ADMINISTRATION AND DISPOSAL OF MEDICINES POLICY

ADMINISTRATION AND DISPOSAL OF MEDICINES POLICY This is a working document and any changes that become necessary to this policy must be notified in writing to the Medicine Management Group via the Chief Pharmacist, East Cheshire Trust THIS POLICY MUST BE READILY ACCESSIBLE AT ALL TIMES AND AT THE POINT WHERE MEDICINES ARE USED. The Medicines Management Group Version 1.0 January 2015 Review: January 2017 1

Policy Title: Executive Summary: Administration and Disposal of Medicines Policy This policy provides guidance to all staff in East Cheshire NHS Trust regarding all aspects of administration and disposal of medicines. Supersedes: Description Amendment(s): of Relevant sections of Safe and Secure Handling of Medicines. Policy New Policy derived from the Safe and Secure Handling of Medicines. This policy will impact on: All health professionals involved in the prescribing, supply, administration and handling of medicines Financial Implications: Financial impact to release staff time to address training needs. Policy Area: Medicines Document Management Reference: Version Number: 1.0 Effective Date: January 2015 Issued By: Chair of Medicines Review Date: January 2017 Management Group Author: Chief Pharmacist Impact Assessment Date: Consultation: Approved by Director: Received for information: APPROVAL RECORD Committees / Group Management clinical and associate directors for each Business Unit Specialist Advice (if required) Pharmacists, Lead nurses / matrons, consultants Other (please specify) Medicines Management Group Medical Director Director of Nursing, Performance & Quality Trust SQS Committee Date Dec 2014 Dec 2014 Dec 2014 Dec 2014 2

POLICY FOR THE ADMINISTRATION AND DISPOSAL OF MEDICINES Table of Contents 1 INTRODUCTION... 4 1.1 Policy Statement... 4 1.2 Definitions... 4 1.3 Organisational Responsibilities... 4 1.4 Planning and Implementation... 5 1.5 Measuring Performance... 6 1.6 Legislation... 6 1.7 Audit... 6 1.8 Review... 6 1.9 Training... 6 1.10 Dignity, Equality and Diversity... 7 2 ADMINISTRATION OF MEDICINES... 8 2.1 Introduction... 8 2.2 Who can administer?... 8 2.3 Checking the Prescription... 8 2.4 Single Nurse Administration of Medicines... 10 2.5 Drug Administration with a Student Nurse / Midwife... 12 2.6 Administration of liquid medicines... 12 2.7 Administration of injectable medicines... 12 2.8. Administration of cytotoxic medicines... 18 2.9 Covert Administration of Medicines (Disguising medication)... 20 2.10 Administration of homely remedies... 20 2.11 Medicine Administration errors... 21 3 DISPOSAL OF MEDICINES... 21 3.1 Introduction... 21 3.2 Disposal and return of medicines not required in clinical areas... 22 3.3 Hazardous Medicines... 24 Appendix one... 25 Appendix two... 30 3

1 INTRODUCTION 1.1 Policy Statement 1.1.1 There are many risks associated with the administration of medicines, often being carried out in busy, noisy environments and with many distractions to the person performing it. The person administering the medicines is often expected to carry out other tasks concurrently (teaching others, managing a patient caseload and dealing with queries). The principle to be adhered to is that the risk of errors or near misses must be reduced to a minimum. This can be achieved by teamwork and excellent clinical knowledge and skills on the part of the health professional The administration of medicines is an event that requires professional judgement. Administration should be undertaken and recorded in a manner, which is clearly understood by the prescriber, nurse, pharmacist and other health care individuals involved in the patients care. This policy guides staff on the principles surrounding the administration and disposal of medicines. The authorisation of a suitably qualified prescriber should be obtained before medicines can be administered to patients; this authorisation can be given in three ways: An instruction written by a suitably qualified prescriber on a Trust prescription chart, or within an electronic prescribing system. In accordance with locally agreed procedures. In accordance with Patient Group Directions 1.2 Definitions 1.2.1 Medicines Management Medicines Management in hospitals encompasses the entire way that medicines are selected, procured, delivered, prescribed, administered, and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes of patient care (Audit Commission 2001). 1.2.2 Registered Nurse Throughout this policy a registered nurse is taken to mean any nurse, midwife and specialist community public health nurses who are registered with the NMC (http://www.nmc-uk.org/registration/useful-information/registrationqualifications/) 1.3 Organisational Responsibilities 1.3.1 Chief Executive 4

Has ultimate responsibility for the implementation and monitoring of the policies in use in the Trust. This responsibility may be delegated to an appropriate colleague. 1.3.2 Medical Director Has Trust Board responsibility for all aspects of medicines management. The Medical Director is responsible for reporting any medicines management issues identified to the Trust Board. 1.3.3 Chair of Medicines Management Group The Chair of the Medicines Management Group has responsibility for coordinating the activities of the Medicines Management Group to ensure that good practice relating to medicines, as described in this policy, becomes embedded in to everyday working practice across the Trust. The Chair will raise any medicines management issues at the Trust SQS Committee. 1.3.4 Chief Pharmacist The Chief Pharmacist has responsibility for ensuring the Trust complies with local and national guidance relating to medicines, and to ensure the service lines are fully informed of their role in maintaining the required standards of practice relating to medicines. 1.3.5 Service lines It is the responsibility of the Clinical Directors and Heads of Service of the service lines to ensure that all staff are trained to carry out the tasks required of them in the prescribing, administration and management of medicines. 1.3.6 Ward / Department Managers Responsibility for the operational implementation of the Medicines Policy, including ensuring staff within their ward / department attends appropriate training. 1.3.7 Pharmacy Staff Responsibility for; providing information and advice to Trust personnel on the handling and storage of medicines used within the Trust, assisting where appropriate in formulating local procedures at ward/departmental/service line ensuring that the laws relating to the safe and secure handling and storage of medicines are complied with. 1.3.8 All staff Are responsible for attending appropriate medicines management training and following guidance set out in this Policy. 1.4 Planning and Implementation This policy has been circulated to the clinical staff in the Service lines for comment The policy will be approved by the Medicines Management Group (MMG). The policy will be uploaded onto the Trust internet policies page and an email containing a link to the policy will be sent to all staff. It is the responsibility of the ward and department managers to inform their staff of the changes in the policy. 5

All staff groups involved in the management of medicines should receive training related to medicines management. The training should be tailored to the requirements of the staff group involved. 1.5 Measuring Performance The Trust may be measured for compliance with NHSLA standard C4 criteria 6, and by the Care Quality Commission 1.6 Legislation 1.7 Audit This policy complies with all relevant legislation and guidelines that are considered to be good practice which relate to the prescribing, supply, storage, security and administration of medicines. East Cheshire NHS Trust recognises its responsibility to check practice in adherence to all trust policies including The Safe and Secure Handling of Medicine Policy through audit. Aspects to be audited as part of a rolling audit programme should include: Administration For example correct documentation of administration / non- administration All audits should be registered with the Trust Department for Clinical Effectiveness. Audit results should be discussed by the Medicines Management Group to identify areas of good and poor practice, and to highlight training needs. A Medicines Management report will be submitted to the Trust SQS Committee twice a year. 1.8 Review It is the responsibility of the Medicines Management Group to review and amend this policy. This policy will be reviewed and up-dated every 2 years. The review of the policy will include feedback from the performance review, audit and training related to the policy. 1.9 Training All staff groups involved in the management of medicines should receive training related to medicines management. The training should be tailored to the requirements of the staff group involved. Aspects of training should include: All groups of staff involved in the management of medicines should receive a medicines management training session as part of their induction 6

Training specifically for medical staff should include sessions about various aspects of medicines management - delivered as part of the F1/F2 training programme Training specifically for nursing staff should include: a training session and assessment for all nurses before undertaking administration of intravenous drugs Training specifically for pharmacy staff should include: completion of a postgraduate certificate / diploma in clinical pharmacy for junior grade pharmacists; attendance of in-house and external training sessions for all pharmacy staff. Training specifically for non-medical prescribers: completion of level 3 / 4 Non-Medical Prescribing Course prior to commencing supplementary / independent prescribing The objectives and contents of all in-house medicines management training should be discussed and approved by the Medicines Management Group. Training needs specifically tailored to individuals, or departments, may be identified following a review and identification of trends from the Trust Drug Incident Reporting scheme. 1.10 Dignity, Equality and Diversity This policy has been impact assessed with regards to dignity, equality and diversity with respect to patient s age, choices, lifestyle and cultural / religious beliefs (see appendix one). 7

2 ADMINISTRATION OF MEDICINES 2.1 Introduction 2.1.1 The responsibilities and accountabilities of Nurses and Midwives are laid down in The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (April 2008) (http://www.nmc-uk.org/) and doctors through the general Medicines Council (http://www.gmc-uk.org/guidance/index.asp). 2.1.2 Medicines must be administered according to the NMC Standards for Medicines Management (2007). 2.1.3 In exercising professional accountability in the best interests of patients, health care professionals must know or ascertain before administration the main therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contra-indications. 2.1.4 The process of administering medicines should be explained to the patient, where appropriate. 2.1.5 Any ambiguity in a prescription must be clarified with the prescriber/ other member of the medical team, or a pharmacist before administration. 2.2 Who can administer? 2.2.1 The following staff are authorised to administer medicines providing they have undertaken the necessary training: A registered nurse A registered midwife A registered medical practitioner or dentist Other professional staff groups in specific clinical areas, provided they have undertaken appropriate Trust approved training e.g. ODA/ODPs in theatres, physiotherapists, radiographers in X-Ray, healthcare assistants in complex care/ophthalmology Agency staff employed through the Trust approved agency may administer medicines independently, in accordance with the limitations above Nursing Auxiliaries, Assistant Practitioners and Healthcare Support Workers may be involved in medicines administration only if they have undertaken approved training and have been formally accredited to do so. Their role is likely to be in ensuring concordance with medicine regimes. Where approved, it will be for administration of a small number of medicines specific to particular clinical areas. The responsibility for medicines administration remains with the registered nurse or registered healthcare professional 2.3 Checking the Prescription 2.3.1 When administering medicines ensure the following are undertaken; 2.3.1.1 Confirmation of patient identity, by visually checking the name band and verbally by asking the patient their name and date of birth. This must be done by two nurses for controlled drugs and some medicines used in paediatrics. 8

2.3.1.2 Ensure that the demographics on the medicine chart match those of the actual patient (i.e. name, date of birth, Hospital number etc). 2.3.1.3 Check the patient does not have an allergy or intolerance to the medicine. Allergies should be documented on the front of the prescription chart and the patient should be wearing a red identity band within the hospital. 2.3.1.4 Check the medicine prescribed is clearly written and unambiguous and, if dosage is weight related, the calculation should be verified (see section 4.7.3 below). 2.3.1.5 Check the correct medicine, formulation, dose and route have been selected. 2.3.1.6 Check precautions and special instructions. 2.3.1.7 Check expiry date of the medicine. For loose tablets that have been supplied in a medicine bottle from Pharmacy, the expiry date should be taken as being 6 months after the date of dispensing unless otherwise stated. 2.3.1.8 Patients own medicines must have been dispensed within the last six months. 2.3.1.9 Ensure the patient receives the prescribed medicine and takes it at the time prescribed. If the patient refuses then this should be escalated to the prescriber. For critical medicines e.g. IV antibiotics, anti-convulsants etc. this should be done within an hour. 2.3.1.10 Do not leave medicines unattended on lockers or in unlocked containers at any time unless for emergency use e.g. GTN spray, salbutamol inhaler. 2.3.1.11 Every section of the medicine chart(s) should be checked to avoid omissions. 2.3.1.12 Report any adverse drug reaction to a prescribed medicine immediately to the prescriber or appropriate member of the team covering the care of the patient. A Trust incident form and yellow card (www.yellowcard.gov.uk) must be completed. 2.3.1.13 Staff should not be interrupted during the preparation and administration of medicines unless there is an emergency. 2.3.1.14 Medicine container labels should not be altered. Medicines that have been removed from their original container should not be administered (with the exception of monitored dosage systems) unless assessed as appropriate by Pharmacy staff. Once taken from their original container the medicine should be administered immediately. 2.3.1.15 If a patient has swallowing difficulties, contact pharmacy for advice regarding crushing tablets or provision of oral liquids. Modified release tablets should not be crushed. 2.3.1.16 In areas where name bands are not worn by patients and where there is, therefore, a possibility of confusion over patient identities, two nurses must perform the administration of medicines. One of these must be a registered nurse. If the second is a nursing auxiliary/health care assistant then they can only be used to check: 9

The patient identity, and That the preparations have been swallowed, inhaled or injected as appropriate Exceptions apply to Outpatient areas, Macmillan Cancer Resource Centre, Community (where only one registered nurse is normally available) and also if a patient refuses to wear a name band on admission. 2.3.1.17 Medicines prepared for administration to a patient; i.e. removed from the container or drawn up in the syringe, and subsequently not used or given to the patient must be destroyed. Medicines must not be returned to the container from which they were removed. If part of an ampoule only is required, the remainder must be discarded. The only exception to this is for multi-dose vials that contain preservative. Always check with pharmacy that multi-dose use is acceptable. 2.3.1.18 Where medicines are omitted document the reason in the nursing record in addition to annotation of the medicine chart. If medicines are unavailable on the ward, every effort should be made to obtain a supply. Failure to supply a medicine to a patient for no good reason will result in completion of an incident form. 2.3.1.19 Make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, ensuring that any written entries and the signature are clear and legible; it is the responsibility of the nurse to ensure that a record is made when delegating the task of administering medicine. 2.3.1.20 When supervising a student nurse or midwife in the administration of medicines, clearly countersign the signature of the student. 2.3.1.21 Midwives should refer to the NMC Midwives rules and code of practice for specific additional information. 2.4 Single Nurse Administration of Medicines 2.4.1 East Cheshire NHS Trust supports the administration of medicines by single registered nurses/medical practitioners providing that the person has demonstrated the necessary level of knowledge and competence. Exceptions to single nurse administration include: Paediatric Patients (single nurse administration is only approved for a specified list of medicines see 4.4.2.1) Injectable medicine administration (including changing IV fluid bags) Where a patient s condition makes it necessary Where a Controlled Drug is involved Where a complex calculation is required When a syringe pump/ driver needs to be programmed Where local circumstances make the involvement of a second person desirable, in the interests of minimising the potential for error (*see below) The above does not apply to community services staff, where single healthcare professional administration is acceptable. However, if a 10

competent second check for a controlled drug is available, this should be utilised, and if a calculation is complex, or unfamiliar, it is the responsibility of the nurse to obtain a second check * Should a practitioner choose to have his/her practice checked, it must be realised that full accountability for the correct administration of the medicine lies wholly with the administering practitioner. Anyone checking is individually accountable for his/her part in the process 2.4.2 Single nurse administration in paediatrics 2.4.2.1 Registered nurses have the option to administer medicines alone, from the list below. Medicines requiring only single nurse check: Paracetamol Ibuprofen Ipratropium Bromide Nebuliser/inhaler Budesonide Nebuliser/inhaler Salbutamol Nebuliser/inhaler Fluticasone inhaler Pancreatin capsules Vitamin E Multivitamins Sodium feredetate Nystatin Emla/Ametop Glycerin suppositories Relaxit enema Phosphate enema Oral antibiotics 2.4.2.2 Each practitioner is accountable for his/her own practice and must ensure at all times that the current policy is not contravened in any way. 2.4.4.3 Any medicine not on the above list requires two nurses to check at least one of who must be an RCN. Where the person administering medicines is not a registered nurse e.g. when a trainee is undergoing instruction, a registered nurse must be present during the whole procedure. In these instances, both nurses must be present throughout the preparation, checking administration and documentation procedure and both nurses will sign the medicine sheet. 2.4.4.4 All nursing staff involved in the administration of medicines to children need to constantly remember that children are particularly vulnerable and that special care should be taken if adult ampoules have to be used. 2.4.4.5 All injections should be prepared away from the child to prevent additional trauma. 2.4.4.6 Independent calculation must be performed using the approved formula, ensuring that the same units are used throughout the calculation. Volume to give = dose required x volume available Dose available 11

2.4.4.7 Most paediatric doses are based on the weight of the child. Where doses are prescribed in micrograms, the dose should always be written in full to avoid any confusion and prevent any potential harm. 2.5 Drug Administration with a Student Nurse / Midwife 2.5.1 Student nurses/midwives may be involved in medicines administration, providing that they are under the direct supervision of a registered practitioner or other authorised person. The accountability for the correct checking and administration remains the responsibility of the authorised qualified person. 2.5.2 Student nurses are able to perform a second check for a qualified nurse administering medicines, although this does not apply to the administration of medicines to paediatric patients. The medications the student nurse can second check will be limited depending on experience: i) During the first year of training the student can check: Non injectable drugs with the exception of Controlled Drugs. Simple IV maintenance fluids with no additives During the second and third year the student can also check: Controlled drugs both oral and parenteral that do not involve complex calculations. Injectable medicines that do not require complex calculation. The type of medicines that are appropriate would include potassium containing fluids, IV vitamins. 2.6 Administration of liquid medicines 2.6.1 Where a liquid medicine dose less than 5ml is to be administered, a medicine spoon is inappropriate. In this situation, a specific oral syringe (purple) should be used. These are available for 1ml increments up to 5ml and 0.1ml increments up to 1ml. Bungs should be used for continual liquid administration including Controlled Drugs to ensure less waste Where large volumes of a liquid medicine are required in adults, a medicine measure may be used e.g. for oral laxatives of 15ml or above. Measures are standard supply issued. 2.7 Administration of injectable medicines 2.7.1 Introduction 2.7.1.1 There are specific additional considerations that need to be taken when preparing and administering medicines by injection. For specific administration guidance and information in relation to intravenous medication, please refer to the current edition of the UCL Hospitals Drug Administration Guide http://www.uclhguide.com/public/ 12

If the drug is not listed, staff should refer to BNF Appendix 6, the BNF C or package insert. Further information is available through the Trust Medicines Information Department on Extension 1268. 2.7.1.2 The principles outlined in NPSA Alert 20: Promoting Safer Use of Injectable Medicines should be adhered to. 2.7.1.3 The principles in the Quality Control North West document Guidance Document Purchasing for Safety should be followed in relation to purchasing injectable. 2.7.1.4 The principles outlined in NPSA Rapid Response Report 002: Heparin Flushes should be adhered to. 2.7.1.5 The procedure for flushing intravenous lines and peripheral cannula must be followed (Royal Marsden Manual of Nursing V8 2011 Procedures Ch.18) and have completed the Trust approved training. Flushes must be prescribed in the usual way, with the exception of sodium chloride 0.9% which is approved for use without prescribing by the Medicines Management Committee. Practitioners (doctors, nurses, midwives, Operating Department Practitioners, physiotherapists registered with their relevant professional body) completing cannulation of a patient must flush the peripheral cannula to check patency after completion of the procedure. 2.7.1.6 It is Trust policy that heparin flushes should not be used as standard practice. Nurses in community, may be asked to administer heparin flushes to patients, who have been prescribed these by another Trust. In this case, extra care should be taken to ensure the strength of heparin supplied, is appropriate to be used as a flush. 2.7.1.7 Additional guidance for the safe use of potassium containing IV solutions is provided in the Trust Intravenous Potassium Policy. 2.7.1.8 Staff administering parenteral medicines must have been successfully assessed as competent in their clinical area and be aware of their professional standards. All new staff in the Trust should complete the Trust IV course and workbook before they are permitted to administer such medicines. The senior nurse in charge of the unit / ward should keep a list of staff assessed as competent to administer intravenous therapy. 2.7.1.9 It is acceptable for authorised personnel to administer medicines prepared in advance of their immediate use only if they have been prepared/dispensed by Pharmacy Aseptic Services. These medicines must be stored and administered in accordance with their labelling and any other relevant directions. 2.7.1.10 Registered and appropriately trained nurses/midwives are permitted to administer any doses, including the first, of intravenous medicines to a patient. The medicine Summary of Product Characteristics (SPC) and the latest edition of the BNF or BNF-C (as appropriate) should be consulted and staff should be familiar with the dose and administration of the medicine. Other information regarding the method of administration, diluent and rate of infusion must be confirmed before administration. The dose should be checked in line with Trust procedures. Nursing staff/midwives administering 13

intravenous medicines must be familiar with the emergency procedures should a patient experience an anaphylactic reaction. 2.7.1.11 All community nurses involved with parenteral administration of medicines, should carry an anaphylaxis kit, and have undertaken anaphylaxis training in the last 12 months. 2.7.1.12 Any ambiguities must be clarified with the prescriber prior to administration of the medicine. 2.7.1.13 Parenteral fluids containing additives must be correctly labelled to show the medicines, dose, volume, diluent, patient s name, ward, date and time or preparation, expiry, the name of the person who prepared it and the name of the person checking. Labels are available from the pharmacy for infusion bags and syringes. The changing of IV fluid bags should be undertaken only by those who are IV trained. 2.7.2 Preparation of Injectable Medicines 2.7.2.1 Practitioners use of central lines to deliver medicines intravenously is gradually increasing as training is made widely available. Some medicines must be given centrally (e.g. noradrenaline). There is a high infection risk associated with giving medicines this way, and requires a skilled practitioner who uses this route in the course of everyday practice (please refer to the UCL guide http://www.uclhguide.com/public/). 2.7.2.2 Medicines must NEVER be added to blood transfusions, blood products, insulin infusions or parenteral nutrition. 2.7.2.3 All injectables prepared on the ward / clinical area must have an intravenous additive label attached to the product. 2.7.2.4 For an IV bolus / infusion not requiring a pump two registered nurses (one may be a doctor or a pharmacist) must check that the medicine, diluent rate, volume (when appropriate) and dose are correct. One of these nurses should then continue with the usual checking procedure prior to administration to the patient. Both nurses should then sign the prescription sheet. The second signature is only a check on the preparation and not the administration. The second checker need not go to the patient s bedside. This excludes the administration of controlled drugs. 2.7.2.5 For IV infusions using a pump two registered nurses (one may be a doctor or a pharmacist) must check that the medicine, diluent, volume and dose of the infusion is correct.the second checker must check the calculation, dosage, preparation and settings of the pump used. This will necessitate going to the patient s bedside. The second signature is a check of all processes involved in the administration of the IV. 2.7.2.6 For IV infusions when the rate of infusion is changed, the new rate on the pump must be second checked. Both staff must sign for this, either on the medicine chart if possible or in the nursing notes. 2.7.2.7 It is recognised as good practice to check infusion pumps at the time of nurse handover, and document this in the nursing notes. 14

2.7.2.8 Nursing auxiliaries may not check or administer IV controlled drugs intravenously at any time. Student nurses may check certain items according to their level of training (see 4.5.2). 2.7.2.9 Pumps should be used for potassium-added fluids and medicines needing accurate administration. Pumps are not necessary for maintenance fluids and antibiotic infusions in small volumes. 2.7.2.10 When an intravenous Patient Controlled Analgesia (PCA) infusion is in progress no other medicines should be given via that intravenous port. However, in exceptional circumstances when a patient is difficult to cannulate and a second cannula has been displaced, other intravenous medicines may be administered via the PCA intravenous port following the same instructions outlined in UCL guide http://www.uclhguide.com/public/ 2.7.2.11 Practitioners must never mix two different medicines without checking with the UCL guide http://www.uclhguide.com/public/ or with pharmacy that they are compatible 2.7.3 Medicine calculations 2.7.3.1 Some medicine administrations can require complex calculations to ensure that the correct volume or dose is administered. The nurse responsible for the administration of the medicine must ensure the calculation is correct. A second practitioner must check the calculation in order to minimise the risk of error. The second check calculation should be made independently of the first one and compared. It can be obtained from: A pharmacist (available during normal working hours and out of hours via the emergency on-call system operated by switchboard) A registered nurse A registered midwife A doctor If there is still doubt that the correct calculation has been made, check again with a senior practitioner. Medicines of any kind must not be given if there is any doubt over the accuracy of the calculation. 2.7.3.2 Nurses administering medicines in patients own home, may do the calculation without a second check, if they are competent to do so. If the calculation is complex, or unfamiliar, it is the responsibility of the nurse to ensure a second check is obtained, as above. 2.7.4 Administration of Injectable Medicines by the Intravenous Route 2.7.4.1 All guidelines in section 4 of this policy should be adhered to. In addition, please refer to the Trust SOP on the Safe Administration of Medicines by the Intravenous Route (appendix two). 2.7.4.2 Prepare and label where appropriate, medicines for injection immediately prior to administration. An exception to this is an already established infusion which has been instigated by another practitioner following the principles set 15

out above, or medicine prepared under the direction of a pharmacist from an aseptic suite and clearly labelled for that patient. In an emergency, where a doctor prepares medicines for injection, you should ensure that the person administering the drug has been part of the preparation process and has undertaken the appropriate checks as indicated in the Trust SOP for the safe administration of medicines by the Intravenous route. 2.7.4.3 Intravenous infusions should NOT be interrupted when a patient leaves the ward to attend another department such as radiology or theatre, other than in exceptional circumstances following discussions with medical staff. 2.7.4.4 If IV maintenance fluids have run out for a patient and no more have been prescribed there is a potential problem that the peripheral cannula could tissue before the prescriber arrives to re-prescribe the fluid. To avoid this problem a registered nurse or midwife assesses as competent in their clinical area may set up a further litre bag of sodium chloride 0.9% to run at a rate of 1 litre over 24 hours, to run for a maximum of 3 hours by which time the prescriber must re-prescribe the fluids. If in doubt please contact the prescriber and ensure that the IV fluid is prescribed before administering. 2.7.5 Administration of Injectable Medicines by the Intramuscular Route 2.7.5.1Many medicines may be administered by this route, provided they are not irritant to soft tissues and are sufficiently soluble. Absorption is usually rapid and can produce blood levels comparable to those achieved by intravenous bolus injection. Relatively large volumes, (from 1ml in the deltoid site to 5ml in the quadracep site) in adults can be given. These values should be halved in children because muscle mass is less. Intramuscular injections should, where possible, be avoided in thrombocytopenic patients and patients on anticoagulants. (Royal Marsden Manual of Clinical Nursing Procedures V8 (2011). 2.7.6 Immunisation 2.7.6.1 The general principles relating to administration of medicines (see 3.1) should be followed when administering immunisation. It is essential that all staff administering immunisations are competent including up dated knowledge of contra-indications and the recognition and treatment of anaphylaxis. Always ensure Resuscitation facilities or an anaphylaxis emergency box is available when administering immunisations and that there is access to the current edition of the Green Book Immunisation against Infections and Disease (HMSO) 2.7.6.2 A record must be kept of the vaccine batch number and the site of the injection if more than one injection is administered. In hospital this should be recorded in the patients notes. In primary care, childhood vaccines will be recorded on the Patient Held Record, child health computer and GP record. Other community-administered vaccines will be documented in the GP record. 2.7.6.3 Patient Group Directions are in place so that immunisations may be administered by appropriately trained registered nurses without an individual, patient specific prescription. 16

2.7.7 Administration of Injectable Medicines by the Subcutaneous Route 2.7.7.1 Hypodermoclysis Staff giving fluids subcutaneously should undergo Trust approved training, be assessed as competent to administer in their clinical area and have a clear understanding of the type of IV fluids that are suitable for subcutaneous use and the volume of IV fluids that can be administered safely via the subcutaneous route. 2.7.7.2 Community nurses, involved with the administration of medicines via a syringe driver, should have undertaken the Trust syringe driver training, at least bi-annually, and should ensure the policy / procedure for the use of syringe drivers within East Cheshire NHS trust is adhered to at all times. 2.7.7.3 Insulin Errors in the administration of insulin by clinical staff are common. In certain cases they may be severe and can cause death. In line with the NPSA Rapid Response Alert 013 issued 16 th June 2010, all staff responsible for the administration of insulin must ensure All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device. Intravenous syringes must never be used for insulin administration All clinical areas and community staff treating patients with insulin have adequate supplies of insulin syringes and subcutaneous needles, which staff can obtain at all times The term units is used for all prescriptions of insulin. Abbreviations, such as U or IU, are never used. Any prescriptions with abbreviated formats of units must be challenged immediately and re-prescribed, clearly endorsing units, before the administration takes place An insulin syringe must always be used to measure and prepare insulin for an intravenous infusion. Insulin infusions are administered in 50ml intravenous syringes or larger infusion bags. Consideration should be given to the supply and use of ready to administer infusion products e.g. prefilled syringes of fast acting insulin 50 units in 50ml sodium chloride 0.9% 2.7.8 Administration of Patient Controlled Analgesia and Epidural Analgesia 2.7.8.1 The preparation and administration of these analgesic infusions is to be carried out by appropriately trained practitioners who have undertaken the Acute Pain Service teaching programme and have been assessed as competent in the practice. 2.7.8.2 Patient Controlled Analgesia (PCA) In order to facilitate continuity of patient care and comply with the principles of medicine security as defined by the pharmaceutical services, Trust guidelines must be followed. Any medicine that is administered in this way must be prescribed and documented on the appropriate Trust PCA prescription and guidelines/ observation chart that complies with the 17

Acute Pain Service Policy (See Acute Pain Service policy file based on every ward/unit) Ready made pre-filled bags should be used as standard practice. It may be necessary to rarely use a custom made bag if the appropriate ready made pre-filled bag is not commercially available Custom made solutions must be identified by the affixed yellow additive label 2.7.8.3 Epidural Analgesia (EA) The principles outlined in NPSA Alert 21: Safer practice with epidural injections and infusions should be followed Medicines that are prescribed and administered in this way must be prescribed and documented on the appropriate Trust EA prescription and guidelines/observation chart that complies with the Acute Pain Service policy Custom made solutions must not be used for epidural analgesia. Ready made pre-filled bags must be used in all cases 2.7.8.4 Replacement of Bag / Syringe of Analgesic Medicine Infusion When an analgesic infusion bag / syringe needs to be replaced, the repeated medicines for infusion must be prescribed and documented on the appropriate prescription and guidelines/observation chart that complies with the Acute Pain Service policy. 2.7.8.5 Duration of PCA and EA infusions Trust procedures must be adhered to when administering analgesic infusions involving custom made solutions (i.e. solutions mixed on the wards / theatres) or drug solutions manufactured in a licensed aseptic unit. PCA infusions The duration of infusion when using ready made bags should not exceed 72 hours, or when using custom made bags should not exceed 24 hours EA infusions The duration of infusion should not exceed the specified expiry time of the bag or the epidural antibacterial filter (96 hours), after which the infusion should be discontinued and both the infusion lines and the medicines are to be removed 2.7.8.6 Disposal of Un-used Solutions Refer to Safe & Secure Handling of Controlled Drugs Policy 2.7.9 Administration of Parenteral Nutrition (PN) See Parenteral nutrition policy for Adults. 2.8. Administration of cytotoxic medicines 2.8.1 Administration of intravenous cytotoxics 2.8.1.1 Only nurses trained in the administration of chemotherapy may administer intravenous cytotoxic medicines. Those administering intravenous cytotoxic 18

medicines must avoid direct contact with cytotoxic medication, and must wear apron and gloves when handling these products. 2.8.1.2 Appointments must be pre-booked. Adequate time according to the regimen should be allowed for each patient. 2.8.1.3 Facilities and staff must be provided to an agreed minimum standard in order for the intravenous chemotherapy and additional supportive medication to be administered professionally and safely. 2.8.1.4 Inpatient chemotherapy is not routinely given in East Cheshire Trust. However, there may be circumstances where a patient who is due to receive outpatient chemotherapy in the Macmillan Cancer Resource Centre is an inpatient but fit to receive the scheduled chemotherapy. In this circumstance the patient may attend the Macmillan Cancer Resource Centre if appropriate or the chemotherapy nurse may administer the chemotherapy to the patient on the ward. 2.8.2 Administration of intramuscular cytotoxics 2.8.2.1 The medical treatment of tubal (ectopic) pregnancies involves the administration of up to two intramuscular doses of methotrexate. 2.8.2.2 Only registered nurses that have undergone the Trust approved appropriate training in the administration of intramuscular methotrexate may administer it. 2.8.2.3 Staff administering intramuscular methotrexate must avoid direct contact with it by wearing an apron and gloves when handling the product. A cytotoxic spillage kit will be provided with the cytotoxic medicines. 2.8.2.4 When administered, the used equipment must be discarded in a purple-lidded sharps bin and sealed. 2.8.3 Administration of subcutaneous cytotoxics 2.8.3.1 The medical treatment of Rheumatoid Arthritis may involve the administration of subcutaneous methotrexate to patients. 2.8.3.2 Only registered nurses that have undergone the Trust approved appropriate training in the administration of subcutaneous methotrexate may administer it. 2.8.3.3 Staff administering subcutaneous methotrexate must avoid direct contact with it by wearing an apron and gloves when handling the product. A cytotoxic spillage kit will be provided with the cytotoxic medicines. 2.8.3.4 When administered, the used equipment must be discarded in a purplelidded sharps bin and sealed. 2.8.4 Administration of oral cytotoxics 2.8.4.1 All oral chemotherapy and other medicines that have been assessed as being Cytotoxic will be labelled clearly with Cytotoxic Drug 19

2.8.4.2 Staff administering oral cytotoxic medicines must avoid direct contact with cytotoxic medication, and must wear apron and gloves when handling these products. 2.8.4.3 Women who are pregnant should not handle cytotoxic medicines. If administration or manipulation of cytotoxic medicines is unavoidable by women who are pregnant, a full risk assessment must be performed by the administrator s line manager before administration/ manipulation takes place. In the event of accidental exposure to oral or IV Chemotherapy or Extravasation, please refer to GMCCN website for guidance www.gmccn.nhs.uk. 2.8.5 Administration of intrathecal cytotoxics Intrathecal chemotherapy is not administered to any patients at East Cheshire NHS Trust. 2.9 Covert Administration of Medicines (Disguising medication) 2.9.1 As a general principle, by disguising medication in food or drink, the patient or client is being led to believe that they are not receiving medication, when in fact they are. The registered nurse or midwife will need to be sure that what they are doing is in the best interests of the patient or client, and be accountable for this decision. 2.9.2 Covert administration should not be confused with the administration of medicines against someone s consent. This policy must be read in conjunction with the Trust s policy Consent to Examination or Treatment. Administering medicines covertly to patients should be carefully considered and there should be adherence to this policy. 2.9.3 The capacity of the patient in relation to medicines should be assessed. If the patient has capacity to consent and refuses medication it cannot then be given covertly. If a patient has not got capacity to consent and refuses medicines then it may be appropriate to administer some medicines covertly. 2.9.4 The decision to use covert medication must be made by the multidisciplinary team (including the presence of the pharmacist) including the views of relatives and carers and any advanced statement or directive made by the patient. 2.9.5 For further information please refer to the Nursing and Midwifery Council advice by topic Covert administration of medicines: Disguising medicine in food and drink. http://www.nmc-uk.org/nurses-and-midwives/advice-bytopic/a/advice/covert-administration-of-medicines/ 2.10 Administration of homely remedies 2.10.1 All registered nursing staff employed by East Cheshire Trust are allowed to administer the following medicines without a prescription to in-patients and 20

Day Case patients of Macclesfield District General Hospital, if they deem themselves competent, and as stipulated in the NMC Code of Conduct http://www.nmc-uk.org/documents/standards/nmcstandardsformedicinesmanagementbooklet.pdf; Paracetamol (for treatment of pain of for reduction of temperature) Senna (for constipation) Glycerin suppositories (for constipation) Gaviscon Advance liquid (for indigestion) 2.10.2 Administration of homely remedies must be documented clearly on the medicine chart as Nurse Administration. 2.10.3 The patient must be reviewed by a Doctor after three doses of a homely remedy have been given. 2.10.4 For dosage instructions of each homely remedy stated above, please refer to the Trust Medicine Chart. 2.11 Medicine Administration errors 2.11.1 All medicine administration errors must be reported using the Trust Incident Reporting process. Any incidents relating to fraud must be reported on Datix and also reported to the Chief Pharmacist. These will be forwarded onto the Local Counter Fraud Officer accordingly. 3 DISPOSAL OF MEDICINES 3.1 Introduction 3.1.1 The pharmacy will have a set of standard operating procedures which considers the return and disposal of waste within pharmacies. 3.1.2 Since July 2005, the disposal of pharmaceutical waste must comply with The Hazardous Waste (England and Wales) Regulations 2005 (SI 2005 No. 894). The storage, carriage, processing and supply of waste are all subject to stringent controls designed to minimise the negative effects of waste on the environment. As the impact of inappropriate handling of waste could have a considerable effect on the environment, the penalties for breach of the regulations are severe. The Environmental Protection (Duty of Care) Regulations 1991 state all persons involved with the production, transport, storage, treatment or disposal of controlled waste must ensure that it is handled and disposed of safely. 3.1.3 Pharmaceutical waste is likely to consist of; pharmaceutical products returned from individuals (patients own medicines that are no longer required), expired or obsolete stock from the pharmacy or from wards and syringes contaminated with remnant medicines from the preparation of medicinal products (e.g. CIVAS products, cytotoxics chemotherapy etc). 3.1.3.1 Pharmaceutical waste can be divided into 3 types of waste: Hazardous waste Non-hazardous waste 21

Not pharmaceutically active and possessing no hazardous properties Most pharmaceutical waste (except cytotoxic or cytostatic agents) is no longer classified as hazardous waste and does not need to be consigned for disposal, but still need to be identified and should be disposed of in a blue lidded yellow bin 3.1.3.2 Best practice suggests that there is a waste transfer note system with the waste contractor to ensure that such waste goes for high temperature incineration. 3.1.3.3 The only medicinal products that are deemed hazardous are cytotoxic and cytostatic medicines. These medicines are defined as products that have one or more of the following hazardous properties: Toxic (H6), Carcinogenic (H7), Mutagenic (H11) or Toxic for Reproduction (H10) and should be disposed of in a purple lidded yellow bin. Hazardous waste is subject to hazardous waste consignment notes. 3.1.3.4 The Hazardous Waste Regulations prohibit the mixing of hazardous waste with non-hazardous waste. Hazardous waste should be disposed of using sharps bins with purple lids. 3.1.3.5 Refer also to the Trust Waste Disposal Policy. The Trust Waste Manager is responsible for raising a consignment note before hazardous waste is removed for incineration off site 3.1.3.6 Under no circumstances must used parenteral products be returned to Pharmacy with administration giving sets or needles. This includes insulin pen devices. 3.2 Disposal and return of medicines not required in clinical areas 3.2.1 Empty containers 3.2.1.1 Empty medicine containers must not be returned to the Pharmacy. Containers with medicine residue must be disposed of in yellow waste bins 3.2.1.2 Ensure that patient names are obliterated from empty containers before disposal. 3.2.2 Patients own medicines 3.2.2.1 Patients own medicines which are no longer required should be sent to Pharmacy. Note: consent must be obtained from the patient before their medication is destroyed or the relatives of deceased patients where appropriate. 3.2.2.2 If the patient uses a compliance aid (e.g. Medidose, etc) that is one that can be re-filled but is no longer required, this should be emptied of medicines and returned to the patient s relatives or the supplying pharmacy wherever possible. 22

3.2.2.3 Community nurses may return medicines to the pharmacy and these should be signed for in the patient record by the pharmacist for audit purposes. 3.2.3 Unused products supplied by Pharmacy Aseptic Services 3.2.3.1 All unused products including antibiotics and parenteral nutrition (PN) must be returned to the Pharmacy for destruction. 3.2.3.2 It must be stored according to the directions on the label until returned to pharmacy 3.2.3.3 All Non-hazardous medicines must be disposed of in a blue lidded yellow bin 3.2.4 Cytotoxic/ Cytostatic Medicine Waste 3.2.4.1 Hazardous waste (cytotoxic and cytostatic waste) must be stored separately from other medicines waste and should be disposed of in yellow sharps bins with purple lids. 3.2.4.2 Hazardous waste is subject to hazardous waste consignment notes. 3.2.5 Part-used medicines UNSUITABLE for re-use: Item Opened vials and ampoules External liquids Oral liquids Used creams and ointments Aerosols/ Sprays Opened suppository or pessary Patches Powders Part used infusion bag or syringe Dropped tablet/capsule Inflammable preparations Eye, ear or nose drops Method Of Disposal Sharps bin (with appropriately coloured lid) Place in a polythene bag (in case of leakage) and place into a sharps bin (with appropriate lid) Place in a polythene bag (in case of leakage) and place into a sharps bin (with appropriate lid) Sharps bin(with appropriately coloured lid) or incineration bag Sharps bin (with appropriate lid) or incineration bag Sharps bin (with appropriate lid) or incineration bag Fold the patch over on itself so that the active ingredient is render irretrievable. Then place in waste container Place the unopened powder into a Sharps bin (with appropriate lid) or incineration bag Sharps bin (with appropriate lid) or incineration bag Sharps bin (with appropriate lid) Large amounts, return to Pharmacy Sharps bin (with appropriate lid) or incineration bag 3.2.6 Part-used medicines SUITABLE for re-use (including in-patient labelled medicines 23

Before returning part used medicines to Pharmacy, please liaise with your ward based team. The ward based team will then place items to be returned to stock in a sealed blue transit bag. The ward based team will be responsible for processing returned ward stock items within the Pharmacy. Items which are to be stored in a refrigerator must be stored according to the instructions on the pack and returned to pharmacy in a blue transit bag clearly label with refrigerated item enclosed. 3.2.7 Expired medicines All expired medicines should be returned to Pharmacy for disposal. 3.2.8 Return of ward stock Before returning ward stock to Pharmacy, please liaise with your ward based team. The ward based team will then place items to be returned to stock in a sealed blue transit bag. The ward based team will be responsible for processing returned ward stock items within the Pharmacy. A review of the ward stock lists should be carried out with the ward manager by the ward pharmacist and pharmacy technician staff every three months. 3.2.9 Return and destruction of Controlled Drugs (CDs) Please refer to the Trust Policy Safe Management of Controlled Drugs 3.2.10 Return and destruction of Clinical Trial Investigational Medicinal products (IMPs): Please ensure that IMPS are not destroyed until a Clinical Trial team member within Pharmacy has been informed as communication with the company will need to have taken place 3.2.10.1 Where the company or organisation co-ordinating or organising the trials provides for the waste removal, the hospital or pharmacy (as the legally responsible party) should ensure that the Trust waste Disposal requirements are met before handing over the waste. 3.2.10.2 It should be noted that accounting for unused investigational medicinal products (IMP) remains the responsibility of the sponsor under the EU Clinical trials Directive. Unused IMPs must not be destroyed or disposed of as medicinal waste without the express permission of the trial sponsor. 3.3 Hazardous Medicines Hazardous medicines are those which contain cytotoxic, cytostatic medication or hormone containing products. Note: Any other medicine which has the properties H6, H7, H10 or H11 is also hazardous. Further advice can be obtained from ward pharmacists or the Medicines Information department on Ext. 1268. 24

Appendix one Equality Analysis (Impact assessment) 1. What is being assessed? The Trust policy for the Administration and Disposal of Medicines Details of person responsible for completing the assessment: Name: Kashif Haque Position: Chief Pharmacist Team/service: Pharmacy State main purpose or aim of the policy, procedure, proposal, strategy or service: This policy provides guidance relating to the Administration and Disposal of medicines for all staff in East Cheshire NHS Trust (ECT). 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 25

3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in 2011. Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester 26

Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) No- none aware of 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? No 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? No Explain your response: Applies equally to all staff employed by the organisation. For patients who can t speak English, translation services are available. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? No Explain your response: Applies equally to all staff employed by the organisation. The Trust has a transgender policy and staff will be mindful of this. DISABILITY: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? No Explain your response: Applies equally to all staff employed by the organisation. Staff need to be mindful of the importance of escalating issues where patients refuse medications, eg learning disability patients refusing anti convulsants. Extra info added into policy at 2.3.1.9 AGE: 27

From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Explain your response: Applies equally to all staff employed by the organisation. No LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? No Explain your response: Applies equally to all staff employed by the organisation. RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? No Explain your response: Applies equally to all staff employed by the organisation. Staff will be aware of issues relating to specific patient groups such as Muslim patients and medications containing porcine products. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? No Explain your response: Applies equally to all staff employed by the organisation. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? No Explain your response: Applies equally to all staff employed by the organisation. 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? No b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children. This policy only relates to staff in relation to the Administration and Disposal of medicines 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that th Policy applies to all patient groups equally. 28

6. Date completed: 28/11/14 Review Date: January 2017 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: 26.2.15 29

Appendix two Procedure 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 must 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 intravenous medicine (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 (i.e. intravenous) 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 should 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 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 monitoring 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 medicine 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 medicine. 5. Check the medicine against the treatment plan, prescription, patient information and local protocol with regard to: 30

patient s identification on prescription chart and on labelled medication allergy status (where relevant for the medicine involved) critical test results (including blood results) regimen and individual medicine name name of medicine the medicine 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 medicine 6. Ensure appropriate documentation for recording monitored parameters is available. 7. Explain the treatment, potential side-effects / adverse reactions and management plan to the patient. 8. Read the product preparation instructions. 9. All staff administering medicines via the intravenous route must maintain a strict Aseptic No Touch Technique (ANTT) in line with Trust policy and follow the Trust peripheral & central intravenous therapy guideline. 10. Assemble the required materials in a clean location designated for the task. This area should be uncluttered and free from interruption and distraction. 11. Check that the medicine 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. 12. Calculate the volume of medicine required to give the prescribed dose. Make a record of the calculation in the patient s notes. Two registered nurses (or one nurse with one doctor or one pharmacist) must check that the medicine and dose of the bolus/ infusion is correct. 13. Prepare the yellow IV additive label for the prepared medicine. 14. Prepare the medicine according to prescription requirements, with reference to relevant technical information, NPSA guidance on Safer use of injectable medication and Health and Safety procedures. 15. Immediately label the prepared medicine. Do not leave unlabelled syringes or infusion bags unattended or in the presence of other unlabelled medicines, as this may lead to error. 16. Place the final syringe or infusion, in a clean tray for transportation to the patient for immediate administration. 31

17. Give the required medication using ANTT following the instruction on the prescription chart. 18. Following administration of the intravenous medicine, observe the patient and site of administration for immediate adverse reaction. 19. Annotate the prescription chart / administration record appropriately following the administration. If administration fails (e.g. loss of IV access), document fully on the prescription chart and the nursing notes. 20. Record any other reason(s) for any deviations from the clinical guidelines on the prescription and in the patient s notes. 21. Communicate with appropriate professional colleagues as required by Trust Policies. 22. 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. The UCL IV guide online can be used as a source of reference for administration and compatibility queries on products http://www.uclhguide.com/public/ 23. Any waste materials should be disposed of in accordance with the Trust Medicines Policy and Trust waste disposal policy. 32