Copyright EMAP Publishing 2020 This article is not for distribution except for journal club use Clinical Practice Keywords Medicines management/ Administration/Oral routes Practical procedures Medicines management Medicines administration 2: procedure for administration of oral medicines

he administration of medicines understanding the causes of these errors Authors Martin Shepherd is clinical is one of the most common pro- can help minimise their occurrence and director of pharmacy and therapy, cedures nurses undertake and guide interventions. They identified sev- Chesterfield Royal Hospital NHS the process is often complex and eral reasons why errors occur, including: T l  Foundation Trust; Eileen Shepherd is time consuming. Organisations will have Misidentification of a medicine; clinical editor, Nursing Times. their own policies and procedures that l Misidentification of a patient; govern the administration of medicines l Lack of knowledge; Abstract The administration of and nurses should be familiar with these; l Poorly written prescriptions, medicines can be a complex and staff who administer medicines should documentation and/or transcription; time-consuming procedure that receive appropriate training and have a l Medicine supply and storage problems; requires knowledge of the medicine competency assessment before carrying l Staff inexperience and lack of training; being administered and its intended out the procedure. l High workload and problem of fatigue therapeutic effect. This second article in The administration of prescribed medi- and stress among staff; a two-part series outlines the principles cines can be carried out by any suitably l Inappropriate skill mix among staff; of medicine administration and the trained and competent member of staff in l Lack of ward-based equipment; procedure for doing so using the oral health or social care. Registered health l Interruptions/distractions. route. Part 1 provided an overview of professionals, such as nurses and doctors, When an error or a near miss occurs, it the routes of administration. are accountable for tasks they delegate to is important that nurses report it immedi- non-registered staff and must ensure that ately, in line with local policy. This will: Citation Shepherd M, Shepherd E non-registered staff who administer medi- l Ensure appropriate care is delivered to (2020) Medicines administration 2: cines are competent. It is important to the patient; procedure for administration of oral remember that when a task is delegated, l Allow the factors contributing to the medicines. Nursing Times [online]; 116: non-registered staff are also accountable error to be explored and, if necessary, 7, 42-44. for their own practice (Royal Pharmaceu- action to be taken to reduce the risk of tical Society and Royal College of Nursing, error recurring in the future. 2019; Specialist Pharmacy Services, 2018). Adherence and concordance Professional responsibilities Risks and avoiding errors Adherence This procedure should be undertaken The procedure for the administration of Although the term ‘compliance’ was previ- only after approved training, supervised medicines involves a number of risks. If ously used to describe patients taking practice and competency assessment, they are to avoid error, nurses need to be medicines as prescribed, the term is now and carried out in accordance with local familiar with the medicines they are considered paternalistic and the term policies and protocols. administering – the information they are ‘adherence’ is more commonly used required to know is outlined in Box 1. (Aronson, 2007). The National Institute for Several systems have been devised to Health and Care Excellence (2009) sug- help health professionals consider the key gests that adherence relates to an agree- aspects of medicines administration in ment about prescribed medicines between which an error(s) can occur. These are often prescriber and patient and “defines the referred to as ‘rights’; one commonly used extent to which the patient’s action version – ‘the five rights’ – is given in Box 2. matches the agreed recommendations”. Medicine administration errors occur Adherence is difficult to measure; how- for a number of reasons. In a systematic ever, it has been estimated that between a review, Keers et al (2013) noted that third and a half of all medicines for long- Box 1. Knowledge needed for term conditions are not taken as intended medicines being administered Box 2. The ‘five rights’ of (NICE, 2009). Non-adherence can be: medicine administration l Unintentional – the patient forgets to l The reason the medicine is take a prescribed medicine; prescribed (therapeutic use) l Right patient l Intentional – the patient consciously l Usual dose l Right medicine decides not to. l Side-effects l Right route The causes of non-adherence are com- l Precautions and contraindications l Right time plex and include: l Route of administration l Right dose l Polypharmacy; l Complicated dose regimens;

Nursing Times [online] July 2020 / Vol 116 Issue 7 42 www.nursingtimes.net Copyright EMAP Publishing 2020 This article is not for distribution except for journal club use Clinical Practice Practical procedures l Unpleasant side-effects; Fig 1. Patient details and allergy status l Cognitive problems or physical CS2 PRESCRIPTION/2020 disability preventing the patient from taking the medicines. Meadow East NHS Trust Allergies If a patient is non-adherent, the medi- cine should be reviewed to assess its: None reported by patient l Appropriateness – is it still required? CS2 PRESCRIPTION/2020 l Safety – is it likely to interact with any Name: Una Chung Hospital No: 867564 Signed: J Harrison other medicines? l Effectiveness – is the patient taking it? MeadowWeight: 53Kg EastHeight: 145cm NHSDoB: Trust 4/11/1952 Date: 10/6/20Allergies l Acceptability – does the patient Regular Prescriptions understand and agree with the need for Check the patient details on the prescription areNone complete reported and theirby patient allergy status Year Date & Month Date the medicine? Name:2020 Una Chung10 June Hospital TimeNo: 867564 Signed: l Regimen clarity – does the patient Drug 07.00 J Harrison Gliclazide 09.00 understand the regimen? Weight: 53Kg Height: 145cm DoB: 4/11/1952 Date: FigDose 2. MedicineRoute Start date prescription Valid period 12.00 10/6/20 l  Side-effects – is the patient 40mg PO 10/6/20 14 days 14.00 experiencing unpleasant side-effects? Signature Dispensed Regular18.00 Prescriptions Medicines that are required should be YearJ Harrison Date10/6/20 & Month Date22.00 given in the smallest appropriate dose and 2020Additional comments10 June Time Drug 07.00 in a form that reduces the number of daily GliclazideDrug 09.0007.00 doses to a minimum. DoseGabapentin Route Start date Valid period 12.0009.00 40mgDose PORoute 10/6/20Start date 14Valid days period 14.0012.00 Concordance Signature1.2g PO Dispensed10/6/20 14 days 18.0014.00 Signature 10/6/20Dispensed 10/6/20 22.0018.00 Concordance describes a shared process J Harrison AdditionalJ Harrison comments 22.00 leading to an agreement between the Additional comments patient and prescriber about the aims of Drug 07.00 Check the medicine prescription includes07.00 all relevant details their treatment and how these can be GabapentinDrug 09.00 DoseCitalopram Route Start date Valid period 12.0009.00 achieved (Aronson, 2007). An important 1.2gDose PORoute 10/6/20Start date 14Valid days period 14.0012.00 part of this process is the quality of the SignatureNurses40mg PO shouldDispensed10/6/20 also 10/6/20 be14 days aware 18.00of14.00 local Infection prevention precautions information patients are given to inform reportingJ SignatureHarrison systems. Dispensed 22.0018.00 Non-sterile gloves are not required rou- AdditionalJ Harrison comments10/6/20 22.00 their decisions. Patient information leaf- Additional comments tinely for this oral administration proce- Administration of oral medicines lets (PILs) must be given with every medi- Drug 07.00 dure. Nurses need to assess individual cine supplied to patients – however, TheCitalopramDrug oral route is the most frequently09.0007.00 used patients for the risk of exposure to blood Penicillin V 09.00 research that examined the content of 100 routeDose of Routemedicine Start dateadministration, Valid period 12.00 as well and body fluids (Royal College of Nursing, 12.00 40mgDose PORoute 10/6/20Start date 14Valid daysperiod 14.00 PILs suggests that many of these leaflets as being1g POthe most10/6/20 convenient14 days and14.00 cost- 2018) and to be aware of local policies for Signature Dispensed 18.00 Signature Dispensed 18.00 do not communicate information about effective (Dougherty10/6/20 and Lister,22.00 2015). glove use. J Harrison 10/6/20 22.00 the rationale and benefits of treatment ManyAdditionalJ Harrison oral comments medicines are given in solid- (Dickenson et al, 2017). As such, it is essen- doseAdditional forms comments such as tablets and capsules, Equipment Drug 07.00 l  tial that when patients are given informa- whichDrug have a high degree of stability07.00 and Prescription; Penicillin V 09.00 tion they have an opportunity to discuss it provideZopiclone accurate dosage. However, 09.00the oral l Disposable medicines container; Dose Route Start date Valid period 12.00 Dose Route Start date Valid period 12.00 with a knowledgeable health professional. route1g canPO be problematic10/6/20 14 days because14.00 of the l Medicines to be administered. 7.5mg PO 10/6/20 14 days 14.00 unpredictableSignature Dispensednature of gastrointestinal18.00 Signature Dispensed 18.00 10/6/20 22.00 Adverse reactions absorptionJ Harrison (see Part10/6/20 1). 22.00 The procedure AdditionalJ Harrison comments All medicines are evaluated to assess their SomeAdditional patients comments find tablets and other 1. Review the patient’s notes and prescrip- safety, but no medicine is entirely risk free. solid-doseDrugN I G H T forms S difficult to take07.00 and, on tion. Check that the details on the pre- Nurses should be aware of: occasion,Zopiclone a liquid formulation might09.00 be scription are complete, including the l Any potential problems patients may moreDose appropriateRoute Start dateor an Valid alternative period 12.00 medi- patient’s name, hospital number, date of experience when taking a medication; cine7.5mg mayPO need10/6/20 to be14 considered.days 14.00 This birth and allergy status (Fig 1). Signature Dispensed 18.00 l  How and when to report suspected shouldJ Harrison be discussed10/6/20 with the prescriber22.00 reactions. andAdditional pharmacist. comments If a patient finds oral 2. Check that the prescription is unambig- In the UK, the Yellow Card Scheme (yel- dosesN I G Hdifficult T S to tolerate, it can be uous/legible and includes the medicine lowcard.mhra.gov.uk) collects and moni- tempting to crush tablets. However, this is name, form (and/or route of administra- tors information on suspected safety con- usually outside of the product licence and tion), strength and dose of the medicine to cerns or incidents involving medicines nurses must seek advice from a pharma- be administered (RPS and RCN, 2019). and medical devices. The scheme is run by cist or the prescribing doctor to ascertain Check the date and time when it should be the Medicines and Healthcare products whether it is safe to do so (Dougherty and administered, that the prescription is Regulatory Authority and relies on volun- Lister, 2015). Modified-release tablets must signed and includes a start and finish date, tary reporting of suspected adverse drug not be crushed or broken as the medicine – if appropriate (Fig 2). A medicine should reactions by health professionals and which should be released over a period of not be administered if there are any con- patients; it aims to provide an early time – may be absorbed immediately, cerns about the prescription; any such warning that the safety of a product may leading to toxicity, or not absorbed at all, concerns should be discussed immediately require further investigation. leading to suboptimal treatment. with the prescriber.

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Fig 3. Select medicine and dose Fig 4. Check patient’s identity

Take the medicine and prescription to the patient and check the patient’s identity. Check Gliclazide their wristband according to local 40mg tablets policy and ensure they Text Lot number XXXXXX state their name and Manufacturer date 09/05/2020 date of birth, rather Expiry date 08/05/2022 than simply confirming any details they are given CS2 PRESCRIPTION/2020

Meadow East NHS Trust Allergies Select the medicine and check the dose against the prescription chart and the expiry date on the packaging None reported by patient Name: Una Chung Hospital No: 867564 Signed: J Harrison 3. Ensure you know why the medicine is FigWeight: 5. 53KgRecordHeight: medicine 145cm DoB: 4/11/1952 administrationDate: 10/6/20 being administered and are aware of potential complications associated with Regular Prescriptions administration (Box 1). If necessary, ask for Year Date & Month Date 10/6 advice from the prescriber or a pharmacist 2020 10 June Time 20:20 07.00 (RPS and RCN, 2019). Drug Gliclazide 09.00 JH Dose Route Start date Valid period 12.00 4. Check the medicine has not been given 40mg PO 10/6/20 14 days 14.00 to the patient and signed for by another Signature Dispensed 18.00 J Harrison 10/6/20 22.00 member of staff. Additional comments

07.00 5. Decontaminate your hands in line with ImmediatelyDrug record that the medicine has been administered according to local policy local policy. Gabapentin 09.00 Dose Route Start date Valid period 12.00 1.2g PO 10/6/20 14 days 14.00 6. Discuss with the patient the medicine theirSignature name, hospitalDispensed number 10/6/20 and18.00 date of their medicine, this should be documented you are going to give to them and gain birth.J Harrison Check their wristband according22.00 to along with the reason for omission; the their verbal consent to administer it. This localAdditional policy comments (Fig 4). It is important to ask prescriber should also be informed. NT is an ideal opportunity to answer any ques- the patient to state, rather than confirm, Drug 07.00 References tions the patient has about their treatment their name and date of birth. 09.00 Citalopram Aronson JK (2007) Compliance, concordance, and check their understanding of the med- Dose Route Start date Valid period 12.00 adherence. British Journal of Clinical icine regimen. 13.40mg CheckPO whether10/6/20 the14 dayspatient 14.00has any Pharmacology; 63: 4, 383-384. allergiesSignature or previousDispensed adverse drug18.00 reac- Dickenson R et al (2017) How much information J Harrison 10/6/20 22.00 about the benefits of medicines is included in 7. Position the patient comfortably so they tionsAdditional (RPS comments and RCN, 2019). If you have con- patient leaflets in the European Union? A survey. can swallow the medicine. cerns, discuss these with the prescriber International Journal of Pharmacy Practice; 25: beforeDrug administering the medicine.07.00 2, 147-158. 8. Decontaminate your hands. Penicillin V 09.00 Dougherty L, Lister S (2015) The Royal Marsden Dose Route Start date Valid period 12.00 Manual of Clinical Nursing Procedures. Wiley- 14.1g AdministerPO 10/6/20 the medicine.14 days 14.00 Blackwell. 9. Select the medicine and check the expiry Signature Dispensed 18.00 Keers RN et al (2013) Causes of medication date (Fig 3). 15.J Offer Harrison a drink10/6/20 of water to help the22.00 patient administration errors in hospitals: a systematic Additional comments review of quantitative and qualitative evidence. swallow the medicine if this is allowed, Drug Safety; 36: 11, 1045-1067. 10. If calculations are required and you are andDrug ensure they have swallowed it.07.00 National Institute for Health and Care Excellence concerned about accuracy, these should be Zopiclone 09.00 (2009) Medicines Adherence: Involving Patients in double-checked by a second person and 16.Dose Dispose Route of Startthe medicinedate Valid period pot according12.00 Decisions about Prescribed Medicines and Supporting Adherence. London: NICE. any concerns raised with the prescriber or to 7.5mglocal policy.PO 10/6/20 14 days 14.00 Signature Dispensed 18.00 Royal College of Nursing (2018) Tools of the Trade: a pharmacist (RPS and RCN, 2019). 10/6/20 22.00 Guidance for Health Care Staff on Glove Use and J Harrison the Prevention of Contact Dermatitis. London: RCN. 17.Additional Decontaminate comments your hands. Royal Pharmaceutical Society and Royal College 11. Decant the required dose into a medi- N I G H T S of Nursing (2019) Professional Guidance on the cine pot, avoiding touching the medicine. 18. Immediately record that the medicine Administration of Medicines in Healthcare Settings. has been administered (RPS and RCN, London: RPS. Specialist Pharmacy Services (2018) Medicines 12. Take the medicine and prescription to 2019) (Fig 5). Matters: A Guide to Mechanisms for the the patient and check the identity of the Prescribing, Supply and Administration of

ALAMY patient against the prescription using 19. If the patient refuses or is unable to take Medicines (in England). SPS.

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