Content

Department Name: Musgrove Park Hospital

Process Name: Inpatient administration as is

Change History: Version Draft Date Author Comments 0.1 Y 04/04/13 David Chalkley 0.2 Y 04/04/13 David Chalkley 0.3 N 18/04/13 David Chalkley Index

1 Map 1 High level map Patient specific directions PSDs

2 Map 2 Rx selection Patient group directions PGDs

PPG 3 Map 3 Rx review Protocols /Policies/Guidelines list

ME 4 Map 4 Clinical checks – Drug appropriateness Medical Emergency list

TPDA 5 Map 5 Clinical checks – Patient factors Two person drug administration list

D(AS) 6 Map 6 Preparation of medication Documentation (area specific) list

7 Map 7 Pre-administration checks

8 Map 8 Administration

9 Map 9 Documentation

10 Map 10 Emergency administration

11 Map 11 Referral to prescriber/transcriber/clinical lead

12 Map 12 Withholding medication

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Author: David Chalkley Version: 0.3 Map 1 – Administration As Is – High level map

Rx = Authorisation to administer

s s e c o r p

y s e p K

e - t Start Patient requires Clinical check of Rx Preparation of Pre-administration Administration and Documentation Process

s Obtain Rx

e Process dose of medication and patient medication checks monitoring Ends d i w

t s u r T

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 2 – Administration As Is – Rx Selection

Rx = Authorisation to administer, PSD = Patient specific direction, PGD = Patient group direction, PPG = Policy/protocol/guideline, Medical emergency list

Patient medication Nurse selects Rx due/required from PSD Clinical check of PSD Rx and patient Or list 2 1 Nurse considers Start Patient requests a Nurse selects Nurse uses PGD Nurse reads Rx appropriateness of s Process dose of medication Go to Map 3

p appropriate Rx as a Rx administration e

t PGD s Or list s s

e This could be a text

c Emergency Nurse follows

o message or email – e.g.

r administration protocol/policy/

p remote prescribing policy

required guideline y

e PPG

K list

Emergency -

Administration e only d i Medical emergency w

t no written Rx Go to Map 10 s

u ME

r Maps do not cover the administration of

T injectable chemotherapy, blood products list 1 or radioactive isotopes

Nurses do the majority of administration with in the trust, however other groups of staff do administer drugs, including: Doctors, midwives, ODPs, radiographers, 2 optometrists, physiotherapists & physiologists. The maps are applicable to administration by these groups of staff

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 3 – Administration As Is – Clinical checks – Rx review

Rx = Authorisation to administer s p e

t Nurse refers Rx s

back to prescriber/

s transcriber/author/ Go to Map 11 s

e clinical lead c o

r No p

y

e Nurse to clinically Appropriate to K

check Nurse Reviews Rx Yes

- From Map 2 continue? Go to Map 4 appropriateness e d i w

t s u r T s

w Rx must be legible, Additional e

i Rx must be

v legal & endorsements

e clinically accurate

r unambiguous clear and accurate

x R

E.g. dose within E.g. Weekly expected limits, administration frequency within states day expected range..etc.

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 4 – Administration As Is - Clinical checks – Drug appropriateness

Rx = Authorisation to administer

s s e

c Refer or

o Nurse experience will Withhold Refer r Go to Map 12 withhold Go to Map 11

p determine the depth to

y which they can review s e appropriateness No p K

e - t

s

e Nurse considers Appropriate to d

i appropriateness of Yes From Map 3 continue? Go to Map 5 w drug selection

t

s E.g. Enoxaparin u r and dabigatran T

w Check for clinically e

i Check for clinically Check for clinically

v significant side Check for clinically Check for duplicate significant relevant e effects from significant drug- drugs/drug classes r

cautions / therapeutic levels

g previous drug interactions or overdose risk contraindications or blood results u administration r D

e c i o w Consider clinical h e Consider protocol/ i

c appropriateness of

v policy/guidelines g e drug selection r u r D

Clinical experience of a nurse may mean they know of a more suitable treatment for a given scenario. Junior nurses knowledge and experience will limit the frequency of this type of intervention

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 5 – Administration As Is - Clinical checks – Patient factors

Rx = Authorisation to administer s p e t Nurse/Patient s

Refer or select route of Withhold Refer s Go to Map 12 withhold Go to Map 11 s administration e c

o Yes r No p

y Nurse considers Is there a Nurse check route Nurse checks Administration e Appropriate to

K patient specific choice of No of administration is patient consents to Yes clinically From Map 4 continue? Go to Map 6 - factors

route? available administration appropriate e d i w

t s u r T

c i w f i e c i v e Check patient e p Check whether r s Check allergy clinical condition

additional Rx’s are s t

r status and relevant n required o

e observations t i t c a a f P

E.g. domperidone with apomorphine

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 6 – Administration As Is – Preparation of medication

Rx = Authorisation to administer, CD = Controlled drug

Nurse refers Rx back to prescriber/ Go to Map 11

s clinical lead p e t No s

s s

e Nurse obtains Can drug be c Yes medication in a

o obtained? r timely manner p

y

e No K

- Drug ready and e Preparation of drug Is the drug Nurse prepares

d Yes Nurse reads Rx equipment ready i From Map 5 required available? drug Go to Map 7 for administration w

t s u r T n o i

Obtain/read and t Adhere to hand g

a Gather drug and follow up to date Drug prepared for u r hygiene and r

a equipment monograph/SPC/ administration

D aseptic technique p instruction leaflet e r p Not all drugs Not all drugs

s Perform Put on protective CD register entry s Check compatibility nd e And calculations and And Programme And equipment / follow 2 check of And made (not c information prior to nd

o / Or get 2 check by / Or equipment / Or any safety preparation / Or completed) r mixing any drugs

p Nurse/doctor requirements

nd n

i 2 No s check n o i

t Compatibility a

i Yes

r issue? a V

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 7 – Administration As Is – Pre-administration checks

Rx = Authorisation to administer

Go to Map 11

Refer

Refer or From Map 6 Withhold Go to Map 12 withhold? s p e

t No s

s Nurse checks Nurse checks dose s Pre-administration Nurse checks drug Nurse checks Nurse checks dose Nurse checks

e patient is due for Safe to

c bedside checks is correct against allergy status with is correct against route is correct identification administration administer? o needed

r Rx patient Rx against Rx against Rx against Rx p

y Yes e K

-

Nurse provides e patient with drug d i information w

t s u r T Checks complete, Not all drugs Only if using pump safe to administer

Go to Map 8

n i

s s s

n Bedside checks Check of pump

e nd o i c with 2 checker setting

t nd o

a 2 r i r p check a V

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 8 – Administration As Is - Administration

IV = Intravenous s

p Go to Map 11 e t s

s

s Yes e

c Nurse administers Referral to o Correct drug is r drug via correct Nurse observes prescriber/ Administration p administered to No From Map 7 route over correct patient clinical lead complete Go to Map 9 y correct patient

e time frame needed? K

- Not all drugs

e d i w

t s

u Not all drugs r T

E.g. Bisphosphonates with glass of water, flush of some IV lines

s Specific Response to Specific s Post administration etc.

e observations therapy Dose titrated to observations

c instructions carried out during documented carried out after o response

r followed administration administration p

n i Observations Observations

s Adjustments to

n documented on therapy documented on o i obs chart, notes or documented on obs chart, notes or t a

i specific chart appropriate specific chart r

a administration

V record

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 9 – Administration As Is - Documentation

PSD = Patient specific direction, LD = Local document, CD = Controlled drug

Nurse records administration on

s PSD document p e

t PSD s

list

s Or s

e Nurse to record Nurse records Nurse creates c Select

o administration on administration on legal record of r document to area specific administration – Process p appropriate From Map 8 record Ends

y administration document Signing and dating administration e record LD K

- list

Or e d i Nurse records w

administration in t

s medical notes u r T

Not all drugs

l s a

e CD register n s Drug o s

i completed and e t administration i

c signed by 2 d

o signed twice r

d nurses p A

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 10 – Administration As Is - Emergency administration

MAR = Medication administration record

All steps carried out by either

s nurse or doctor p e

t Drug prepared as s

per verbal

s Drug required to be Patient instruction / Allergy status 2nd check of correct 2nd check of correct s administer in a identification e From Map 2 following checked drug dose

c medical emergency checked information leaflet o r or guideline p

y e

K Administration

-

retrospectively e nd documented on Response d

i 2 check of correct Drug as Process correct document observed and

w route administered Ends (Usually trust MAR documented t

s chart) u r T

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 11 – Administration As Is – Referral to prescriber/transcriber/clinical lead

Rx = Authorisation to administer

No

Prescriber/ Nurse documents Nurse refers Rx transcriber/ Safe/ Administration not clinical decisions back to prescriber/ clinical lead appropriate/ From Map safe/appropriate/ Yes and discussions in transcriber/clinical amends Rx/ writes possible to Go to Map 3 3,4,5,6,7,8 possible medical notes lead new Rx/ does administer? nothing This process may vary in time scale and order depending upon the Yes treatment required and degree of urgency Yes Yes

s Nurse refers Rx Safe/ p Administration not Nurse contacts e back to prescriber/ Rx to be Rx to be appropriate/ t No safe/appropriate/ pharmacist for No s transcriber/clinical amended? amended? possible to possible advice s lead administer s e

c No o

r Nurse may choose to go to p

another doctor or straight to a y

e senior prescriber prior to this point

K Nurse contacts Safe/

-

consultant/senior Rx clarified/ appropriate/ Yes e prescriber for Rx clinically justified possible to d i advice administer w

t s u

r No T Nurse documents clinical decision, Nurse makes justification for clinical decision as decision and Administer Yes to whether to conversations in drug? administer drug medical notes No

Process Ends

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Map 12 – Administration As Is – Withholding medication

Nurse documents This step could be first

y any clinical depending upon the s e reasons for treatment required and

p Nurse indicates K

Nurse informs

e degree of urgency

- reason for withholding t prescriber/clinical s medication in e

withholding lead of withheld Process

s Medication to be d i From Map medication on appropriate s withheld medication and Ends w

e administration section of

4,5,7 t c record administration reason (if s o appropriate) r

u record and/or in r p medical notes T

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Patient specific directions (PSD) PSD Area PSD Area A+E cas card A+E Patch testing request form Phototherapy Biers block proforma A+E Phototherapy request form - Psoralen Phototherapy Fascia iliaca block proforma A+E Intravesical immucyst prescription SIU IV sedation proforma A+E Neonate IVN prescription SNU Propofol sedation proforma A+E Adult IVN administration record Trust wide Blue outpatient prescription form - Used Endoscopy Adult MAR chart Trust wide as IP PSD GU med EPR GU med Adult pain chart - PCA, epidural, local Trust wide anaesthetic bolus and infusions GU med outcome slip GU med Adult surgical proforma - Day case pre-op, Trust wide anaesthetic record, Day case post-op Electrolytes administration record ITU Anaesthetic record Trust wide Inotropes administration record ITU Blood component chart Trust wide Renal replacement prescription ITU Chlordiazepoxide - Alcohol withdrawal Trust wide assessment Sedation infusion record ITU Enteral tube feeding regime (emergency) Trust wide Epidural /Spinal analgesia record Maternity Enteral tube feeding regimen Trust wide Cyclophosphamide prescription MDC Fluid - DKA fluid prescription Trust wide Ibandronic acid prescription MDC Fluid chart Trust wide Infliximab prescription MDC Heparin chart Trust wide Natalizumab prescription MDC Insulin - DKA fixed rate insulin Trust wide Rituximab prescription MDC Insulin - Prescription chart Trust wide Mosaic - Chemotherapy Oncology, Insulin - VRIII chart Trust wide haematology, adult and paediatric Cataract pathway - intra-operative x 2 Ophthalmology MRSA decolonisation chart Trust wide CAU medical record - drug administration Paediatrics Paracentesis form Trust wide record Paediatric MAR chart Paediatrics Warfarin chart Trust wide Paediatric surgical proforma - Pre-meds, Paediatrics Mifepristone administration record W5 anaesthetic record, post-op meds

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Patient group directions (PGDs) Drug Area Drug Area Amoxicillin A+E Simvastatin Chest Pain Nurses Chloramphenicol x 2 A+E Lidocaine for skin biopsy Dermatology Clarithromycin x 3 A+E Paracetamol and Ibuprofen DSC Flucloxacillin A+E Paracetamol and Ibuprofen to Paediatrics DSC Flumetasone + clioquinol A+E Aureocort® ENT Fluorescein A+E Lidocaine/phenylephrine ENT Ibuprofen A+E Locorten® ENT Oxybuprocaine A+E Naseptin® ENT Paracetamol A+E Fleet® General surgery, Endoscopy, Diagnostic imaging Penicillin V A+E MOVIPREP® General surgery, Endoscopy, Diagnostic imaging Trimethoprim A+E Picolax® or Senna General surgery, Endoscopy, Diagnostic imaging Paracetamol and Ibuprofen Blake Anti-infectives x 17 GU Med Lidocaine for cardiac implant Cardiology Vaccines x 2 GU Med Adrenaline CCOT Chlorhexidine mouthwash ITU Gelofusine® CCOT Anti-d immunoglobulin x 2 Maternity Hydrocortisone Injection CCOT Ranitidine and Metoclopramide Maternity Intravenous Hartmann’s CCOT Eye preparations x 12 (TBC) Ophthalmology Intravenous Metoclopramide CCOT Lidocaine for PICCs PICC team Lidocaine injection x 2 CCOT Gadovist® Radiology Nebulised ipratropium bromide CCOT Glucagon injection Radiology Nebulised salbutamol CCOT Hyoscine butylbromide injection Radiology Sodium chloride 0.9% CCOT Metoclopramide Solution Radiology GTN CCU nurses Primovist® Radiology Aspirin 300mg Chest Pain Nurses Ultravist® (Iopromide) injection Radiology Aspirin 75mg Chest Pain Nurses Paracetamol and Ibuprofen SAL Bisoprolol Chest Pain Nurses Paracetamol Sheppard Clopidogrel Chest Pain Nurses Entonox Trust wide GTN Chest Pain Nurses

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Protocols /Policies/Guidelines National Trust wide Local Area Midwife exemption Homely remedies Asthma proforma A+E Remote prescribing - record on MAR Biers block A+E Nitrous oxide sedation A+E Stroke A+E, Dunkery #NOF proforma A+E, orthopaedics Protocols and policies - Dobutamine, adenosine stress tests, metoprolol cardiac CT, primary angioplasty, angiogram, Cath lab angioplasty Protocols and policies - Local anaesthetic, iodine, acetic acid Colposcopy Protocols and policies - Diagnostic agents Diagnostic imaging Protocols and policies - Xylocaine, fentanyl, midazolam Endoscopy ,buscopan, Lidocaine Protocols and policies - E.g. Salbutamol, methacholine, citric Lung centre acid, hypertonic saline etc Vit K - Midwife exemption Maternity Vit K - Record of oral vit k regimen Maternity Phototherapy request form - Psoralen Phototherapy Protocols - e.g. Intra-articular, soft tissues injections, botulinum Physiotherapy

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Emergency administration All areas Antidotes - naloxone, flumazenil Lipid rescue - Intralipid Oxygen Resus boxes - Adrenaline, atropine, amiodarone Resus supplementary drugs - Adenosine, calcium chloride, magnesium sulphate, sodium bicarbonate

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 TWO PERSON DRUG ADMINISTRATION Administration of Controlled Drugs. Check and witness administration of blood and blood products. Administration of IV drugs, fluids and additives All other injectable drugs for therapeutic purposes (e.g. SC, epidural, IM). Most drugs in Children's Unit & Somerset Neonatal Intensive Care Unit. Complex calculations. Complex drug administration regimens Drugs outside usual area of competence If a local management decision has been taken which requires specific 2 person checking procedure.

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Documentation (area specific) Local document Area Asthma proforma A+E Stroke - thrombolysis proforma A+E, Dunkery #NOF proforma A+E, orthopaedics Angiogram/angioplasty care pathway Cath lab Cardiac MRI scanner - adenosine stress test Cath lab Cardiac MRI scanner - dobutamine stress test Cath lab Medical notes Cath lab Primary angioplasty record Cath lab Colposcopy EPR system (Viewpoint) Colposcopy Endoscopy unit nursing care plan Endoscopy GU med EPR GU med GU med outcome slip GU med Birth notes - Vit K Maternity Post natal notes - Vit K Maternity Record of oral vit k regimen - Vit K Maternity Intensive eye drop chart Ophthalmology Medical notes Physiotherapy Radiology CRIS system Radiology Administration of gaviscon SNU

Process Owner: Musgrove Park Hospital Last Revised Date: 04/04/13 Index Author: David Chalkley Version: 0.3 Legend

Terminator Annotation Use this symbol to show a comment or additional information (Start/End) Use this symbol to indicate the start or end of a process (Notes)

Use this symbol to indicate an off page reference, allows Go to / Process movement to related task or related page Use this symbol to indicate any event, task or action From

Use this symbol to indicate a decision point. The question is Decision? Document Use this symbol to indicate documents (input or output) and shown in the icon and there may be multiple outputs any attached documents excluding Patient Medical Record activity

Use a one-way arrow to show what is produced by an event. Also to show sequence of events. Case notes Use this symbol to indicate Case note activity

Use this symbol to illustrate multiple issues. Number 1 accordingly

Map, Process, stage of process

Abbreviations

Map of process

Detailed map of individual step(s) in process

Variations within step(s) of process

Process Owner: [Enter Name of Stakeholder] Last Revised Date: [Enter Date of Revision] Author: [Enter Name of Author] Version: [Enter Version No]