Approved. Approved. Approved

Transcription

1 Page 1 of 38 TCP 021 Intravenous Administration for Adults TCP 021 Cross reference This policy should be read in conjunction with: Safe & Secure handling of medicines MM 026 Aseptic Non Touch Technique TCP 113 Policy for the use of infusion devices in BSUH TCP 075 Cannulation policy TCP 035 Progress and date of approval (Approved /under review Approved Approved Approved Approved Manager Responsible Authors Deborah Bolton Deborah Bolton Date 26/02/08 Policy Number TCP 021 Previous code CO 021 Version number 2 Approving Committee Trustwide Clinical Policies Signed by Chair of the Committee Review Date February 2010 Consultation and Ratification Schedule Name of Committee Date of Committee Trustwide Clinical Policies Committee 26 February 2008

2 Page 2 of 38 TCP 021 Contents 1. Introduction 2. Indications for IV therapy 3. Contra-indications 4. Principles for practice 5. Infection control 6. Equipment needed 7. Procedure 8. Requirements to be an assessor 9. Electronic documentation 10. Monitoring effectiveness References Appendices Equality Impact Assessment

3 Page 3 of 38 TCP Introduction All staff who undertake the administration of intravenous (IV) therapy via an established route must have attended an IV course within the Trust or be able to provide evidence of study in other organisations. This must be followed by a period of supervised practice and successful completion of the BSUH competency based assessment. Staff must attend a theoretical IV update every 3 years. This update needs to be followed up by a competency based assessment within 4 weeks of the theory session. This assessment will be carried out using the NPSA competencies. (see appendices) Bank and agency staff may administer IV therapy as long as they have completed the above training. If an agency nurse is a former employee of BSUH and was competent to administer IVs, they may continue to do so within BSUH, as long as they attend an IV update every 3 years. This document should be used in conjunction with other BSUH policies: Safe and secure Handling of Drugs (TCP026), Cannulation (TCP035), Aseptic Non-Touch Technique (TCP113), Policy and Guidelines for infusion devices in BSUH (TCP 075). The emphasis is to meet the holistic needs of the patient/client. Practitioners should only administer IVs to patients in their own care. A practitioner is one who is professionally registered and legally accountable for practice. E.g. Doctors, Nurses, Operating Department Practitioners, Radiographers, Midwives. A register of all training and staff competent in IV skills is held by the IV Team, Garden Room, Rosaz Cottage, RSCH. Ext Indications for IV Therapy a) Administration of prescribed IV fluids and medication. b) To maintain and correct electrolyte imbalance. c) Administration of emergency and lifesaving medication where rapid effect is required. d) Administration of blood and blood products. e) Administration of Total Parenteral Nutrition. f) Administration of medication that may not be administered by any other route. 3. Contra-indications

4 Page 4 of 38 TCP 021 a) When alternative routes would be as effective e.g. oral b) When the patency of the vascular access device is in doubt. c) When administration exceeds a practitioner s competence. This should be passed on to a more experienced practitioner and not omitted. d) When workload exceeds the ability to carry out administration safely. e) If a patient does not give consent. f) Where it is not clinically indicated. 4. Principles for Practice a) IV therapy may only be administered by a currently registered practitioner who has received appropriate training and successfully completed the BSUH competency based assessment. b) First and subsequent doses of medication may be given by a practitioner, provided they are confident that it is safe to do so. c) Each department manager should maintain a register of staff who are competent to administer IVs. d) Practitioners moving between specialities should ensure that they have relevant specialist knowledge and skills before continuing to administer IV therapy. e) Practitioners should only administer IVs in the area within which they are working. They must not move to other areas for the sole purpose of administration of IVs. Exceptions to this are: Medical Staff, Chemotherapy Team, Pain Team, Night Co-ordinators, IV Team and Bleep holders. f) If administering IVs for clinical trials, the practitioner must be sure that a protocol for the trial is available. The Local Research Ethics Committee must have ratified the protocol. g) The practitioner should only administer drugs with which he/she is familiar. All therapy must be administered via an established vascular access device. E.g. cannula, central venous catheter. h) IV therapy should be administered according to a correctly completed prescription. i.e. legible, correct patient details, correct drug, dose, time, route of administration, signed and dated. If this is not the case, the practitioner should not administer the IV. Medical staff must be informed of any omissions and it must be documented in the notes. If the practitioner is concerned, they should complete a Datix Form. i) The practitioner must positively identify the patient/client to whom the IV is being administered. The patient/client hospital number must be checked against both the identity band and the prescription chart. If for any reason there is no name band, the practitioner may identify the patient/client verbally. If a patient is unconscious, a practitioner other than those administering the IV must identify the patient and apply a name band. j) 2 registered practitioners must check medication to be administered intravenously, one of whom should also be the practitioner who administers the IV medication. k) Each practitioner is responsible for checking

5 Page 5 of 38 TCP 021 The fluid/drug is the one prescribed The integrity of the container The expiry date of the drug/fluid The appearance of the fluid The mode of reconstitution from a powder to a liquid Date and time of previous dose Any allergies Blood levels The patency of the vascular access device. l) Student nurses must not act as a second checker for any IV therapy. They must not check infusion devices and must not be used as escorts for patients leaving the ward with IV Therapy in progress. m) Student Nurses must never administer/supply medicinal products without direct supervision. Their mentor must understand that as a Registered Nurse they are accountable for this. n) Health Care Assistants are not permitted to check IVs in BSUH unless there is a local protocol in place. o) All IV therapy must be administered using an aseptic non-touch technique. p) When an infusion is in progress, the practitioner must ensure that drugs to be given and infusion fluids are compatible. If this is not the case, flushes should be given prior to administration, in between drugs and following administration. q) All IV therapy should be administered using a 10ml syringe or larger, to comply with manufacturers guidelines. r) For intermittent injection, the patency of the vascular access device must be demonstrated with a flush of 5 mls of sodium chloride 0.9% in a 10ml syringe. If more than one drug is being given, the practitioner should administer 2-3mls flush in between administration. Once administration is complete, the practitioner must administer a flush to ensure that the vascular access device is clean. The amount may vary depending on the device in use. s) All flushes must be prescribed and the amounts administered documented on fluid balance charts. Medical staff or nursing staff who are IV competent may prescribe flushes, on the PRN part of the prescription chart. When signing the prescription chart, nurses must print RN in the signature box. t) Intravenous fluids should be prescribed on the correct infusion chart. Rates should be checked hourly. All fluid administered should be documented accurately on a fluid chart (see appendix) u) All fluids containing potassium must be administered using a volumetric pump. Ideally all fluids should be administered using pumps if they are available. v) All lines should be clearly labelled with the date and time they were connected. w) All lines on critically ill patients should be clearly labelled with the drug they are administering.

6 Page 6 of 38 TCP 021 x) If a patient is to be moved from the ward area with IV therapy in progress e.g. to x-ray, a registered practitioner should accompany them. y) Patients with IV fluids and pumps are not permitted to leave the wards without a nurse escort in order to smoke. They will be doing so against medical advice. If they have an infusion device, they must be accompanied by a registered nurse and they must not use their mobile phone. z) Cannula sites should be checked for signs of phlebitis, infection and infiltration every shift and each time a drug is administered, or infusion connected. Use visual phlebitis score and infiltration scale below. Scores should be documented on the observation chart and be placed at the end of the patients bed. Treatment should be commenced according to scores. Visual phlebitis score (VIP) Findings Score Action IV site appears healthy 0 No sign of phlebitis. OBSERVE CANNULA One of the following is present -pain at IV site, slight redness at IV site Two of the following are present- pain, swelling, erythema All the following are present-pain, erythema, induration ALL of the following are present-pain, erythema, induration, palpable venous cord, All of the following are present- pain, erythema, induration, palpable venous cord, pyrexia (Jackson 1998) 1 Possible signs of phlebitis RESITE CANNULA 2 Early stages of phlebitis RESITE CANNULA 3 Medium stage of phlebitis RESITE CANNULA CONSIDER TREATMENT (this may be heat application to cause vaso dilation) 4 Advanced stage of phlebitis or start of thrombophlebitis. RESITE CANNULA CONSIDER TREATMENT 5 Advanced stage of thrombophlebitis RESITE CANNULA TREAT WITH ANTI BIOTICS CONSIDER ANTI COAGULANT THERAPY

7 Page 7 of 38 TCP 021 Infiltration Scale Grade Clinical Criteria 0 No symptoms 1 Skin blanched Oedema <2.5cm in any direction Cool to touch With or without pain 2 Skin blanched Oedema cm in any direction Cool to touch With or without pain 3 Skin blanched Gross oedema >15cm Cool to touch Mild to moderate pain Possible numbness 4 Skin blanched Skin tight and leaking Skin discoloured, bruised, swollen Gross oedema >15cm in any direction Deep pitting tissue oedema Circulatory impairment Moderate or severe pain Infiltration of any blood product, irritant, or vesicant (INS 2000) Any action taken should be recorded in the clinical records. All peripheral cannulae and central lines should be removed prior to a patients discharge, unless the patient is to receive IV therapy in the Community. Intravenous drugs that may not be given by nursing staff/odps/ radiographers/midwives If staff are working in high dependency or critical care areas, they may be required to give drugs not usually administered in ward areas eg sedatives and anti-arrythmics, that may lead to a loss of consciousness, and cytotoxic drugs. These drugs can only be administered by Nursing staff, ODPs or Radiographers, if they can demonstrate knowledge of the drug and/or have received additional training to administer. This should involve a competency based assessment. Information and training may be given by pharmacy. Training for some drugs is included in the Advanced Life Support course.

8 Page 8 of 38 TCP 021 Staff should seek help for administration of drugs with which they are unfamiliar. 5. Infection Control All vascular access devices and administration sets should be viewed as a closed system and a source of microbial infection. a) Aseptic non-touch technique must be employed at all times. b) Manipulations of IVs should be kept to a minimum and lines observed for leakage. c) Standard gravity lines must be changed no more frequently than every 72 hours unless otherwise indicated. e.g. when the cannula is resited or there is blood in the joints. All new lines must be labelled with the time and date of change. Both should be recorded in the clinical record. d) Peripheral cannulas should be routinely changed every 72 hours. e) Cannula must be secured using a sterile, moisture permeable, IV dressing. E.g. Tegaderm. f) Adhesive tape must not be placed over the IV dressings g) Date and time of insertion of cannula should be documented using the micropore strip provided with the cannula dressing. h) IV dressings should be changed when they are soiled. Film dressings will last for the life of the cannula. i) All infusions containing medication e.g. Heparin, Ionotropes, Insulin must be changed every 24 hours. j) Administration sets for intermittent drug infusion e.g. antibiotics, should be changed every 24 hours or according to the stability of the drug. They should not be disconnected from the patient and bunged off for long periods of time and then reconnected. If lines are not in use, they should be left connected to the patient. k) Cannula caps should be closed when not in use, and all 3 way taps have caps applied. l) Caps should be changed each time the line is accessed. m) Needle free connectors e.g. Swanlock, are recommended for all central lines. These may be accessed 100 times and should be changed weekly. 6. Equipment needed Clean plastic tray or receiver Syringes (10 ml or larger) Needle (blue needles or filter needles should be used for reconstitution to reduce the risk of particulate contamination) Drugs Reconstitution Fluids/ fluid for administration IV additive labels

9 Page 9 of 38 TCP Procedure 2% chlorhexidine wipes eg PDI wipes should be used for accessing lines. Single use 2% chlorhexidine eg Chloraprep should be used for dressing changes 0.9% sodium chloride flushes Non-sterile gloves Apron Sharpsbin Two practitioners must be present. a) Wash hands with soap and water, followed by alcogel. b) Put on non- sterile gloves and apron. (NB handwashing protects the patient, gloves protect the practitioner) c) Gather together all equipment d) Clean out plastic tray with chlorhexidine wipes e) Reconstitute drugs as per manufacturers recommendations and prescription chart. Remember to take displacement values into consideration to ensure correct concentration if dividing the dose. This information is available on the summary of product characteristics (data sheet). Information is also available on the internet, National IV Guidelines. (MEDUSA)or via the Medicines information helpline. f) Remove gloves, alcogel hands and apply fresh pair of gloves. g) Check identity of patient. h) Check if they have any allergies. i) Check capacity of patient. If they have capacity ensure they understand the proposed procedure and ensure they have no objections. If not, take advice on consent prior to proceeding j) Inspect vascular access device for patency, signs of infiltration and signs of infection and phlebitis. (use phlebitis score for cannulae) k) Clean administration/injection port/needlefree valve with alcohol swab for 30 seconds and allow to dry. l) Instil 5 ml 0.9% saline flush into peripheral cannulae, monitoring the patient for pain and swelling. For central lines, aspirate blood back up the line and flush with 10 mls 0.9% saline. m) If patency is in doubt, stop. Resite cannula, or use alternative lumen of central lines if possible. If patency is proven, continue. n) Insert syringe of drug into port. o) Administer slowly following manufacturers' guidelines. This will ensure proper haemodilution and prevent speed shock If patient complains of any discomfort or shows signs of a reaction, stop the administration and call for help as required. p) Detach syringe when administration is completed.

10 Page 10 of 38 TCP 021 q) Flush cannula with 5 mls 0.9% NaCl, flush central lines with at least 10 mls of 0.9% NaCl. (short term central lines require locking with heaprinised saline to maintain patency.) r) Remove gloves and decontaminate hands. s) Document on the prescription chart t) When several drugs are to be administered down the same vascular access device, ensure that at least 2 mls of 0.9% NaCl is flushed down the line in between the drugs to reduce risks of incompatibility. u) Not all drugs are compatible with 0.9% saline. Read manufacturers recommendations for flushes required. e.g. use 5% dextrose with amphoteracin and amiodarone. 8. Requirements to be an Assessor Assessors must fulfil the following criteria: A Registered Practitioner who holds a current IV Certificate and a recognised teaching/assessing certificate. E.g. ENB 998. D32,33, A1,A2, CG7307, PHCHSE. Administer IV Therapy regularly. 9. Electronic Documentation Where there is reference made to documentation on charts, this includes electronic charts and signatures in areas where they are used. This conforms to the Data Protection Act and the NMC Guidelines for the administration of medicines and record keeping. 10. Monitoring Effectiveness The aim of this policy is to provide guidance to staff in the delivery of IV preparations, thereby ensuring safe administration. This policy will be monitored for effectiveness by keeping a record staff who administer IV therapy being kept by BSUH. This record will be kept both by electronic and paper versions. Annual audit of incidents reported on Datix, enabling identification of trends across the trust. References CDC Guidelines 2007 Data Protection Act (electronic signature and passwords)

11 Page 11 of 38 TCP 021 Dougherty, L and Lamb, J Intravenous Therapy in Nursing Practice. Churchill Livingstone : London EPIC Guidelines 2007 ICNA Guidelines 2001 INS Guidelines 2000 Jackson, A Infection Control: A Battle in Vein Phlebitis. Nursing Times 94(4), Manual of Clinical Nursing Procedures. Intravenous Management. The Royal Marsden Hospital 2007 Nursing and Midwifery Council (NMC) Standards for Medicines Management NMC Code of Professional Conduct 2007 Pickstone, M A Pocketbook for Safer IV Therapy. Scitech Educational: Kent Royal College of Nursing (RCN) Standards for Infusion Therapy Richardson, D Handbook of Infusion Therapy. Springhouse: Pennsylvania. Weinstein,S.M Plumers Principles and Practice of Intravenous Therapy. 7 th Ed. Lippincott: Philadelphia.

12 Page 12 of 38 TCP 021 Please forward this document to the IV Team. APPENDIX 1 This will be kept as proof of competency and names will be entered into the IV database. (Please do not send NPSA documentation) Assessment for Intravenous Therapy. Name Job Title.... Area of Work.. Directorate.. Competent to Practise: Date Assessed Signature of Assessor Yes / No... Comments Please complete and return to: IV Team, Garden Room, Rosaz cottage, RSCH

13 Page 13 of 38 TCP 021 APPENDIX 2 NPSA workforce competence March 2007 statement on prescribing injectable medicines Word file available at Workforce competence statement Injectable medicines competence 1 Prescribing injectable medicines Prescribing of injectable medcines Summary Indicative links to KSF Dimension & Level Activity scope This workforce competence is directly applicable to healthcare professionals who undertake the prescribing of injectable medicines for adults or children. Its content is also relevant to healthcare professionals who are responsible for the delivery of healthcare to adults or children. It includes the reviewing of indications and contraindications for use, calculation of administration volume and rate of administration, selection of injectable medication and initiation of a monitoring regimen. Health and wellbeing HWB7: Interventions and treatments Level 3: Plan, deliver and evaluate interventions and/or treatments Key words and concepts Prescription The document which describes the medication determined by a properly authorised individual for an individually named patient. It includes the medication to be used, the dose, dilution, mode of delivery and time period for delivery. Monitoring regimen Competent Y/N

14 Page 14 of 38 TCP 021 A systematic plan for observing the physiological impact of prescribed medication therapy enabling subsequent adjustment to maintain or improve the health of a patient. Communication with professional colleagues includes communication within and between appropriate members of teams. Appropriate member of the team Include: registered nurse, midwife, doctor, pharmacist, laboratory scientific officer and phlebotomist. Adverse reactions related to any fluid or drugs given through a cannula Include: neurogenic, anaphylactic and hypovolaemic shock, cardio-genic shock, septic shock and allergy. Performance criteria You need to: 1. Read the patient s notes, prescription and relevant protocol or clinical guideline and identify any special instructions, investigations (including abnormal blood test results), baseline parameters such as weight, or issues for which you need to seek advice. 2. Confirm that the parenteral route is the most appropriate route for administration of injectable medication to the patient (i.e. consider and exclude oral or other routes of administration). 3. Determine the appropriate regimen for the patient, which medication to prescribe, dose, frequency, route, rate of administration, type and frequency of monitoring e.g., blood test results, clinical assessment and body weight measurements. 4. Assess the appropriateness of the intended treatment against the patient s current health status and concurrent medication, particularly in relation to intended therapeutic outcomes and potential drug interactions with concurrent medication. 5. Prescribe according to legislation, national and local prescribing guidelines and relevant clinical information to ensure safe and optimal delivery of treatment. Include the following in the prescription for injectable medicines: Patient s name, hospital/nhs Number, date of birth or address; the allergy status of the patient; date and time; the approved name of the injectable medication (in full, do not abbreviate); the dose and frequency (ensuring, where necessary,

15 Page 15 of 38 TCP 021 that recent parameters have been used to calculate dose, for example, weight and laboratory test results); the route of administration, for example, intravenous, sub-cutaneous, epidural; date and time for re-assessment of the prescription; start and finish date/time or maximum number of doses; prescriber s signature. Where relevant, the prescription or a readily available local protocol must specifiy the following: brand name and formulation of the medicine; concentration of the total quantity of medicine in the final infusion container or syringe; name and volume of diluent or infusion fluid; rate and duration of administration; stability information concerning the medicine to help determine the correct expiry date and time; type of rate control infusion device or pump required; the age and weight of all children under the age of 16 years; arrangement for fluid balance or clinical minitoring should be made on an individual basis and according to local protocol and clinical need. 6. Process the prescription legibly, ensuring your intention for treatment is clear, accurate and complete, and that there are no ambiguities. 7. Record requirements for monitoring the patient s response to treatment (for example, frequency and type of blood tests and weight measurement) in the patient s notes and communicate requirements to professional colleagues. 8. Record the reason(s) for any deviations from the clinical guidelines on the prescription and in the patient s notes. 9. Explain the treatment and potential side effects and their management to the patient and/or carer and accurately answer any questions at a level and pace that is appropriate to: their level of understanding; their culture and background; their preferred ways of communicating; their needs. 10. Check that the patient and/or carer understand the treatment to be given and any potential side effects together with their management. 11. Modify any subsequent prescriptions in light of the patient s tolerance, side effects, complications, monitored

16 Page 16 of 38 TCP 021 parameters and response to treatment. 12. Communicate with appropriate professional colleagues as required by local guidelines. 13. Recognise when you need help and seek advice and support from an appropriate source when the needs of the individual and the complexity of the case are beyond your competence and capability. Knowledge and understanding You need to apply: Legislation, regulations and guidelines 14. An in-depth understanding of national and local injectable medication guidelines and their application. 15. A working understanding of the local guidelines for patient records, their storage and confidentiality of information. 16. An in-depth understanding of the national and local prescribing guidelines. 17. A working understanding of the Guidelines on the Administration of Medicines. 18. A working understanding of local guidelines for waste and sharps handling and disposal. 19. A working understanding of risk management and patient safety principles and causes of medication errors. Clinical knowledge 20. An in-depth understanding of the disease progression and the potential impact on physiological systems. 21. An in-depth understanding of the relevance of other treatment modalities and clinical conditions. 22. An in-depth understanding of diagnosis, care plan, protocol and guidelines. 23. An in-depth understanding of principles and practice of prescribing injectable medication. 24. An in-depth understanding of the indications and contraindications for the injectable medication. 25. An in-depth understanding of drug calculations appropriate to the prescribed injectable medication, dose dilution and length of delivery. 26. An in-depth understanding of the side effects of injectable medicines and their assessment, monitoring, prevention and management. Technical knowledge 27. A working understanding of different venous access devices and their care. 28. A working understanding of administration by the subcutaneous route, and intravenous bolus and/or infusions.

17 Page 17 of 38 TCP 021 Procedures and patient management 29. A factual knowledge of the roles and responsibilities of other team members. 30. A working understanding of the limits of one s own knowledge and experience and the importance of not operating beyond these.

18 Page 18 of 38 TCP 021 NPSA workforce competence March 2007 statement on prescribing injectable medicines Word file available at Workforce competence statement Injectable medicines competence 2 Preparation of injectable medicines Summary Indicative links to KSF Dimension & Level Origin Activity scope This practice competence is directly applicable to healthcare professionals who undertake the preparation of injectable medicines in clinical areas prior to administration to adults or children. It includes interpretation of the prescribed instruction, reviewing indications and contraindications for use, calculation of administration volume and rate of administration, and preparation and labelling of the injectable medication in readiness for administration. Health and wellbeing HWB7: Interventions and treatments Level 3: Plan, deliver and evaluate interventions and/or treatments This is a new workforce competence proposed and developed by the National Patient Safety Agency (NPSA). Prescription The document which describes the medication determined by a properly authorised individual for an individually named patient. It includes the medication to be used, the dose, dilution, mode of delivery and time period for delivery. Monitoring regimen A systematic plan for observing the physiological impact of prescribed medication therapy, enabling subsequent Competent Y/N

19 Page 19 of 38 TCP 021 adjustment to maintain or improve the health of a patient. Communication with professional colleagues includes communication within and between appropriate members of teams. Appropriate members of the team Include: registered nurse, midwife, doctor, pharmacist, laboratory scientific officer and phlebotomist or any other member of the healthcare team. Adverse reactions related to any fluid or drugs given through a cannula Include: neurogenic, anaphylactic and hypovolaemic shock, cardiogenic shock, septic shock and allergy. Performance criteria You need to: 1. Read the patient s notes, prescription and relevant protocol or clinical guideline and identify any special instructions, investigations (including abnormal blood test results), baseline parameters such as weight, or issues for which you need to seek advice. 2. Confirm that the prescription has been written clearly and fully to enable accurate and safe interpretation of the therapeutic instruction intended by the prescription, and also safe preparation. The prescription should include the following: patient s name, hospital/nhs number, date of birth or address; the allergy status of the patient; date and time; the approved name of the injectable medication (in full, do not abbreviate); the dose and frequency (ensuring, where necessary, that recent parameters have been used to calculate dose, for example, weight and laboratory test results); the route of administration, for example, intravenous, sub-cutaneous, epidural; date and time for re-assessment of the prescription; start and finish date/time or maximum number of doses; prescriber s signature. Where relevant, the prescription or a readily available local protocol must specify the following: brand name and formulation of the medicine; concentration of the total quantity of medicine in the final infusion container or syringe; name and volume of diluent or infusion fluid; rate and duration of administration; stability information concerning the medicine to help

20 Page 20 of 38 TCP 021 determine the correct expiry date and time; type of rate control infusion device or pump required; the age and weight of all children under the age of 16 years; arrangement for fluid balance or clinical minitoring should be made on an individual basis and according to local protocol and clinical need. 3. Confirm that the parenteral route is the most appropriate route for administration of medication to the patient (i.e. consider and exclude oral or other routes of administration). 4. Assess the appropriateness of the intended treatment against the patient s current health status and concurrent medication. 5. Check the medication against the treatment plan, prescription, patient information and local protocol with regard to: patient s identification on prescription chart and on labelled medication; allergy status (where relevant for the medication involved); critical test results (including blood results); regimen and individual medication name; name of medication; the medication s fitness for administration (assessed by appearance and condition); diluents and dilution volumes; dose; administration route and duration; type of infusion control device or pump; expiry date/time of the medication. 6. Assemble the required materials in a clean location designated for the task. This area should be uncluttered and free from interruption and distraction. Materials will include; medication ampoules/vials, diluent, needle(s), alcohol wipes, disposable protective gloves, clean reuseable plastic tray and sharps bin for disposal of waste. 7. Check that the medication selected matches with the product prescribed. Check packaging and containers for damage and ensure that the materials have not passed their expiry date. Check that storage up to this point has been as required, for example, in the fridge. 8. Calculate the volume of medication required to give the prescribed dose. Make a record of the calculation in the patient s notes and arrange for an appropriate co-worker to check the calculation.

21 Page 21 of 38 TCP Prepare the label for the prepared medication. 10. Cleanse hands according to local policy and put on a pair of disposable gloves. Disinfect the surface of the plastic tray in which preparation is to be undertaken. 11. Prepare and arrange the medication, diluents and needles on the tray and using a non-touch technique (i.e. avoid touching areas where bacterial contamination may be introduced), prepare the medication according to prescription requirements, with reference to relevant technical information, NPSA guidance on Safer use of injectable medication and Health and Safety procedures. 12. Immediately label the prepared medication. Do not leave unlabelled syringes or infusion bags unattended or in the presence of other unlabelled medication, as this may lead to error. 13. If multiple preparations of injectable medications are being undertaken, or if there is a delay between preparation and administration, syringes and infusion fluids should be labelled immediately, according to local policy. 14. Place the final syringe or infusion, the empty ampoule/vial and prescription chart in a clean tray for transportation to the patient for immediate administration. 15. Where a monitoring regimen has been prescribed, ensure that appropriate documentation for recording monitored parameters is made available, for example, fluid balance chart. 16. Record the reason(s) for any deviations from the clinical guidelines on the prescription and in the patient s notes. 17. Communicate with appropriate professional colleagues as required by local guidelines. 18. Recognise when you need help and seek advice and support from an appropriate source when the needs of the individual and the complexity of the case are beyond your competence and capability. Knowledge and understanding You need to apply: Legislation, regulations and guidelines 1. An in-depth understanding of national and local injectable medication guidelines and their application. 2. A working understanding of the local guidelines for patient records, their storage and confidentiality of information. 3. An in-depth understanding of the national and local prescribing guidelines.

22 Page 22 of 38 TCP A working understanding of the Guidelines on the Administration of Medicines. 5. A working understanding of local guidelines for waste and sharps handling and disposal. 6. A working understanding of risk management and patient safety principles and causes of medication errors. Clinical knowledge 7. A working understanding of the disease progression and the potential impact on physiological systems. 8. A working understanding of the relevance of other treatment modalities and clinical conditions. 9. An in-depth understanding of diagnosis, care plan, protocol and guidelines. 10. An in-depth understanding of the principles and practice of prescribing injectable medication. 11. An in-depth understanding of the indications and contraindications for injectable medication. 12. An in-depth understanding of drug calculations appropriate to the prescribed injectable medication, dose dilution and length of delivery. 13. An in-depth understanding of the side effects of injectable medicines and their assessment, monitoring, prevention and management. Technical knowledge 14. A working understanding of different venous access devices and their care. 15. A working understanding of administration by the subcutaneous route, and intravenous bolus and/or infusions. Procedures and patient management 16. A factual knowledge of the roles and responsibilities of other team members. 17. A working understanding of the limits of one s own knowledge and experience, and the importance of not operating beyond these.

23 Page 23 of 38 TCP 021 NPSA workforce competence March 2007 statement on prescribing injectable medicines Word file available at Workforce competence statement Injectable medicines competence 3 Administration of injectable medicines Summary Indicative links to KSF Dimension & Level Origin Activity scope This practice competence is directly applicable to healthcare professionals who undertake the administration of injectable medicines to adults or children. It covers the preparation and administration of injectable medicines. It includes the assessment of the patient s fitness for treatment, the checking of the treatment drugs against the prescription and patient information, calculation of the amount needed to deliver the required dose, drug administration and the education of the patient/carer with regard to benefits and side effects. Health and wellbeing HWB7: Interventions and treatments Level 3: Plan, deliver and evaluate interventions and/or treatments This is a new workforce competence proposed and developed by the National Patient Safety Agency (NPSA). Key words and concepts Prescription The document which describes the medication determined by a properly authorised individual for an individually named patient. It includes the medication to be used, the dose, dilution, mode of delivery and time period for delivery. Monitoring regimen A systematic plan for observing the physiological impact of Competent Y/N

24 Page 24 of 38 TCP 021 prescribed medication therapy, enabling subsequent adjustment to maintain or improve the health of a patient. Communication with professional colleagues includes communication within and between appropriate members of teams. Appropriate members of the team Include: registered nurse, midwife, doctor, pharmacist, laboratory scientific officer and phlebotomist. Adverse reactions related to any fluid or drugs given through a cannula Include: neurogenic, anaphylactic and hypovolaemic shock, cardiogenic shock, septic shock and allergy. Performance criteria You need to: 1. Read the patient s notes, prescription and relevant regimen protocol and identify any special instructions, investigations (including abnormal blood test results) or issues for which you need to seek advice. 2. Greet and accurately identify the patient. 3. Introduce yourself and any colleagues involved in the procedure to the patient and/or carer. 4. Assess the patient s physical condition and their fitness for treatment, and seek advice from an appropriate team member if required. 5. Check the medications against the treatment plan, prescription, patient information and local protocol with regard to: patient s identification on prescription chart and on any labelled medication; allergy status (where relevant for the medication involved); critical test results (including blood results); regimen; name of medication; the medication s fitness for administration (assessed by appearance and condition); diluents and dilution volumes; dose (ensuring where necessary, that recent parameters have been used to calculate dose, for example, weight and laboratory test results); administration route, rate and duration of treatment; expiry date/time of the medication; arrangements for fluid balance and clinical monitoring should be made on an individual basis and according to local protocol and clinical need. 6. Explain the treatment and potential side effects/adverse

25 Page 25 of 38 TCP 021 reaction and their management to the patient and/or carer and accurately answer any questions at a level and pace that is appropriate to: their level of understanding; their culture and background; their preferred ways of communicating; their needs. 7. Check that the patient and/or carer understand the treatment to be given and any potential side effects together with their management. 8. Prepare the dose, carrying out calculations, dilutions etc in accordance with local policy and with reference to technical information provided for the medication. 9. Undertake a final check of the medication against the prescription and the patient s identity before administration, according to local checking procedures. 10. Give the required medication via the prescribed route, at the prescribed rate according to local medicines administration guidelines, local control of infection and Control of Substances Hazardous to Health (COSHH) guidelines. 11. After administration, observe the patient and the site of administration to monitor for immediate adverse effects. 12. Record the administration in the patient s notes, prescription chart and/or patient-held records, as appropriate, according to local guidelines. 13. Dispose of waste materials (sharps etc) in accordance with local guidelines. 14. Communicate with appropriate professional colleagues as required by local guidelines. 15. Recognise when you need help and seek advice and support from an appropriate source when the needs of the individual and the complexity of the case are beyond your competence and capability. Knowledge and understanding Legislation, regulations and guidelines 1. An in-depth understanding of national and local injectable medication guidelines and their application. 2. A working understanding of the local guidelines for patient records, their storage and confidentiality of information. 3. An in-depth understanding of the national and local prescribing guidelines. 4. An in-depth understanding of the Guidelines on the Administration of Medicines. 5. A working understanding of local guidelines for waste

26 Page 26 of 38 TCP 021 and sharps handling and disposal. 6. A working understanding of risk management and patient safety principles and causes of medication errors. Clinical knowledge 7. A working understanding of the disease progression and the potential impact on physiological systems. 8. A working understanding of the relevance of other treatment modalities and clinical conditions. 9. An in-depth understanding of diagnosis, care plan, protocol and guidelines. 10. An in-depth understanding of principles and practice of prescribing injectable medication. 11. An in-depth understanding of the indications and contraindications for the injectable medication. 12. An in-depth understanding of drug calculations appropriate to the prescribed injectable medication, dose dilution and length of delivery. 13. An in-depth understanding of the side effects of injectable medicines, and their assessment, monitoring, prevention and management. Technical knowledge 14. A working understanding of different venous access devices and their care. 15. A working understanding of administration by the subcutaneous route, and intravenous bolus and/or infusions. Procedures and patient management 16. A factual knowledge of the roles and responsibilities of other team members. 17. A working understanding of the limits of one s own knowledge and experience, and the importance of not operating beyond these.

27 Page 27 of 38 TCP 021 NPSA workforce competence March 2007 statement on prescribing injectable medicines Word file available at Workforce competence statement Injectable medicines competence 4 Monitoring the administration of injectable medicines Summary Indicative links to KSF Dimension & level Origin Activity scope This workforce competence covers monitoring the administration of injectable medicines for adults or children. It includes the initiation and delivery of a monitoring regimen Health and wellbeing HWB7: Interventions and treatments Level 3: Plan, deliver and evaluate interventions and/or treatments This is a new workforce competence proposed and developed by the National Patient Safety Agency (NPSA). Prescription The document which describes the medication determined by a properly authorised individual for an individually named patient. It includes the medication to be used, the dose, dilution, mode of delivery and time period for delivery. Monitoring regimen A systematic plan for observing the physiological impact of prescribed medication therapy, enabling subsequent adjustment to maintain or improve the health of a patient. Communication with professional colleagues includes communication within and between appropriate members of teams. Appropriate members of the team Include: registered nurse, midwife, doctor, pharmacist, laboratory scientific officer and phlebotomist or any other member of the healthcare team. Adverse reactions related to any fluid or drugs given Competent Y/N

28 Page 28 of 38 TCP 021 through a cannula Include: neurogenic, anaphylactic and hypovolaemic shock, cardiogenic shock, septic shock and allergy. Performance criteria You need to: 1. Read the patient s notes, prescription and relevant protocol or clinical guideline and note any previously identified special instructions, investigations (including abnormal blood test results), baseline parameters such as weight, or issues for which you need to seek advice. The arrangements for fluid balance or clinical monitoring should be made on an individual basis and according to local protocol and clinical need. 2. Assess the appropriateness of the intended treatment against the patient s current health status and concurrent medication. 3. Refer to technical infor mation relating to the injectable medication being prescribed and identify any monitoring recommendations for which you need to seek advice. 4. Determine the appropriate regimen for the patient and include both type and frequency of monitoring activity. Give consideration to fluid balance, potential effect of interaction between concurrent medications, adverse reactions, access site, laboratory tests and physical parameters, for example, weight. 5. Record requirements for monitoring the patient s response to treatment and record the reason(s) for any deviations from the clinical guidelines in the patient s notes. Communicate requirements to professional colleagues. 6. Explain the treatment and potential side effects, monitoring regimen and their management to the patient and/or carer and accurately answer any questions at a level and pace that is appropriate to: their level of understanding; their culture and background; their preferred ways of communicating; their needs. 7. Check that the patient and/or carer understand the treatment to be given and any potential side effects together with their management. Communicate the role that the patient and/or carer can play in the early alert of staff to adverse reactions to medication therapy and how this assists the monitoring process. 8. Ensure that local arrangements are in place to deliver the monitoring regimen requested according to local policy.

29 Page 29 of 38 TCP Record the results of monitoring in the patient s notes, on the prescription chart, or on the monitoring chart according to local policy. 10. Communicate results of monitoring to members of the clinical team and ensure that any deviations from expected monitoring results are communicated in a timely way to appropriate members of the team so that action can be taken. 11. Modify any subsequent prescriptions in light of the patient s tolerance, side effects, adverse reactions, complications and response to treatment. 12. Communicate with appropriate professional colleagues as required by local guidelines. 13. Recognise when you need help and seek advice and support from an appropriate source when the needs of the individual and the complexity of the case are beyond your competence and capability. Knowledge and understanding You need to apply: Legislation, regulations and guidelines 1. An in-depth understanding of national and local injectable medication therapy guidelines and their application. 2. A working understanding of the local guidelines for patient records, their storage and confidentiality of information. 3. An in-depth understanding of the national and local prescribing guidelines. 4. A working understanding of the Guidelines on the Administration of Medicines. 5. A working understanding of local guidelines for waste and sharps handling and disposal. 6. A working understanding of risk management, patient safety principles and causes of medication errors. Clinical knowledge 7. A working understanding of the disease progression and the potential impact on physiological systems. 8. A working understanding of the relevance of other treatment modalities and clinical conditions. 9. An in-depth understanding of diagnosis, care plan, protocol and guidelines. 10. An in-depth understanding of principles and practice of prescribing injectable medication therapy. 11. An in-depth understanding of the indications and contraindications for injectable medication therapy. 12. An in-depth understanding of drug calculations

30 Page 30 of 38 TCP 021 appropriate to the prescribed injectable medication; dose dilution and length of delivery. 13. An in-depth understanding of the side effects of injectable medicines, and their assessment, monitoring, prevention and management. Technical knowledge 14. A working understanding of different venous access devices and their care. 15. A working understanding of administration by the subcutaneous route, and intravenous bolus and/or infusions. Procedures and patient management 16. A factual knowledge of the roles and responsibilities of other team members. 17. A working understanding of the limits of one s own knowledge and experience, and the importance of not operating beyond these.

31 Page 31 of 38 TCP 021 Appendix 3 Promoting safer use of injectable medicines A standard operating procedure for: prescribing, preparing and administering injectable medicines in clinical areas Introduction The use of injectable medication has many healthcare benefits for patients. The complexities associated with the prescription, preparation and administration of injectable medicines means that there are greater potential risks for patients than for other routes of administration. Weak operating systems increase the potential risk of harm, and safe systems of work are needed to minimise these risks. Step 1: Prescribing 1.1 All prescriptions for injectable medicines must specify the following:. patient s name;. prescriber s signature;. the approved medicine name;. the dose and frequency of administration;. the date and route of administration;. the allergy status of the patient Where relevant, the prescription, or a readily available local protocol, must specify the following:. brand name and formulation of the medicine; concentration or total quantity of medicine in the final infusion container or syringe;. name and volume of diluent and/or infusion fluid;. rate and duration of administration;. stability information to determine the expiry date of the final product;. type of rate-control pump or device(s) to be used;. the age and weight of any patient under 16 years of age, where relevant;