Medication Administration

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Social Care

Introduction
In many social care settings the administration of medication has become an integral part of the job description of some social care staff. In recent years the inspection reports of the regulatory bodies in all UK areas have highlighted the administration of medication as an area of weakness, where potentially life threatening mistakes could be made. There is however, at the present time, no consistency and few accredited training courses in place for care staff on medication. Unlike S/NVQs and other recognised social care qualifications, there is little similar training available on medication which staff can attain to demonstrate competence. It has been left to social care providers to access ad hoc and local initiatives, either from the local pharmacist, training college or other training providers, courses which vary so much in content that the safe administration of medication cannot be assured. This practice guide is not intended to be a policy and procedures manual, these should be put in place locally for each situation and service user group. This guide will highlight the basic principles of safe medication administration and raise awareness of care staff in diverse social care settings, of the importance of the safe handling and administration of medication to service users. Staff in childrens services may not be required to administer medication as frequently/regularly as in other care settings for example older people's services, however, they must ensure their knowledge and practice is up to date, as practice principles apply in every setting (Further information regarding the Administration and Control of Medicines in Care Homes and Childrens Settings is available from The Royal Pharmaceutical Society of Great Britain.)

Issues to be addressed
The Top Ten The following headings are the main areas of safe medication procedure which should be addressed by care staff and each section listed below should be described within locally held medication policies and procedures. 1. Ordering medicines This must be done by a responsible person working within locally defined protocols. There are three main groups of medication as defined by the Medicines Act 1968 and these are:General Sale List (GSL) These medicines can be purchased from any shop. Pharmacy Only (PO) These medicines may only be purchased from a pharmacy. Prescription Only Medicines (POM) These medicines can only be obtained with a prescription. In care and domiciliary settings many medication orders will be repeat prescriptions. Staff must ensure that when re-ordering all of the following are correct: name of service user name and strength of medication amount ordered will be sufficient for the specified time period

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As a matter of best practice, all service users medication should be reviewed every 3 months or as required by the professional prescribing the medication in conjunction with the pharmacist and the care setting. 2. Storage of medicines All medication needs to be stored in a clean, lockable, secure facility so that they cannot be mixed up with other peoples medicines and cannot be stolen. If a trolley is used this must be secured to the wall when not in use and be big enough to hold all medication required. In communal care settings staff must ensure medication is stored in a designated place, at an appropriate temperature e.g. room temperature or in a fridge if necessary and protected from light. In domiciliary settings staff need to ensure service users are aware of the correct way of storing their medication at home and advise against areas that are too damp, too warm or unhygienic for storing medicine. Controlled drugs must be stored in cupboards that comply with the Misuse of Drugs (Safe Custody) Regulations 1972 as amended. Controlled Drugs cabinets should be reserved for controlled drugs only, holding nothing else it is not a safe and should not hold jewellery, cigarettes etc. A separate bound Controlled Drugs Register (CDR) must be kept to record all controlled drugs held. Any stock of stored medication should be audited, rotated and checked for expiry dates on a regular basis (see section 7 for further information.) 3. Administration of medicines All organisations should have in place their own local policies and procedures for the safe administration of medication for that particular care setting. Safe administration is defined as medicines given in such a way as to avoid causing harm to the person taking the medicine. Apart from homely remedies, a prescription must always be obtained from a registered medical/dental practitioner or a nurse prescriber, for any medicine administered to another person. Medicines must never be removed from their original containers or bottles in which they were dispensed by the pharmacist. This includes Monitored Dosage systems (MDS) or other compliance aids. Staff must always follow set procedures within their care settings and adhere to the main principals of safe administration. identify the medication correctly identify the person correctly know what the medicine is intended to do know whether any special precautions are needed

(See the rights of safe medication listed below). Under no circumstances should medication prescribed for one person be given to another, even if they are both on the same medicine.

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Medicine must only be dispensed from its container at the time of administration for the person for whom it is intended. It must never be decanted into another container or given to someone at a later time. Staff need to be aware that medicines can have two names, the generic name based on the medicines main ingredient like paracetamol and its propriety/trade name like Anadin. 4. Self-administration on medicines Self medication is the term used to describe the service user storing and administering medicines for their own use. All individuals should be encouraged to self administer their own medicines, however, where this is not possible the medication should be handed over to staff for administration. It should be noted that the service user still retains their legal rights concerning their medication, as any medication prescribed for a particular person remains their personal property. In all care settings where the service user wishes to self-medicate a risk assessment must be carried out according the organisations self-administration risk assessment policy. The purpose of the risk assessments is to: Ensure that the service user can administer their medication without supervision. Ensure that all medicine is taken as prescribed by the service users GP. Minimise the risk to the service user or to others. Ensure that security and control can be maintained, with the service user taking responsibility for the storage of their own medicine.

Organisations have a duty of care to all service users and staff and this must be taken into consideration when assessing the competency of a service user to self-medicate. If a dispute occurs regarding competency, an independent person like the GP may be called to advise, however, the final decision rests with the person responsible. Staff should do regular compliance checks to ensure the service user is taking their medication as prescribed and offer support if needed to continue safe self-medication administration. 5. Recording and record keeping As previously stated medicines are the property of the service user for whom they are prescribed, however, providers are required to keep records of medicine used by service users, ensure that there are regular reviews of medication being taken by service users and a record kept within the service users care/support plan. All medication records should be referenced back to the original prescription and not the previous Medicine Administration Record (MAR) chart. An up to date record of current medication prescribed for each service user must be maintained. Medicine records should be kept together in once place. All records should be clear, legible, in black ink and signed. Providers need to keep a record of the initials and full signatures of all staff that are in any way involved with the care and administration of medication. Each provider should have in place policies and procedures which describe the following: 3 Ordering of medicines; receipt of medicines; MAR charts; the disposal/destruction of medicines.
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It is not the purpose of this practice guide to give details for the above, as each care setting will require the procedures to be specific to that setting, however, the principals and content will be similar. The main purpose of medication recording should be to provide an accurate audit trail from the initial prescription to the final disposal of the medicine. 6. Homely remedies (Non prescribed medication) Homely or household remedies refer to medicines that can be obtained without a prescription from a retail chemist/pharmacy or supermarket/convenience store. Examples of homely remedies are: - antacids; mild analgesics; cough medicine; decongestants; antihistamines; anti-diarrhoea preparations; laxatives and vitamins. Staff must always check with the pharmacist that homely remedies will not have any adverse interactions with the prescribed medication the service user is already using. Home remedies must be fully documented and their administration recorded in the service user MAR sheet. The GP, pharmacist and provider should compile an agreed list of homely remedies and this should be regularly reviewed. A running total of all stock held should be kept to ensure there is an audit trail of when and to whom these medications are being given. Staff should also ensure they know what these homely remedies contain as an accidental overdose, for example paracetamol, may occur if the service user is taking medication which already contains paracetamol. 7. Controlled drugs A definition of Controlled Drugs is: - dangerous or otherwise harmful substances which are designated a controlled drug under the Misuse of Drugs Act 1971 and subsequent regulations and amendments. There may be situations where a service user is prescribed as part of an ongoing treatment programme, a medicine that is controlled under the Dangerous Drug Act (e.g. methadone, which is extensively used in the maintenance therapy of drug users addicted to heroin and other opioid drugs.) All such medicine entering a centre must be reported to senior management and recorded in a separate bound Controlled Drugs Register (CDR). All entries must have the date; service users name; medication name, strength; dosage; time of administration; running total of stock and be signed by two appropriately trained staff. These drugs should be stored inside a locked metal cupboard. The cupboard should be securely fastened to the wall. Only staff with authorised access to the drug cupboard are permitted to hold the controlled drugs cupboard keys and these keys should never be given to a member of staff who is not permitted to access controlled drugs. The keys must be kept on the person of a designated member of staff at all times and signed for at each shift changeover of staff in a book kept especially for this purpose. As detailed in previous sections above, the organisation needs to put in place policies and procedures that cover the following, where controlled drugs are concerned :-

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uses of controlled drugs; safe administration; storage and security; disposal of controlled drugs and controlled drugs register.

Any discrepancies in the number of controlled drugs must be reported immediately to the designated person in charge. The registration authority (CSCI, Care Commission) must be informed and if necessary the police. 8. Common side effects from medicines All medicines can potentially cause side effects or adverse reactions and these can vary from person to person. Side effects may be minor or extreme enough to be life threatening. Common side effects include :- rashes; stiffness; breathing difficulties; shaking; swelling; headaches; nausea; drowsiness; vomiting; constipation; diarrhoea; weight gain, - this list is not exhaustive. Side effects can either present as one symptom or as a combination of symptoms. Staff must monitor all medication given and record any adverse reactions in the service users care/support plans. The service users GP must be contacted and the medication stopped until informed otherwise. All medication should come with a description leaflet, which lists possible side effects. These should be retained for future reference. If medication for service users come in MDS packs then the pharmacist should be contacted for information on all medication dispensed in this manner. Older people are particularly susceptible to reacting adversely to medication and are often already taking many different types of medication (polypharmacy). Staff should be particularly vigilant with older people. Common adverse reaction symptoms in older people are: - restlessness; falls; confusion; drowsiness; depression; constipation; incontinence and Parkinsons symptoms. Policies and procedures should be put in place locally, describing the steps to be followed in the event of an adverse reaction to a medicine, whether minor or life threatening. 9. Errors associated with the administration of medicine Medication errors happen, but when they do it is important that there is a no blame policy that encourages staff to report errors immediately. An error in the administration of a medicine can be at best inconvenient or at worse fatal. Common medication errors include; 5 under administration; over administration; incorrect medication; incorrect prescription; non administration; non recording; administration of wrong medicine to wrong service user administration at wrong time.

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When any error in administering medication occurs, the local procedure must be followed immediately and should include the following steps: Report immediately to line manager and follow directions given Report immediately to the prescriber/GP/pharmacist and follow direction given If serious error is made the service user may need hospital treatment Document error fully

All incidents should be fully investigated, the results documented and every possible action taken to prevent the mistake happening again. If serious negligence or an attempt to cover up the mistake is discovered, this should be treated as a disciplinary offence. Failure to record medication errors is a Registration Offence for qualified staff and should be reported to the NMC. The Care Commission and CSCI also require to be notified of medication errors. 10. Disposal of medicine Dispensed medication for individual service users either at home or in a care setting can be described as household waste or is covered by the Hazardous Waste Regulations 2005. These medications can be returned to the dispensing pharmacist for disposal. However, care situations that provide nursing care are not covered by this legislation and must make their own arrangements for the disposal of unwanted medicine through a licensed waste management company. There should be a written policy in place which describes the local procedure for recording of unwanted medication to be returned to the pharmacist. All medication should be recorded and signed for by the receiving pharmacist and a copy kept by the organisation.

The rights of safe medication administration The right service user Check identity of the service user The right medicine Check identity of medicine to be given The right dose Check the amount to be given, be careful to distinguish between strength and the quantity to be given The right time Check time of day for the medicine to be taken The right route Check the route by which the medicine is to be administered and follow procedures for that route Adapted from Dimond, B (2002) Legal Aspects of Nursing, 3rd edition, Longman, LONDON and Smith, J. (2004) Building a safer NHS for patients Improving Medication Safety, DOH, HMSO, LONDON.]

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Principles of good practice getting the basics right.

Number 1 Principle People have freedom of choice in relation to their medicines. Individuals must consent to take medication and it is within their rights to refuse to take medication. People with altered mental states may refuse due to their inability to discern their need to take medication. It therefore may be necessary to devise strategies to encourage service users to take their medication as prescribed without resorting to coercion or deception. Any refusal should be recorded and a risk assessment regarding medication done. They are also free to self-medicate Care staff know what medicines each individual is taking. Staff should familiarise themselves with what medication each service user is taking on a regular basis and why each medicine has been prescribed and the condition for which they are being treated. Medicines are given safely and correctly. See rights on previous page. Medicines are stored safely. Check the recommended storage instructions for each medicine temperature, light, use by date etc. Staff who help people with their medicines are competent to do so. All staff should receive instruction/training before being allowed to administer medication without supervision. A complete account of medicines is kept. All medication should be recorded on each individual service users MAR sheet, including homely remedies. The dignity and privacy of the individual is preserved when medicines are given. Not all medication is administered by mouth. Therefore any topical/ invasive routes of administration or for those service users who have difficulty in swallowing, medicines should be given in private. Medicines for individuals are available when needed. All prescriptions should be ordered on a regular basis to ensure continuous supply. Systems and timing of medication administration should be person centred and not dictated by other organisational needs and timetables. The social care service has access to advice from a pharmacist. Organisations should foster good relationships with the local pharmacist, whose expertise will assist in providing information and support. Contact details of the local pharmacist should be readily available so that staff can contact the pharmacist as required. Medicines are only used to cure or prevent disease or to relieve symptoms and not to punish or control behaviour. Medication should never be used as a means of restraint under any circumstances. Unwanted medicines are disposed of safely. See Top Ten number Ten.

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Prescribed medicines are the property of the person to whom they have been prescribed and dispensed. Medication should not be shared or borrowed from another persons supply. Once a medicinal product has been prescribed to an individual, the medicine is then that persons own property and to use it for someone else is theft.
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Legal and ethical issues

Accountability In the administration of medication, the staff member responsible must exercise accountability by: Acting in a manner as to promote and safeguard the interests and well being of the service users. Ensure that no action or omission is made which would be detrimental to the interests, condition or safety of the service users. Maintain and improve their competence. Acknowledge any limitations in knowledge and competence and decline any duties and responsibilities they are unable to perform in a safe manner until given proper instruction to fulfil the task.

In establishments where trained nursing staff are employed, the nurse is responsible for his/her own practice and must work within the NMC guidelines for the administration of medicines. Where a nurse delegates any responsibility to another care worker, the nurse must ensure the competence of the care worker and that the delegation does not compromise existing care. The nurse remains responsible and accountable for the appropriateness of the delegation. The National Minimum Standards require the registered person puts in place policies and procedures for the receipt, recording, storage, administration and disposal of medicines. These policies and procedures are to protect not only the service users but also staff, who are responsible for the administration of medication. All staff have a duty of care to the service users and should be appropriately trained before undertaking any medication administration. Understanding the legal framework The Medicines Acts 1968 and various amendments cover the legal management of medication. While care staff are not expected to have detailed knowledge of the legislation, they do need to be aware of the legal difference between types of drugs and the legal framework that allows them to handle medicines on behalf of the service user. The following is a list of legislation that has a direct impact upon the handling of medication within a social care setting. 8 The Medicines Act 1968 The Misuse of Drugs Act 1971 The Misuse of Drugs (Safe Custody) Regulations 1973 SI 1973 No 798 as amended by Misuse of Drugs Regulations 2001 The NHS Scotland Pharmaceutical Service (Regulations) 1995 The Social Work (Scotland) Act 1968 as amended by The Regulation of Care Act 2001 The Children Act 1989 The Childrens Act (Scotland) 1995 The Data Protection Act 1998 The Care Standards Act 2000 The Regulation of Care (Scotland) Act 2001 The Health and Social Care Act 2001 Adults with Incapacity (Scotland) Act 2000
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The Health Act 200 Health and Safety at Work Act (1974) The Control of Substances Hazardous to health Regulations (1999-COSHH) Hazardous Waste Regulations (2005) Mental Capacity Act (2005) The Access to health records Act (1990)

This list is not exhaustive and organisations should enable all staff to access documentation pertinent to the administration of medication like the examples listed above.

This practice guide was produced for practitioners by SCA Social Care Practice Sub committee with particular acknowledgement of the work of Nancy Hamilton.

SCA March 2008

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