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Chapter 3: Drug administration by nurses

Learning objectives for this chapter

By the end of this chapter, we would like you to understand:

- Who can administer drugs and when.

- The regulations around the preparation of drugs for administration.

- How drugs can be administered safely.

- The differences in administration protocols for controlled and non-controlled drugs.

- The rules surrounding the delegation of medication administration and how this can be performed safely.

Who can administer which drugs, and under what circumstances?

Under the NMC Code (2015), nurses can prescribe or administer medicines in accordance with the limits of their training, the law and in accordance with any local or national policies and guidance. In line with prescribing rules for other healthcare professions, nurses should not prescribe for anyone they have a close personal relationship with, or prescribe drugs for themselves unless absolutely necessary.

Preparation of Medication for Administration

Medication should never be prepared in advance and should only be administered by a registrant who was involved in its preparation. No healthcare professional should ever administer medication they have not helped prepare. Nurses should have a good understanding of the weight systems used in prescription and be able to calculate drug dosages correctly. They should also understand common abbreviations used in prescribing, although any lack of clarity in the instructions should be questioned. It is also important to understand any necessary requirements for the safe handling of harmful medications. The nurse should also be aware of the correct local procedure for dealing with spillages, and safe disposal of any contaminated equipment.

Medicines in tablet form should not routinely be crushed to make it easier for the patient to take it without approval by a pharmacist. This is because crushing will change the way in which the medication is absorbed into the body and this may make the drug less effective. Many tablets are prepared by the manufacturer with an enteric coating which prevents the tablet from breaking down in the acid contained in the stomach so that it can progress to the small intestine where the tablet can break down gradually and be absorbed into the body more readily. Crushing removes the protective effects of this coating.

Introduction to Safe Drug Administration Procedure

The NMC Standards for Medicines Management (2016) outline the nurse's responsibilities for safe drug administration in more detail. A registered nurse can administer any prescription only medicine, or general sales list or pharmacy medication with a single signature. Before administering a drug, a nurse should be certain of the patient's identity and confirm this with wrist bands and asking the patient for their name and date of birth, as well as checking that the patient is not allergic to the drug. The nurse should have a good understanding of the drug they have been asked to administer - for example, its therapeutic use, normal dosage, known adverse effects and any specific contraindications or precautions associated with that medication. The nurse should also be familiar with the patient's care plan and the need for that patient to receive that medication.

The nurse should also check that the prescription for the medication and the labels on the container are clear and unambiguous. If there is any uncertainty over any aspect of the prescribed instructions, the nurse should investigate this further by contacting the prescribing healthcare professional for clarification. The nurse should also consider the prescribed dosage, route and timing and compare this with their knowledge and experience. Finally, the nurse should always check the expiry date on the medication.

The patient's current condition should also be considered when administering a prescribed drug. For example, if the patient's current condition or vital signs contraindicate the medication then the drug should not be given and advice should be sought. The patient may also choose to withdraw their consent to receive the medication, and this should be respected and adhered to, assuming that the patient is assessed as having the mental capacity to refuse treatment.

The medication administration should immediately be clearly and accurately recorded in the patient's notes, with the nurse signing and printing their name, and recording the date and time that the drug was administered. If the drug was deliberately not administered, this should also be recorded in the notes along with the reason. Nurses have a legal responsibility to ensure that they clearly record this information. This should also be undertaken if the registered nurse has delegated the drug administration to another individual.

Finally, after receiving the medication, the patient should be monitored for any evidence of an adverse reaction. Nurses should seek support from the prescriber in this event, but also be aware of the necessary emergency care required to support a patient having a serious reaction. Allergic reactions are commonly characterised by a rash, hives, sneezing and bronchospasm but may progress to anaphylaxis, a systemic allergic response which can cause respiratory distress and loss of consciousness. Patients suspected of having an allergic response should be monitored for signs of the reaction developing into anaphylaxis. An antihistamine such as hydroxyzine and a corticosteroid such as prednisolone should be administered. However, if anaphylaxis is suspected, the patient should receive high flow oxygen therapy and an emergency intramuscular injection of adrenaline, which can be repeated every 5 minutes until the patient has stabilised. Bronchospasm can be treated with salbutamol, delivered by a nebuliser.

The nurse's responsibilities under the NMC Standards for Medicines Management (2016) may be condensed into the "5 rights" rule, which prompts the nurse to consider these points in an easy to remember fashion. The right patient should receive the right dosage of the right medication via the right route at the right time. This has been expanded on by some experts to become the "7 rights rule" or even the "9 rights rule" to cover the other aspects of drug administration covered in this section. These rules expand on the "5 rights rule" by also including the addition of checking that the right form of the drug has been prescribed, that the drug is being administered for the right reason, and that the patient exhibits the right response to it. Finally, the nurse should complete the right documentation after administering the medication. These rules are shown below in Figure 1.

Rule

Explanation

Right patient

Does the nurse have the correct patient and patient notes? Check by asking the patient for their name and date of birth and checking wrist bands.

Right dosage

Has the medication been prescribed at the right dosage? Could an unusual dosage be a medical error? Or is the dose adequate to achieve the aims of the patient care plan?

Right medication

Is the medication correct? Could there be an error in the written instructions? Has the nurse obtained the correct medication from the drug cupboard? Does the patient have a history of allergies to any medications?

Right route

Is the right route for this medication indicated in the patient record? Would an alternative route be more appropriate?

Right time

Is the drug being administered at the indicated time? Have previous doses of the drug been administered at the right time? Does the time of this dosage need to be altered?

Right form

Has the drug been prescribed in the most suitable form?

Right reason

Is the rationale for the selection of the prescribed drug correct? Would another drug be more appropriate?

Right response

Is the patient responding to the medication as expected? For example, is the patient's blood pressure reducing in response to the administration of an antihypertensive drug such as a β-blocker like propranolol? Any signs of an allergic response to the medication should also be identified.

Right documentation

Has the nurse completed the appropriate documentation correctly in accordance with NMC and local guidelines? Has a second competent individual witnessed the administration if appropriate? This may include the patient's notes and a controlled drug record if appropriate.

Figure 1: The "rights" of drug administration

Administration of Controlled vs Non-Controlled Drugs

Controlled drugs can also be administered by nurses, but these are subject to additional legislation and local protocols, which should always be followed. Second signatories are usually other nurses, student nurses, doctors or pharmacists; however, if none of these professionals are available, the NMC recommends not compromising patient care by waiting for a suitable professional to countersign, but to consider another competent person instead. Good practice suggests that ideally this second signatory should witness the entire drug administration process, and this is usually reflected in local policies. Normally, a second signature is required for the administration of controlled drugs in the hospital environment, however this is not always possible in the community setting and in this case, local policy and procedures should be followed. When a patient has been prescribed oral controlled medication for immediate consumption the administration and the patient's consumption of the medication should be witnessed by the administering nurse and a second registered nurse, as well as following any other relevant local procedures. The recommendations produced by the National Institute of Health and Care Excellence (NICE) for the use of controlled drugs stipulate that the name of the patient receiving the drug should be recorded, along with the date and time of the dosage, the name, dose, formulation and strength of the controlled drug. This should be supported with the clearly printed name and signature of the registered nurse administering the nurse, as well as the name, date and signature of the person witnessing the medication administration.

Delegation of Drug Administration

A registered nurse can delegate the administration of drugs to a healthcare assistant or student nurse, but this should never be administered without supervision. This introduces the possibility of errors into the patient's care, therefore delegation of drug administration should be carefully considered. If it becomes necessary to delegate this task, the nurse has the responsibility to ensure that the person they delegate to is a competent individual. If the nurse has any doubts regarding competency, they should not delegate drug administration even if this means refusing a direct request from another healthcare professional. This is because the registered nurse is considered to be accountable for the practice of any individuals they have delegated the task to. A student nurse is legally considered in the UK to be responsible for their practice, but to not yet have the experience and ability to be considered fully accountable for their practice. The nurse should ensure that the individual has adequate education and training to understand how and why the medication should be administered, and should offer further support if necessary. Any training or education should be recorded, and the NMC Standards for Medicines Management (2016) stipulate that the overseeing registered nurse should always countersign the administration of drugs by a student. Safe and effective delegation can be guided using the "5 rights of delegation" rule as shown in Figure 2. Following this rule ensures that the right task is assigned to the right person under the right circumstances, and that they receive the right directions to carry out the task safely. The delegation should also be supervised and evaluated in the right way.

Rule

Explanation

Right task

Is the task specific and one that is suitable, legally and ethically, to be delegated?

Right circumstances

Does the individual being delegated to have the right resources and equipment to carry out the task safely?

Right person

Is the right person doing the delegating? Is the person being delegated to competent and willing?

Right communication and directions

Has the person being delegated to received clear and concise instructions and do they understand the objectives, expectations and their own limits? Do they understand how to report and record the process appropriately?

Right supervision and evaluation

Will the person being delegated to receive appropriate evaluation and feedback? Will their performance be monitored and is the person doing the delegating available to intervene or offer support if necessary?

Figure 2: The "5 rights" of delegation

Conclusion

In conclusion, this chapter has introduced the role of the nurse in drug administration in the context of NMC guidance and UK law. We have also reviewed the benefits of delegation of routine drug administration tasks to other colleagues, and how this can be approached in a safe manner in order to ensure patient safety and care quality.

References

NMC. (2015). The Code for Nurses and Midwives. Nursing and Midwifery Council. [Online]. Available at: http://www.nmc.org.uk/standards/code/ [Accessed: 10 November 2016].

NMC. (2016). Standards for Medicines Management. Nursing and Midwifery Council. [Online]. Available at: http://www.nmc.org.uk/standards/additional-standards/standards-for-medicines-management/ [Accessed: 10 November 2016].


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