For some time, I’ve questionned the accuracy of measuring liquid medication and how much is wasted in the process. I recognised that both administering and auditing liquid medication has unique problems and the current system of decanting to measure amounts given against stock has several drawbacks.
I undertook the task of exploring how this aspect of care could be improved and devised a system of ensuring accurate recording and monitoring of liquid medication administration.
The process of decanting the liquid into a container to measure volume will always lead to some of the dispensed medication being lost as residue in the measuring container. This can be exacerbated if the liquid is a syrup or has a high viscosity. This loss of volume causes inaccuracies when auditing and continual decanting can lead to the provider over-ordering medication to compensate for volume loss.
There are obvious cost implications with over-ordering, but a secondary issue is that external auditors such as the Care Quality Commission (CQC) or pharmacies can raise unfounded concerns regarding in-house stock.
Decanting liquid medication can also increase the risk of aerobic contamination of the liquid. On each occasion the medication is poured from one vessel to another, there is a possibility of contamination from the person decanting and from the surrounding air. Further contamination could be caused by the vessel and the storage facilities.
Policies and procedures need to address these issues, including detailing how the vessel should be cleaned and dried before and after each use.
During previous audits it has been established that pharmacies sometimes dispense larger volumes of medication than is indicated on the label. This can lead to concerns being raised unnecessarily when medication is left unused at the end of a 28-day cycle. The decanting process must therefore include all received liquid medication, and practitioners shouldn’t rely on the amount printed on the label.
Medication should always be measured carefully, but there are occasions when a team may have reason to monitor the accuracy of liquid medication administration and audit more closely. This may be due to finding excess stock at the end of a 28-day cycle or a CQC requirement due to medication administration having failed to meet minimum standards. There may be concerns raised regarding an individual staff member and their compliance to a medication policy or a resident may display unexpected symptoms, relapse or not respond as expected to a prescribed treatment.
This thorough audit will generally be carried out by decanting large volumes of liquid medication which can be time consuming, particularly in a large care setting, and will require two staff members to count and countersign if a daily audit is required.
An alternative option is visually calculating the volume lost against the initial volume received, but this is unreliable and inaccurate.
Those living in a care setting are nearly always reliant on others for assistance when they are unable to self-administer medication. Care homes are responsible for ensuring those in their care have access to their prescribed medication and auditing and monitoring medication is an important aspect of meeting this need.
There are numerous systems used by care providers to assist in the storage and administration of medication, however none specifically address the issues surrounding liquid medication.
Medication administration is generally monitored by counting stock during a drug round or during an audit. A senior staff member or a visiting regional manager and pharmacy staff or CQC inspectors carry out these counts. Audits establish several things; including confirmation that the medication in stock is what is expected, taking into consideration the total amounts received into the care home and the recorded amounts administered or destroyed.
I wanted to ensure that we were able to:
- Monitor outcomes of accurate consumption of prescribed medication;
- Assist in compliance of regulatory requirements in the administration of medication;
- Ensure liquid medication is appropriately dispensed and audited;
- Assist staff in monitoring dosage on each occasion of administration;
- Reduce time lost to care in the monitoring and decanting of liquid medication;
- Provide a written real time record of dispensed medication.
Liquid medication measurement system (LiMMS)
I developed a system to provide accurate indicators of liquid medication administration. What was important for me and my team was a system that is simple in its concept involving very little cost or time, and one that involves the use of a digital set of scales.
The system I developed was to:
- Weigh each bottle on delivery and record this measurement, ensuring it is accurate;
- Weigh the bottle again before and after each dose has been given;
- Record this measurement on the new ’liquid medication record’.
The system was introduced to staff as a pilot initially to all pro re nata (PRN) liquid medications given in the home. Staff were monitored to find out how accurately they were able to measure when recording liquid volumes during the initial rollout. Medication sheets (Marr) were reviewed at each handover alongside the liquid medication record sheet.
I made sure that staff were aware that the two amounts - mls and g - will not match. The system will only provide a decreasing volume indication for each dose dispensed. However, the trial showed that staff became confused when recording measurements because of the amount recorded increasing in numerals, while the volume in the container was decreasing.
Members of the management team and senior staff carried out spot checks throughout the pilot. This allowed any anomalies to be addressed quickly and to offer support and advice to staff during the pilot process.
Following the initial trial of one 28-day medication cycle, the system was extended to all liquid medications on all units within the care home.
During the pilot, medication issues in administration or record keeping were quickly highlighted. These included Marr sheets signed to indicate that medication had been administered despite, on inspection, the volumes not decreasing as expected or in some cases not reduced at all. Again on inspection medication volumes recorded were in excess of the expected amounts prescribed or were out of the established pattern for the prescribed amount.
On each occasion staff found an error they were requested to have the volume checked by another staff member before giving any further medication. Staff then provided a written statement immediately and photocopied all documentation. The information was passed to the home manager for review. These records were then held in staff personnel files along with any investigation records to support supervisions, training needs and competency assessments or disciplinary actions.
Each issue was investigated and resulted in retraining and/or disciplinary action being taken where required. The pilot was then rolled out for subsequent 28-day cycles for all units for all liquid medication.
The system is now established within the care home.
It has also been made available to the provider to rollout in its other care settings and the outcome for residents is that an accurate, real-time record of liquid medication administered is now available. This assists staff when reviewing medication with residents’ prescribers and with their next of kin.
The system also ensures each resident is dispensed medication from their own container and eliminates the possibility of shared medication.
The system has allowed for more accurate monitoring and has been used to support the process of monitoring and managing staff competence and compliance to good practice. Medication recording errors have been reduced, as the system does not allow for guessing or other interpretation of volume.
Over-ordering and over-stocking of medication is no longer an issue so pharmacies no longer need to compensate for loss due to decanting.
The piloted system has been shown to reduce the time taken to accurately record volumes of prescribed liquid medication. Clear and accurate records are now available for audit; so the system has also reduced audit time.
Compliance to NMC guidelines and CQC minimum standards is now evidenced and assists in the process of inspection. Where anomalies have been noted the records have been used initially to support further training. Evidence is now available for staff to demonstrate their competencies in safe administration of liquid medication and monitoring of appropriate dosage. This can be used alongside competency assessments including NVQ and nurse portfolios.
Staff have been confident in questioning the outcomes of recordings and provided support to their peers during the piloting of the system. This has increased staff communication regarding medication administration outcomes and their instigating reviews of medication.
The pilot provided clear indications of volumes of liquid medication administration. This was without the necessity of decanting the liquid in order to calculate the amount left in the bottle. Patterns of volume use emerged quickly which allowed staff to raise concerns if the recorded amounts were outside what they expected.
The pilot has shown the system can be used to establish a standardised best practice system for use within care settings and will assist providers to support regulatory compliance in the recording and administration of liquid medication. The system can be used to support any quality assurance audit and provide evidence for those schemes.
Standing back and critically assessing the everyday actions and interventions care home nurses undertake provides an opportunity for learning. By reflecting and questioning our practice we can change and improve the outcomes for our residents, ensure a safe working environment and demonstrate a clear line of accountability for the care we give.
Karen Davies, Manager, Rose Court Care Home HC-One