In recent years a number of key events have highlighted the dangers associated with inaccurate administration of medicines. The death of a patient in 2001 due to the inadvertent administration of vincristine via the intrathecal route prompted a range of activities coordinated at national level to improve the safety of patients prescribed intrathecal chemotherapy.
In the same year the Audit Commission (2001) published a report into the management of medicines in acute hospitals in England and Wales. This stressed the need for hospitals to improve standards of medication safety and recommended that the ‘monitoring of competencies in administration of medicines should be given a high priority’. Also in 2001 the government established the National Patient Safety Agency (NPSA) to establish a unified mechanism across the NHS for reporting and analysis of healthcare-related incidents.
In 2005 the NPSA published the first results of incidents reported via its National Reporting and Learning System (NRLS). This report, circulated to trusts, suggested that 10% of all untoward incidents reported across the NHS were medication-related and the NPSA highlighted concern that ‘learning how to administer medicines is not well taught’.
The Healthcare Commission (2007) has again alerted NHS trusts to the need to assess the competency of all staff working with medicines. In response to these concerns many trusts have established local arrangements to test nurses’ knowledge and skills in safe drug administration prior to allowing them to undertake clinical practice. Increasingly the use of e-learning has been adopted to facilitate access to such tests (Hare, 2006).
When administration of medicines takes place in an institutionalised setting such as a hospital ward or nursing home it is important that detailed and comprehensive procedures and standards exist in order to encourage safe, legal and effective practice. These should not only take account of relevant legal and professional frameworks such as the Medicines Act (1968) and the NMC (2004) Guidelines for the Administration of Medicines, but also of local policies and procedures.
As the principles of clinical risk management have developed within healthcare settings over the last few years, so has the need for all practitioners involved in the use of medicines to work collectively to minimise the risks associated with prescribing, supply and administration of medicines. Such collaboration may range from the development of appropriate documentation to the provision of education and training in medicines-related issues.
The pace of development and marketing of new medicines and new formulations emphasise the need to keep up to date. For practitioners directly involved in drug administration, this poses particular dangers when medicines with which they are unfamiliar are prescribed. Nurses need access to resources such as the British National Formulary to check information prior to administering medicines in accordance with the NMC guidelines (NMC 2004).
Principles for the administration of medicines (NMC 2004)
Know the therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contraindications.
Be certain of the identity of the patient to whom the medicine is to be administered.
Check that the prescription on the label on the dispensed medicine is clearly written and unambiguous.
Consider the dosage, method of administration, route and timing of the administration in the context of the condition of the patient and co-existing therapies.
Check the expiry date of the medicine to be administered.
Check that the patient is not allergic to the medicine before administering it.
Contact the prescriber or another authorised prescriber where contraindications to the prescribed medicine are discovered, where the patient develops a reaction to the medicine or where assessment of the patient indicated the medicine is no longer suitable.
Make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient.
Countersign the signature of a student when supervising a student in the administration of medicines.
Delegation on administration
The law does not dictate who can administer medicines, and legal frameworks only cover the prescription and supply of medicines. However, local policies specify how medicines are administered to patients.
In secondary care this is usually the responsibility of the registered nurse but in the community healthcare support workers may be responsible for the administration of medicines such as eye drops or topical treatments. The NMC recommends that medicines administration by nursing students is countersigned by the supervising registered nurse.
The NMC reminds nurses that they are professionally accountable for any aspect of care that they delegate to unregistered colleagues. However if healthcare support workers are delegated care that is part of their employment contract, have received training and been assessed as competent by their employer to undertake a task then the employer accepts vicarious liability for the care delivered by them (NMC, 2006).
It is vital that healthcare support workers work within their sphere of assessed competence.
Audit Commission (2001) A Spoonful of Sugar: Medicines Management in NHS Hospitals Audit Commission London
Hare, C. et al (2006) Safer medicine administration through the use of e-learning. Nursing Times; 102: 16, 25-27.
Healthcare Commission (2007) The Best Medicine. London: Healthcare Commission.
Nursing and Midwifery Council (2004) Guidelines for the administration of medicines. London: NMC.
Nursing and Midwifery Council (2006) Delegation of Care. London: NMC