Single Nurse Administration of Injectable Medicines in Community Hospital Clinical Areas

This policy has been designed for guidance in the prescribing, preparation and administration of injectable medication by the following routes:

• Intravenous – via direct injection or infusion
• Intramuscular (IM)
• Subcutaneous (S/C) – via direct injection or infusion (following Palliative Care guidelines)

The guidance is applicable for all registered and qualified health care professionals who will be administering the above medications in clinical areas where second checking by another practitioner is not available. This will only be for clinical areas within NHS Borders Community Hospitals. Where it is recognised that there are frequently occasions (i.e.: night shift) where there is only one registered nurse on duty.

This policy represents a change in practice for the organisation.

Before the introduction of this policy at NHS Borders there was a requirement for second checking of all intravenous medication in all areas. Second checking (where 2 competent people independently check).

Second checking of injectable medicines included on the above list should continue in all community settings.

Second checking of all injectable medicines should continue in clinical areas not stated above (non-community settings).

Consent to treatment

It is a general legal and ethical principle that valid consent must be obtained before starting treatment and provision of information is central to the consent process. If a competent patient refuses an intervention or treatment their wishes must always be respected.

Allergy /Sensitivities

A patient / service user’s allergy status must be confirmed prior to prescribing or administering any medication. Any documentation relating to administration of medication must document any allergies / sensitives relating to the patient / service user. This information must be available to all members of the healthcare team involved in the care of the patient.

In order to distinguish between a serious allergy and drug intolerance, the symptoms of any reported allergy should be documented in the medical notes/ care records if known.

Anaphylactic shock

Anaphylaxis usually occurs within minutes of contact with the allergen; however, anaphylaxis can occur several hours later. A practitioner administering any kind of medication that is known to carry an increased risk of causing anaphylaxis must observe the patient for 10 minutes after administration. As anaphylaxis may reoccur up to 72 hours after the initial treatment, the patient / service users should be advised to report any symptoms such as breathlessness, swelling or rash as soon as possible. In all cases of suspected anaphylaxis dial 999 immediately for assistance, and if trained and competent to do so commence with the administration of adrenaline. If there is no clinical improvement the dose should be repeated after 5 minutes. New or potential allergies must be documented and highlighted to the Prescriber.

The staff member must ensure that the episode is documented in the patient / service user’s notes, and an incident report is completed by the end of the working shift. Pre-packed anaphylactic shock packs containing adrenaline are available to be used in the event of an anaphylactic reaction. The staff member must ensure that that they have medications for anaphylaxis or severe reaction to medications in the clinical area or patient’s home prior to administration.

It is important to remember that the dose of adrenaline required for adult patients is different to the dose required in paediatrics. Staff must ensure that they administer the appropriate dose for their client group. Availability and expiry dates of anaphylactic shock packs must be checked regularly. New supplies should be ordered from pharmacy in advance. Community nurses must store adrenaline in accordance with the correct temperature as advised by the manufacturer. Adrenaline must not be left in the car or other cold place overnight.

Medications administered by the H@H team should not be administered for the first time within the patients’ home with only 1 staff member available. Normal practice would be that the medications are administered for the first time during hospital admission prior to discharge home with H@H support. If this is not available then a second staff member should be available during first administration of medication.

Administration of medications

All medications should be administered following the NHS Borders online MEDUSA injectable medicines guide including use of appropriate infusion devices and NICE guidance on intravenous infusions.

The NPSA Injectable medicines Risk Assessment tool (APPENDIX) should be used in identification of any local risk factors within the clinical area to provide a high-risk baseline for preparation of injectable medications. Risk factors identified should be eliminated when practicable. If this is not possible awareness of the implications should be escalated to Area Drug and Therapeutic Committee (ADTC).

Single checking administration of injectable medicines

In certain circumstances NHS Borders supports single-handed administration of all medicines without supervision including the intravenous drug administration.

It is recognised that in some clinical settings e.g. Community Hospitals second checking by another registrant of medications prior to administration may not be available and single checking would be permitted in this instance.

The practitioner who administers the medicine is ultimately accountable and responsible to ensure medication is administered and must complete documentation thoroughly.  

Medicines can be administered single handed by a registered nurse who can demonstrate / provide evidence of competence in this practice and has undertaken NHS Borders IV medication, Peripheral vascular cannulation and venepuncture modules and completed CARS system competencies they must also be able to be competent at working as an independent clinician.

Competency to administer medicines single handed must be demonstrated and recorded in the practitioner’s personal file.

Newly registered and recently appointed registered nurses / clinicians must become familiar with the use of drugs in the relevant clinical areas they work in and demonstrate knowledge of this policy and procedure prior to undertaking single handed drug administration.

They must have successfully completed the IV medication, peripheral vascular cannulation and venepuncture modules with practical competence completed on CARS learning system. They must also be able to work as a competent independent clinician.

Double-checking administration of injectable medicines

Two practitioners are required to check injectable medicines in all other clinical areas without exemption and circumstances within NHS Borders. Staffing levels within other clinical areas provide the ability to complete double-checking of injectable medications.

Any medication stated on the list above requires a second practitioner check, even in community settings.

Dispensing of medications for single checking administration

Omnicell electronic dispensing systems must be used to dispense medications for administration. This provides a wide availability of previously agreed medications for the Community Hospital team.

This practice also provides a robust dispensing process check. And allows monitoring replacement and auditing of medications used.

Disposal of medications/consumables after administration

NHS Borders policy regarding safe transportation, administration and disposal of consumable must be adhered to during this process. Registered staff are responsible in ensuring all consumables are disposed of using the recommended systems.

Documentation

All Registered Professionals and healthcare staff are required to keep contemporaneous records which are unambiguous and legible. The NMC Standards of proficiency for nurses (2018) outlines the requirements of nursing records and clear documentation.

Standards of proficiency for registered nurses - The Nursing and Midwifery Council

Adverse event Reporting

Medication errors are to be reported via the Board Adverse events reporting system (In-phase) in accordance with Board policy. The objective of the reporting system is improvement in care and not a blame tool.

The Yellow Card scheme should be used to report any issues with a medicine, vaccine, medical device or blood-product.

Reports can be submitted directly to the MHRA through the Yellow Card scheme using the online form, by downloading a copy of the form from the Yellow Card website, using the Yellow Card app, or by freephone on 0800 731 6789. Alternatively, patient Yellow Cards may be available from pharmacies and GP surgeries.