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Medicines Management
Training Day for Nurses
Aims of the session
•Introduction of the medicines code
•Recent developments in therapeutics
•New policies and updates in the recent changes
Several areas are not going to be discussed today but
presentations are available on request should you be
interested.
If at any point you feel that we are speaking too quietly or
the fonts used are too small, please do not hesitate to let
us know
And now…
SAFETY PROCEDURES!!
The Medicines Code
and Related Issues
The Medicines Code
•Over 100 pages of policies and procedures
•On the intranet
•First point of referral for advice
How many of you have seen it?
•We will be accessing the Medicines Code online later in
the day.
Disposal of Medication
•Letter of authority to remove CDs from wards
•CDs will be destroyed or removed from wards by pharmacists.
•Removal/destruction should be recorded in CD register
•Consult the pharmacy team for information on disposing and
returning of medications, as current practice is under review.
Dispensing & Handling.
Medicines Core Standards
For Community Teams
•Core standards for selected community teams are
published in the Medicines Code.
•Covers aspects such as ordering, storage, transport and
dispensing.
•Nurse dispensing competency assessment has been
rolled out across the Trust.
Handing Out / Delivering
Medicines in the Community
•Non-nurses can undertake this role.
•If the medication is new the authorized employee must make
sure:
There is a patient information leaflet provided with the
medication
The service user is advised that further information can
be obtained from their care co-ordinator
The medicines are bagged, labelled (with name and
address of patient) and sealed

Handing Out / Delivering
Medicines in the Community
•The service user or agreed deputy is known or clear
identification is provided.
•The service user is made aware that no advice on the
medicines can be provided.
•That there is no risk to the non-nurse should they decide
not to hand over the medicines.
•The non-nurse has the right to refuse to undertake the
role.
Covert Administration of
Medicines in Adults - 1
•Adults with capacity have the right to decline medication
unless detained under the Mental Health Act.
•If an adult who lacks capacity spits out or refuses
medication, as a last resort, a best interest decision can be
made by the MDT, involving the next of kin / advocate if
possible, to administer essential medicines.
•The advice of a pharmacist should be obtained to explore
other strategies. This should be obtained retrospectively
even if covert administration is used initially.
Covert Administration of
Medicines in Adults - 2
•A Covert Administration Nursing Care Plan to record the
decisions of the MDT is available on the Intranet and as an
appendix to the Medicines Code.
•A review of the decision must take place at least annually
on long stay units and at least monthly on acute units. A
review must also take place if there is a change in
capacity.
Section 58
•Outlines the requirements for treatment that requires
informed consent, or a second opinion from another
doctor (SOAD) that the treatment is necessary and in the
patient’s best interests.
•Consent or SOAD must be obtained if 3 months have
elapsed since first treated during a current period of
detention. Applies to medication and to ECT, (different
forms).
•Form T2 – consent has been given, (to medication).
•Form T3 – consent has not been given, (to medication).
Nurse Dispensing
•Should be to the same standards as a pharmacy department.
•This includes - one person dispensing alone then a second
person coming afterwards checking all the details. It is not a
shared job!
•CDs are excluded… (Temazepam)
•Training is available for ward staff and community teams.
•If not trained, a separate procedure applies limiting the
quantity dispensed to cover for up to 72 hours (or 96 hours to
cover a bank holiday).
Remote Prescriptions I
•The NMC no longer supports the taking of verbal orders
unless backed up by an electronic confirmation, ideally a fax
or email (from the prescribers own email account) and in
exceptional circumstances a text message. This message
must be retained on the mobile receiving it until the
prescription is countersigned by prescriber or deputy and the
message copied verbatim into the patient’s notes.
•Remote prescriptions are for exceptional circumstances only.
•Nurses have the right to refuse a remote prescription.
Remote Prescriptions II
•Controlled Drugs (inc. temazepam) cannot be remotely
prescribed. Other benzodiazepines can.
•The medication should have previously been prescribed…
exception of palliative care or in isolated units where remote
prescribing of new drugs can take place in very exceptional
circumstances.
•The prescriber must have details of all the medicines
currently prescribed. Ask if there are any contra-indications or
side-effects associated with the new medication.
Remote Prescriptions III
•The prescription must be read back to the prescriber,
preferably by a second person.
•The remote prescription must be correctly documented
on the drug chart and in the service user’s notes.
•Remote prescriptions have a limited validity. As
required drugs should be single stat dose. Regular
prescriptions are limited to a maximum of 72 hours,
though should ideally be signed within 24 hours.
See Medicines Code for further details…
Medication Errors
•Reporting errors (and near misses) is extremely important.
Other teams might be facing similar problems.
•Reporting is now online across the Trust.
•Actions taken in response to incident
Better documentation
Improved training & new / improved systems
•Disciplinary action is extremely unusual and is only
considered if the incident involves reckless practice or if
attempts are made to cover up the error.
Real Examples of Trust Errors
“When I went to administer the patients medication I
noticed that one drug had not been given for the last five
days. On checking the prescription I found that the doctor
had omitted to specify what time(s) the drug should be
given. It appeared that no-one had bothered to find out
from medical staff what was intended. Because of this
several different nurses had followed the previous
administration gap and just omitted to give it”.
Always read the prescription – don’t rely on or copy what
a nurse did before you – you are responsible !
Real Examples of Trust Errors
“When a patient went out on a days leave I packed the
medication for him using the approved procedure but
omitted to fill in the drug chart with the correct codes.
Instead I just left blanks for the day. The following day
nursing staff did not administer any medication as they
assumed the previous day’s non-administration
(according to the chart) was deliberate and should
continue”.
If unsure, get clarification – don’t rely on or copy what a
nurse did before you – you are responsible !
Real Examples of Trust Errors
“I administered the patients teatime dose of Co-Codamol
at 5pm but then noticed that the lunchtime dose had
been delayed and wasn’t actually given until 3pm.
Therefore, there had only been two hours between the
doses”.
Always read the medication chart very carefully at each
administration time, for every drug, and ensure you
check the record of administration as well as the
prescription. Do not assume that previous medication
rounds went according to schedule.
Real Examples of Trust Errors
“I gave the patient their evening 5mg dose of donepezil,
then noticed that the patient had a second chart with a
prescription for donepezil 10mg on it, also in the evening.
The administration record showed that both these doses
had been given on the last two nights. On checking with
the nurse in charge I was told that the 5mg dose should
have been cancelled when the larger dose was written”.
Even though originally a prescribing error, nurses on the
previous evenings should have viewed the prescriptions
holistically and questioned why there were prescriptions
for the same drug, in different doses, on two charts.
Real Examples of Trust Errors
“When I was assisting a patient with daily care I found
two Fentanyl patches attached. They were both the
same strength and on checking the prescription it was
found that only one was prescribed. It seems that the
nurses administering the last patch hadn’t removed the
one from three days before”.
It appears that the new patch was adhered to a fresh
area before removing the previous one that was then
forgotten. With transdermal patches best practice is to
remove the used patch before administering the new
one.
Real Examples of Trust Errors
“A healthcare assistant came back from delivering
medicines to a community patient but they had not been
at home. The HCA reported that he had therefore left the
medicines with a neighbour and put a note through the
patients letter box to explain. However, on checking the
patients care plan, there was nothing to authorise leaving
medication with a neighbour if delivery wasn’t possible”.
Any contingency plans around delivering medication to
community patients must be fully agreed within the team
and with the patient beforehand and must be
documented. Ad hoc delivery to a third party could be
dangerous and so must not occur.
Real Examples of Trust Errors
“At the time of the patients discharge I issued the bag of
TTO medicines that had come up from pharmacy to the
patient and their carer. A few hours later the carer
phoned the ward to report that some of the medicines in
the bag had another patients name on them. However,
thankfully, no incorrect administration had occurred”.
This was originally a pharmacy supply error and that was
investigated within the dispensary. However, it was also
a nursing error as the contents of the TTO bag should
have been checked before issue and also the (correct)
content discussed and explained to the patient / carer.
Real Examples of Trust Errors
“Instead of administering my patient with a test dose of
zuclopenthixol depot I accidentally selected a dose of
flupenthixol and administered that instead”.
Great care is needed when reading prescriptions and
also when selecting medication to be administered, as
many drug names sound / look the same and a lot of
medication packaging is also very similar.
Amisulpride / Sulpiride. Promazine / Promethazine.
Zolpidem / Zopiclone. Escitalopram / Citalopram.
Fluoxetine / Paroxetine.
Real Example of a Catalogue of Errors !
A junior doctor who was asked by his consultant to start
mirtazapine at dose of 15mg, misheard and wrote it up at
a dose of 50mg.
Error 1 – the junior doctor did not check the dose of a
medication he was unfamiliar with.
Error 2 - a nurse, who whilst recognising that 50mg was
not a valid dose, did administer and record a 45mg dose,
(that being closest to the dose prescribed).
Error 3 - This was repeated by a second nurse over the
weekend ! On the Monday, the patient complained of
dizziness and nausea and all was discovered.
Discussion
•Why don’t nurses fill in more medication error reports?
•Only around 20 administration errors are reported each
month across the Trust. Intensive reporting weeks have
demonstrated that the actual number occurring is probably
closer to 600 per month. (Includes administration record
omissions).
•Why are doctors (prescribing) errors reported even less?
•Only between 3 and 6 prescribing errors are reported each
month across the Trust. Intensive reporting weeks have
demonstrated that the actual number occurring is probably
closer to 200 per month.
Accessing Trust medication
guidance on Intranet
Volunteers Please!