process as for IV preparation and administration should apply.
Refer to NUH IV administration policy.
Process for recording administration of medicines
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The practitioner must:
 Initial the appropriate box on the inpatient prescription chart
 Write the actual dose administered if a dose range has been
prescribed
 Document the time of administration (if administering from
the ‘as required’ or ‘once-only’ section)
The practitioner performing a two-person check must also initial
the administration box. A diagonal line is drawn across the
administration box and both practitioners sign.
If the patient is acting as the second checker, see 6.5.3.
If the medicine is being administered in a non-inpatient setting, it
is best practice to prescribe and document administration on an
approved prescription chart. If this is not possible, full details of
the medicines administered must be documented in the medical
notes.
6.16
6.17
6.17.1
Administration of medicines to patients who are pre-op
fasting
Regular medication should be given with up to 50 mL water (1mL
per kg in children), which can be repeated as necessary.
The principal exception is oral hypoglycaemic drugs (diabetic
tablets) which should be omitted. If there is any doubt always ask
the team looking after the patient or the anaesthetist.
Refer to NUH guideline for eating and drinking before general
anaesthesia or sedation for surgery, interventional radiology or
endoscopy.
Non-administration of medicines
If a medicine is omitted for any reason, the practitioner must:
 initial and record the reason for non-administration, using
the appropriate code, in the appropriate column of the
inpatient prescription chart.
 record the reason and action taken on the Medicines
management chart (either incorporated into main
prescription chart or separate blue MM chart)
 inform the doctor for that patient in case an alternative
medicine or route of administration is needed.
Permitted codes for omission of medication are written on the
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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6.17.2
6.17.3
6.18
6.19
inpatient medication chart
Non-administration of medicines: Medicines not available
 Seek a supply of the medicine by contacting Pharmacy or
the on-call pharmacist if out-of-hours. If a supply cannot be
made available, contact a doctor who must make a clinical
decision about whether to omit or delay a drug. See critical
drugs list available on MMC website.
 Once a supply is available, it must be administered promptly,
recording the time administered and signature/initials. The
timing of the next dose may need to be adjusted.
 Medicines dispensed by pharmacy for an individual patient
must be administered to that patient only. Under exceptional
circumstances medicines dispensed by pharmacy for one
patient may be used for another, if authorised by a
pharmacist, but a supply for all patients must be obtained as
soon as possible. Patients’ own medicines brought in from
home must never be administered to another patient.
 For regularly prescribed medication it is the responsibility of
the practitioner administering to ensure a supply is available
for the next dose time.
Non-administration: NBM
If patient is NBM for food and fluid regarding their ability to
swallow, advice must be sought from the medical team regarding:
 Which key medicines to continue; which to omit
 Alternative routes for administration
 Whether early insertion of nasogastric tube is appropriate
 Alternative forms of oral administration, e.g. liquid, crushing
tablets
See Appendix 1 and 6.7.2
Vomiting of medicines
If a patient vomits within 30 minutes of their medications being
administered, the nurse must contact the doctor in charge of the
patient who must use their clinical judgement to decide which, if
any, medicines should be re-administered. If they are to be readministered, the doctor must prescribe the appropriate drugs on
the once-only section of the drug chart.
Covert administration of medicines
Covert administration of medicines should be a final contingency
measure rather than regular practice.
 The decision to administer medication covertly must only be
taken when a patient is assessed as lacking capacity to
refuse, and the treatment is proportionate and in the
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patient’s best interest. Ensure that the medication is
definitely required to treat an active problem. Stop all other
drugs (e.g. preventative drugs). Consider a non-oral route
(e.g. transdermal patch).
 Patients who find taking medication difficult when presented
to them in the usual way (either because they find it hard to
swallow pills or tablets, the medication distasteful or they do
not understand cognitively what to do with medication when
it is presented to them), but are more willing to take
medication when it is delivered in either food or drink and
are aware that they are receiving medication in this way, are
not actively refusing treatment and therefore this is not
covert administration. All efforts to alleviate their difficulties
e.g. use of liquid medication or referral to a speech and
language therapist must be considered. See section
appendix 1. A pharmacist can advise on the
appropriateness of crushing tablets, opening up capsules
etc.
 Administration of medicines to patients who lack the
capacity to consent and are unable to appreciate that they
are taking medication, for example, unconscious patients
should not need to be carried out covertly. If these patients
recover awareness, their capacity to consent should be
reassessed at the earliest opportunity.
 All staff have a role in assessing the capacity of the patient
to take their medication, and should document the reasons
for presuming mental incapacity in the health records. This
must be regularly reviewed.
6.20
Specific administration requirements for medicines identified
in current and previous national medicines alerts
6.20.1
Insulin
 All subcutaneous insulin must be administered by a
commercial insulin pen device (disposable or cartridge pen)
or using a vial and dedicated insulin syringe with needle.
 All insulin drawn up from a vial for intravenous infusion
must be drawn up using a dedicated insulin syringe with
needle.
 Where possible the patients must draw up and selfadminister their own insulin in accordance with the NUH
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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self-administration policy (CL/MM/005).
 Patients should use commercial pen needles (i.e. BD
microfine, FinePoint Ultra GlucoRx). There is no need for a
patient who is self-administering to use a safety needle (eg
Auto Shield Duo).
If the patient is unable to self-administer the nurse should
administer insulin using a pen device with an appropriate safety
needle (e.g. AutoShield Duo) to protect against needle stick
injuries. If the nurse is not able to use the pen device or a pen
device is not available they should use a vial and a dedicated
insulin syringe with needle. If a vial preparation is not available,
they should seek advice from Pharmacist or Diabetes Specialist
Nurse. Nurses must NEVER draw up insulin directly from an
insulin pen cartridge or disposable pen device.
6.20.2
Gentamicin and vancomycin
 For neonates the Gentamicin care bundle must be followed.
 Prior to administration the nurse must confirm whether a
level needs to be taken. If a level has already been taken the
nurse must confirm whether the medical team is awaiting the
results of the level before the next dose is administered.
 If the prescription is unclear refer to the antibiotic website or
the prescriber responsible for that patient.
6.20.3
Methotrexate- see separate NUH procedure (appendix to
CLMM013 cytotoxic medicines)
Low Molecular Weight Heparin (LMWH)- therapeutic doses
Before the enoxaparin is administered, the nurse must check:
 the patient’s weight or estimated weight is documented on
the drug chart and/or in the medical notes
 the indication for the LMWH is stated on the drug chart
 the dose is correct for the patient’s weight.
6.20.4
6.20.5
If any of these details are incomplete or incorrect, the nurse must
contact the prescriber or the doctor responsible for that patient.
Opioids
Prior to administration of opioid medicines in anything other than
an acute emergency, the nurse administering must ensure they
are familiar with the following characteristics of that medicine and
formulation:
 usual starting dose
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6.20.6
6.20.7
6.20.8
6.20.9
 frequency of administration
 standard dosing increments
 symptoms of overdose
 common side-effects
Heparin Flushes
Refer to NUH IV administration policy
Oxygen
Refer to CL/MM/032 Medical Gases Policy
Potassium
Refer to CL/MM025 Concentrated potassium and sodium policy
Midazolam
Refer to Conscious sedation policy
7.0
Training and Implementation
7.1
Training
Please refer to the trust’s Training Needs Analysis for details of
training to support delivery of this document.
7.2
Implementation
This is an update to an existing policy and will be implemented
through the existing channels, e.g. nurse induction
7.3
Resources
No additional resources are required
8.0
Trust Impact Assessments
8.1
Equality Impact Assessment
An equality impact assessment has been undertaken on this draft
and has not indicated that any additional considerations are
necessary.
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8.2
Environmental Impact Assessment
An environmental impact assessment has been undertaken on this
draft and has not indicated that any additional considerations are
necessary.
8.3
Here For You Assessment
A Here For You assessment has been undertaken on this document
and has not indicated that any additional considerations are
necessary.
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9.0
Policy / Procedure Monitoring Matrix
Minimum
requirement
to be
monitored
Responsible
individual/
group/
committee
Process
Frequency
for monitoring of monitoring
e.g. audit
Responsible
individual/
group/
committee for
review of
results
Responsible
individual/
group/
committee
for
development
of action plan
Responsible
individual/
group/
committee
for monitoring
of action plan
Undertake
Directorate
level risk
assessment
Individual
Managers
Monitoring of Formal
Risk Register review
annually
Monitoring bimonthly via
ORC
Directorate
Governance
Forum
Directorate
Governance Forum
/ ORC quarterly
Individual
Managers
Review of
DATIX
incidents
Directorate
Governance
Forum and
Individual
managers
Directorate
Governance
Forum
Directorate
Governance Forum
/ ORC
quarterly/Medicines
Safety Group
(standard
template for
‘failure to comply
with legislation
relating to
administration’
available from
MMC)
Review of
incidents
Ongoing
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10.0
Relevant Legislation, National Guidance and Associated NUH
Documents
10.1
List all of the following which are relevant:
1. Legislation
Legislation for midwives (‘midwives rules’). They must comply with:
 The Medicines for Human Use (Miscellaneous Amendments)
Order 2010. SI 2010/1136.
 NMC 2007 Standards for medicines management.
 The current rules and standards are set out in the Nursing and
Midwifery Council (Midwives) Rules 2004 (SI 2004/1764); the
Nursing and Midwifery Council (Midwives) (Amendment) have
subsequently amended Rule 11 Rules 2007 (SI 2007/1887).
 Midwives Rules and Standards (NMC, 2004) and specifically
“Rule 7 – Administration of Medicines”,
 The code: Standards of conduct, performance and ethics for
nurses and midwives (NMC, 2008)
 The Medicines Act (1968),section 52
 The Misuse of Drugs Act (1971),
The full list of midwives exemptions can be found on NMC circular
06/2010.
2. National Guidance
3. Associated NUH Documents(with NUH referencing)
NMC Standards for Medicines Management current edition
NPSA alerts:
 Promoting safer use of injectable medicines
 Risks with Intravenous Heparin flush solutions
 Reducing dosing errors with opioid medicines
 Safer Lithium therapy
 Reducing harm from omitted and delayed medicines in
hospital
 Safer administration of insulin
 Patient safety alert: Methotrexate
Critical drugs list, stored on MMC website
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NUH IV policy, current edition
Policies for administration via the enteral route; adult and paediatric
NUH Positive identification of patients procedure, current edition
NUH guideline for eating and drinking before general anaesthesia or
sedation for surgery, interventional radiology or endoscopy
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Appendix 1: Process for nurses to follow when patient unable to swallow
solid dosage form (i.e. tablet or capsule)
Is medication still necessary?
NO
Omit dose and annotate on blue MM chart
(Discuss with medics)
YES
Urgently contact medical staff and pharmacist
for advice and supply
YES
Is it a medicine on the Critical Drugs List?
NO
Does the patient have a feeding tube e.g.
NG, PEG, Jejunostomy and is it safe to
use?
YES
NO
Consult pharmacist to discuss appropriate
formulation. Don’t give medicines by a feeding
tube without checking it is safe; alternative
doses or routes may be required. Follow local
and national guidance on how to administer.
Follow documented advice on safest oral intake.
Consult pharmacist to discuss appropriate
formulation; alternative doses or routes may be
required and thickener may need to be added.
YES
Have they had a SLT assessment or
nurse dysphagia screen?
.
YES
Is it safe to give oral intake?
NO
Give licensed medication where possible. Discuss
with pharmacist before crushing tablets or opening
capsules. Follow local guidance.
Keep NBM and discuss with medical staff
and pharmacist as soon as possible about
alternative routes e.g. injectable, rectal,
transdermal. Annotate on Medicines
Management chart.
.
The administration of medication via enteral feeding
tubes is likely to be outside of the licensed indications and route of administration in the
product’s summary of product characteristics. The crushing of tablets and opening of
capsules will also place the medicine outside of its product licence. When a medicine is
unlicensed or used in an unlicensed way any untoward event becomes the responsibility of
the prescriber and therefore the Trust.
This appendix ratified by MMC May 2014
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Appendix 2: The following steps must be completed for each drug that is
administered by the ORAL route.
1. RIGHT PATIENT, RIGHT MEDICATION CHART
Ask patient name and date of birth as per NUH Positive identification of patients procedure. Check the patient
name and unique identifying number (i.e. NHS number, N number, S number, K number) on the drug chart
matches the patient’s name and unique identifying number on their wristband.
2.RIGHT DAY & TIME
Check all the pages of the drug chart including ‘once only’ and ‘as required’ sections plus any additional charts
in use to identify which drugs are due on this drug round
check when the last dose was administered
prioritise which drugs should be given first
check the prescription is legible, unambiguous and is signed.
3. CONTRAINDICATIONS
Check the ALLERGY box on the front of the drug chart. This must be completed and signed before any drugs can
be administered.
4. RIGHT DRUG RIGHT INDICATION
Look up any unfamiliar drug names in the BNF/BNF for Children
5. RIGHT ROUTE
Check the route that is prescribed
6. RIGHT DOSE
Check the dose is reasonable refer to the BNF /BNF for Children as appropriate. Check the patient’s weight if
applicable. Contact a pharmacist if there is any doubt. Where necessary complete calculations to establish the
number of tablets /volume of liquid to administer.
7. RIGHT FORM
Select the correct form of the correct drug required (tablet /capsule/liquid)
8. RIGHT STRENGTH
Select the correct strength of drug preparation required
9. RIGHT EXPIRY
Check the expiry date on the product has not passed
10. SECOND CHECK
A second check is required for:
All controlled drugs
All cytotoxics
All administration to children and neonates (under 18 years if nursed in a paediatric area and under 16 years if
nursed in an adult area) unless drugs specifically exempt- see list on MMC website
The second checker is responsible for checking all the steps 1-9
11. RIGHT PATIENT
Recheck the patient’s identification
12. ADMINISTER THE DOSE
Where appropriate follow the manufacturer’s instructions or additional warning labels on the product, e.g. shake
the bottle for liquid medicines.
13. SIGN THE DRUG CHART IMMEDIATELY TO RECORD ADMINISTRATION
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Appendix 3 Medicines administered as a parenteral direct injection or as
a parenteral infusion-REFER TO NUH IV ADMINISTRATION POLICY ALSO
The following steps must be completed for EACH drug that is administered as
a direct injection or infusion
1. RIGHT PATIENT, RIGHT MEDICATION CHART
Ask patient name and date of birth as per NUH Positive identification of patients procedure. Check the
patient name and unique identifying number (i.e. NHS number, N number, S number, K number) on the
drug chart matches the patient’s name and unique identifying number on their wristband.
2.RIGHT DAY & TIME
Check all the pages of the drug chart including ‘once only’ and ‘as required’ sections plus any
additional charts in use to identify which drugs are due on this drug round.
Check when the last dose was administered. Prioritise which drugs should be given first. Check the
prescription is legible, unambiguous and is signed by an authorised prescriber.
3. CONTRAINDICATIONS
Check the ALLERGY box on the front of the drug chart. This must be completed and signed before any
drugs can be administered.
4. RIGHT DRUG RIGHT INDICATION
Look up any unfamiliar medicines in the BNF, BNF for Children or other appropriate reference. Check
that you know the usual reason for giving the medicine, the reason for giving it to this patient and
important side effects. Refer to the medical notes or the prescriber if there is any doubt.
5. RIGHT ROUTE
Check that the medicine can be administered via the intravenous route. Determine whether the
medicine will be administered by direct injection (injection from a hand held syringe), or by infusion (in
an infusion container and administered over a period of time.) The rate of infusion may be controlled
by an infusion device such as a volumetric pump or syringe pump (Refer to Part B of the Nottingham
Guide to Intravenous Therapy, “Essential Technical Information for Intravenous Medicines”, to identify
the most appropriate method.)
6. RIGHT DOSE & RATE
Check the dose is reasonable. Check the patient’s weight if applicable. Refer to the BNF, BNF for
Children, other appropriate reference, pharmacist or the Medicines Information Service (extension
61200 / 64185) if there is any doubt. If an infusion, determine the rate that will be required. Write down
and complete any calculations.
7. RIGHT DILUENT FOR THE INJECTION (if applicable)
If the injection is in powder form, refer to Part B of Nottingham Guide to Intravenous Therapy
“Essential Technical Information for Intravenous Medicines” to identify the diluent and volume
required for reconstitution of the injection
8. RIGHT INFUSION FLUID (if applicable)
If the injection requires further dilution for infusion, refer to Part B of Nottingham Guide to Intravenous
Therapy “Essential Technical Information for Intravenous Medicines” to identify a suitable
concentration and infusion fluid.
9. RIGHT LINE (if applicable)
Check whether the medicine will be administered peripherally or centrally. Peripheral IV access should
be used for IV medicines wherever possible. Central access is essential for administration of some
medicines. Refer to Part B of Nottingham Guide to Intravenous Therapy “Essential Technical
Information for Intravenous Medicines” as necessary.
10. RIGHT DILUTION (if applicable)
Complete calculations to establish the volume of injection and volume of infusion fluid required for the
correct dilution.
11. RIGHT PREPARATION
Select the correct form and strength of the right medicine. Select the correct diluent & infusion fluid if
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required.
12. RIGHT EXPIRY
Check the expiry date of the medicine and diluent has not passed, and for an infusion, that it is
suitable for the prescribed duration of the infusion
13. SECOND CHECK
A second check is required for all parenteral infusions. The only exception is subcutaneous injection
of prophylactic dose low molecular weight heparin, e.g. enoxaparin
The second checker is responsible for checking all the steps 1-12 and 16. For an infusion they must
also:
observe the preparation of the infusion including additions to bag/syringe, step 14
check the pump and the starting rate that has been set are correct, step 15
check the patient’s identity at the patient’s bedside, step 16,
subsequent changes in rate, step 19
sign the prescription for administration, step 20.
14. PREPARE THE DOSE OR INFUSION
If necessary, prepare the dose required as described in Part A of the Nottingham Guide to Intravenous
therapy “Procedure for preparing and administering intravenous medicines”. For infusions, refer to
information in Part B of Nottingham Guide to Intravenous Therapy “Essential Technical Information for
Intravenous Medicines”.
Follow the manufacturer’s instructions, e.g. gently swirl the vial for injections which are in suspension
form
The vials of any unused medicines should be kept until administration to the patient has commenced
and the identity of these should be rechecked as they are discarded
15. SET THE RATE ON THE PUMP (if applicable)
16. RIGHT PATIENT
Recheck the patient’s identification with the second checker at the patient’s bedside
17. START THE INFUSION OR ADMINISTER THE DOSE
18. RIGHT FLUSH (if applicable)
Identify the type of flush that is required after administration and repeat all relevant steps. Heparin
flushes are not required for peripheral cannulae. Saline flushes have to be identified by a second
checker but the administration does not have to be observed by the checker.
19. RIGHT RATE CHANGE (if applicable)
Step 6 must be completed for any rate changes and all rate changes must be second checked. Both
checkers must sign either on the prescription or a monitoring chart. For inotropes in critical care and
uterine stimulants in obstetrics where doses are being titrated to response constantly, the rate must
be second checked and documented at least hourly.
20. SIGN THE DRUG CHART IMMEDIATELY TO RECORD ADMINISTRATION
Both practitioners must sign the prescription. For infusions, this also indicates that the initial rate has
been second checked
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Appendix 4: MIDWIVES RULES TABLE
A table to show how midwives rules are applied at NUH
Separate table available from Medicines Management Committee
Appendix 5: for ‘What involvement students can have in medication preparation and administration’
Separate information available from Medicines Management Committee
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Appendix 6: Equality Impact Assessment (EQIA) Form (Please complete all sections)
Q1. Date of Assessment:
Q2. For the policy and its implementation answer the questions a – c below against each characteristic (if
relevant consider breaking the policy or implementation down into areas)
a) Using data and supporting
b) What is already in place in c) Please state any
Protected
information, what issues,
the policy or its
barriers that still need to
Characteristic
needs or barriers could the
implementation to address
be addressed and any
protected characteristic
any inequalities or barriers to proposed actions to
groups experience? i.e. are
access including under
eliminate inequality
there any known health
representation at clinics,
inequality or access issues to
screening
consider?
The area of policy or its implementation being assessed:
Race and
Ethnicity
Gender
Age
Religion
Disability
Sexuality
Pregnancy and
Maternity
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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Gender
Reassignment
Marriage and
Civil Partnership
Socio-Economic
Factors (i.e.
living in a poorer
neighbour hood
/ social
deprivation)
Area of service/strategy/function
Q3. What consultation with protected characteristic groups inc. patient groups have you carried out?
Q4. What data or information did you use in support of this EQIA?
Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from
surveys, questionnaires, comments, concerns, complaints or compliments?
Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups
identified or to create confidence that the policy and its implementation is not discriminating against any
groups
What
By Whom
By When
Resources required
Q7. Review date
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Appendix 7: Environmental Impact Assessment
The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the
significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b)
implement mitigating actions.
Area of
impact
Environmental Risk/Impacts to consider
Action Taken (where
necessary)
Waste and  Is the policy encouraging using more materials/supplies?
materials
 Is the policy likely to increase the waste produced?
 Does the policy fail to utilise opportunities for
introduction/replacement of materials that can be recycled?
Soil/Land  Is the policy likely to promote the use of substances
dangerous to the land if released (e.g. lubricants, liquid
chemicals)
 Does the policy fail to consider the need to provide adequate
containment for these substances? (e.g. bunded containers,
etc.)
Water
 Is the policy likely to result in an increase of water usage?
(estimate quantities)
 Is the policy likely to result in water being polluted? (e.g.
dangerous chemicals being introduced in the water)
 Does the policy fail to include a mitigating procedure? (e.g.
modify procedure to prevent water from being polluted;
polluted water containment for adequate disposal)
Air
 Is the policy likely to result in the introduction of procedures
and equipment with resulting emissions to air? (e.g. use of a
furnaces; combustion of fuels, emission or particles to the
atmosphere, etc.)
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Energy
Nuisances
 Does the policy fail to include a procedure to mitigate the
effects?
 Does the policy fail to require compliance with the limits of
emission imposed by the relevant regulations?
 Does the policy result in an increase in energy consumption
levels in the Trust? (estimate quantities)
 Would the policy result in the creation of nuisances such as
noise or odour (for staff, patients, visitors, neighbours and
other relevant stakeholders)?
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Appendix 8: We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit
The We Are Here For You service standards have been developed together with more than 1,000 staff and
patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe
and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but
with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their
inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization.
Please rate each value from 1 – 3 (1 being not at all, 2 being affected and 3 being very affected)
Value
Score (13)
1.
Polite and Respectful
Whatever our role we are polite, welcoming and positive in the face of adversity, and are always
respectful of people’s individuality, privacy and dignity.
2.
Communicate and Listen
We take the time to listen, asking open questions, to hear what people say; and keep people
informed of what’s happening; providing smooth handovers.
3.
Helpful and Kind
All of us keep our ‘eyes open’ for (and don’t ‘avoid’) people who need help; we take ownership of
delivering the help and can be relied on.
4.
Vigilant (patients are safe)
Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates
attention to detail for a clean and tidy environment everywhere.
5.
On Stage (patients feel safe)
We imagine anywhere that patients could see or hear us as a ‘stage’. Whenever we are ‘on stage’
CL/MM/008 Administration of Medicines Policy (excluding IV administration) version 7, February 2016
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we look and behave professionally, acting as an ambassador for the Trust, so patients, families and
carers feel safe, and are never unduly worried.
6.
Speak Up (patients stay safe)
We are confident to speak up if colleagues don’t meet these standards, we are appreciative when
they do, and are open to ‘positive challenge’ by colleagues
7.
Informative
We involve people as partners in their own care, helping them to be clear about their condition,
choices, care plan and how they might feel. We answer their questions without jargon. We do the
same when delivering services to colleagues.
8.
Timely
We appreciate that other people’s time is valuable, and offer a responsive service, to keep waiting to
a minimum, with convenient appointments, helping patients get better quicker and spend only
appropriate time in hospital.
9.
Compassionate
We understand the important role that patients’ and family’s feelings play in helping them feel better.
We are considerate of patients’ pain, and compassionate, gentle and reassuring with patients and
colleagues.
10. Accountable
Take responsibility for our own actions and results
11. Best Use of Time and Resources
Simplify processes and eliminate waste, while improving quality
12. Improve
Our best gets better. Working in teams to innovate and to solve patient frustrations
TOTAL
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Appendix 9
CERTIFICATION OF EMPLOYEE AWARENESS
Document Title
CL/MM/008 Administration of Medicines Policy
(excluding IV administration)
Version (number)
7
Version (date)
5 February 2016
I hereby certify that I have:
 Identified (by reference to the document control sheet of the above
policy/ procedure) the staff groups within my area of responsibility to
whom this policy / procedure applies.
 Made arrangements to ensure that such members of staff have the
opportunity to be aware of the existence of this document and have the
means to access, read and understand it.
Signature
Print name
Date
Directorate/ Divisions
The manager completing this certification should retain it for audit and/or other
purposes for a period of six years (even if subsequent versions of the
document are implemented). The suggested level of certification is;
 Clinical divisions- general manager or nominated deputy
 Corporate directorates - deputy director or equivalent.
The manager may, at their discretion, also require that subordinate levels of
their directorate / department utilize this form in a similar way, but this would
always be an additional (not replacement) action.
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