Professional guidance on the administration of medicines in healthcare settings

Professional guidance to support the safe administration of medicines across healthcare settings.

Published: 31 January 2019

Updated: 31 January 2023

This was published when the organisation was the Royal Pharmaceutical Society.

Introduction

This professional guidance has been co-produced by the Royal Pharmaceutical Society (now the Royal College of Pharmacy) and Royal College of Nursing (RCN) and provides principles-based guidance to ensure the safe administration of medicines by healthcare professionals.

One of the roles of a professional body is to develop professional standards and guidance that are supportive, enabling and professionally challenging. The importance of professional standards and guidance alongside regulatory standards in supporting patient safety has been repeatedly emphasised^1,2,3.

The guidance was developed in response to the announcement of the withdrawal of the Medicines Management Standard by the Nursing and Midwifery Council and will be hosted on the RCPharm and RCN websites. Application of this guidance is a multidisciplinary responsibility. All staff groups involved in the administration of medicines should be involved in developing organisational policies and procedures.

In addition to corporate and clinical governance responsibilities, registered healthcare professionals are personally responsible for putting patients first and for a commitment to ethics, values, principles and improvement. They are also responsible for practicing within their own scope and competence, using their acquired knowledge, skills and judgement.

The Royal College of Pharmacy (RCPharm) is the body responsible for the leadership and support of the pharmacy profession within England, Scotland and Wales.

The Royal College of Nursing is a professional body and a trade union representing nursing staff working in the public, private and voluntary sectors.

How the guidance was developed

This guidance was developed following an eight-week consultation as part of the project on the Safe and Secure Handling of Medicines and was overseen by a multidisciplinary Task and Finish group including service users. Details of those who responded to the consultation and of those individuals involved in the development of this guidance are acknowledged in the Professional Guidance on the Safe and Secure Handling of Medicines.

If you have any comments on this guidance, please contact the RCPharm Professional Support team at [email protected]. If you have suggestions for additional resources or practice guidance, please contact the RCN Advice Team on 0345 772 6100.

Scope

The guidance is aimed at registered healthcare professionals; the principles however, can be applied in any healthcare setting by any persons administering medicines.

The clinical elements of the prescribing of medicines (such as choice of medicine, treatment duration and method of administration) are beyond the scope of this guidance.

The guidance applies across the UK.

Administration of medicines

1. Medicines are administered in accordance with a prescription, Patient Specific Direction⁴, Patient Group Direction⁵ or other relevant exemption specified in the Human Medicines Regulations 2012 (Schedules 17 and 19, as amended)⁶. Medicines that are not Prescription Only Medicines may be administered according to a locally agreed homely remedy protocol^7,8. The different legal mechanisms that are used for the prescribing, supply and administration of medicines are described in Medicines Matters⁹.

2. Organisational policies define who can administer medicines, or when appropriate delegate the administration of medicines, within a particular setting.

3. The organisation has a policy for self administration of medicines. Patients maintain responsibility for the administration of some or all of their medicines, during a stay in the healthcare setting, unless a risk assessment indicates otherwise.

4. The risk assessment incorporates elements such as any risks to the patient or others, the patient’s ability to manage the tasks involved and consent. Such risk assessments are repeated as necessary.

4.1. The assessment determines whether:

4.1.1. the storage and administration of the patients’ medicines remain under the supervision of a healthcare professional.

4.1.2. the patients’ medicines are stored under the supervision of a healthcare professional and the patient self- administers under supervision.

4.1.3. the patient assumes full responsibility for the storage and self administration of the medicine.

5. Records are kept of any assessment undertaken and the outcome. The record includes details, including the time and date, of the patient’s agreement to assume responsibility of the self-administration of their medicines, where appropriate.

6. Processes are in place to ensure that the patient has access to an adequate supply of the correct medicines taking into account any changes made to patients’ medicines whilst in the healthcare setting. These are appropriately stored so that they are fit for use, and so that the medicines cannot be subject to unauthorised removal e.g. by other patients or visitors.

7. Registered healthcare professionals who administer medicines, or when appropriate delegate¹⁰ the administration of medicines, are accountable for their actions, non-actions and omissions, and exercise professionalism and professional judgement at all times.

8. Those administering medicines are appropriately trained, assessed as competent and meet relevant professional and regulatory standards and guidance.

9. There are organisational policies and procedures in use for the medicines administration process. (See also 15 below.)

10. Wherever possible, the actions of prescribing, dispensing/supply and administration are performed by separate healthcare professionals. Exceptionally, where clinical circumstances make it necessary and in the interests of the patient, the same healthcare professional can be responsible for the prescribing and supply/administration of medicines. Where this occurs, an audit trail, documents and processes are in place to limit errors.

11. The organisation has a procedure to minimise the risks associated with the handling or administration of a medicine.

12. Suitable equipment and devices which aid the administration of medicines are available.

13. Sufficient information about the medicine is available to enable identification and correct use of the medicine.

14. Before administration, the person administering the medicine must have an overall understanding of the medicine being administered and seeks advice if necessary from a prescriber or a pharmacy professional.

15. The organisation’s administration procedure is followed. This may include, but is not limited to, checking the following:

15.1. The identity of the patient.

15.2. The prescription or other direction to administer meets legal requirements, is unambiguous and includes where appropriate the name, form (or route of administration), strength, and dose of the medicine to be administered.

15.3. That issues around consent have been considered^{11,12,13,14,15,16,17,18,19,20}.

15.4. Allergies or previous adverse drug reactions.

15.5. The directions for administration (e.g. timing and frequency of administration, route of administration and start and finish dates where appropriate).

15.5.1. any ambiguities or concerns regarding the direction for administration of the medicine are raised with the prescriber or a pharmacy professional without delay.

15.5.2. Any calculations needed are double checked where practicable by a second person and uncertainties raised with the prescriber or a pharmacy professional.

15.6. The identity of the medicine (or medical gas) and its expiry date (where available).

15.7. That any specific storage requirements have been maintained.

15.8. That the dose has not already been administered by someone else (including patient or carers).

16. A risk assessment informs organisational policies/procedures for second signatories, witness requirements, and delegating.

17. Records are kept of all medicines administered or withheld, as well as those declined. (See also the professional guidance on the safe and secure handling of medicines.)

17.1. Such records are completed at the time of the administration/refusal or as soon as possible thereafter and are clear, legible and auditable.

17.2. Where a medicine is not administered or refused, details of the reason why (if known) are included in the record and, where appropriate, the prescriber multidisciplinary team is notified in accordance with the organisation policies and procedures. Appropriate action is taken as necessary.

18. Any adverse drug reaction experienced is managed in accordance with the organisation policy/procedures. Where appropriate, details of the reaction are documented and reported nationally (i.e. as a Yellow Card²¹) or through local risk management systems (i.e. into the National Reporting and Learning System²²).

19. Controlled drugs (CDs) are administered in line with relevant legislation and organisational policies/procedures. (See also the professional guidance on the safe and secure handling of medicines.)

20. In exceptional circumstances, where a change or addition to the administration details is required and a delay in administering a medicine (other than a Schedule 2 CD) would compromise patient care, verbal orders are used. The process is underpinned by risk assessments and organisational policy and/or procedures.

20.1. Where appropriate, the prescriber requesting the changes provides a prescription or amends the drug chart or medication administration record containing the new administration details as soon as possible (ideally within 24 hours).

20.2. If the prescriber is unable to issue a new prescription or amend the drug chart or medication administration record, the changes are communicated by an appropriately secure electronic method. The patient’s records are updated.

Covert administration

21. Medicines are administered covertly only to people who actively refuse their medication and who are considered to lack mental capacity²³ in accordance with an agreed management plan.

22. Where deemed necessary, covert administration of medicines takes place within the context of existing legal and best practice frameworks (see below).

23. There are organisational policies and procedures in place covering covert administration.

Further guidance on covert administration

Adults with Incapacity (Scotland) Act 2000. (accessed online 31/01/18)
Department of Health and Social Care. Mental capacity act 2005: deprivation of liberty safeguards. (Accessed online 17/10/18)
Department of Health and Social Care. Mental Health Act 1983: Code of Practice. (Accessed online 29/08/18)
National Institute for Health and Care Excellence. (2017). Guideline NG67: Managing medicines for adults receiving social care in the community.
National Institute for Health and Care Excellence. (2015). Quality Standard QS85: Quality Statement 6: Covert medicines administration.
National Institute for Health and Care Excellence. (2014). Social care guideline SC1: Managing medicines in care homes.
PrescQIPP. (2015). Best practice guidance in covert administration of medicines.

Transcribing

24. Transcribing can be defined as the act of making an exact copy, usually in writing. In the context of this guidance, transcribing is the copying of previously prescribed medicines details to enable their administration in line with legislation (i.e. in accordance with the instructions of a prescriber).

25. Organisational policies and procedures for transcribing are underpinned by risk assessment. Such policies are clear about
who can transcribe, when it can be used, and the difference between transcribing and prescribing.

26. Organisations have safeguards in place to ensure that transcribed information is not inadvertently used as a prescription.

27. Since transcribing is the copying of medicines information for the purposes of administration, it cannot be used in place of prescribing to issue or add new medicines or alter/change original prescriptions.

28. Transcribing is used only in the patient’s best interests to ensure safe and continuous care: ensuring the medication is administered accurately, without undue delay.

29. Those undertaking transcribing are appropriately trained and assessed as competent to do so.

30. An audit trail exists for all transcribed medicines.

31. Medicines are not transcribed where details are illegible, unclear, ambiguous or incomplete. Particular care is taken in transcribing details of high risk medicines such as insulin, anticoagulants, cytotoxics, or controlled drugs.

32. Organisational policy defines the procedure for dealing with errors in transcribed information.

Glossary

COVERT ADMINISTRATION: The defined process whereby a formal decision has been made between healthcare professionals and carers, for medicines to be administered in a disguised format without the knowledge or consent of the patient who lacks mental capacity.
EXEMPTIONS: Specific medicines that certain healthcare professionals can sell, supply and/or administer in the course of their professional practice as specified by the Human Medicines Regulations 2012 (as amended).
HEALTHCARE SETTINGS: Includes: ambulance services, community health services, dental practices, dispensing doctor practices, GP practices, hospitals (NHS and private), mental health community services, pharmacies, private clinics (including physiotherapy and aesthetic), and secure environments.
PATIENT: The term ‘patient’ includes adults, children and young adults, service users, clients and in the in the case of maternity services, women. In some cases, it may also apply to parents and or guardians.
PATIENT GROUP DIRECTION: A written direction that allows the supply and/or administration of a specified medicine
or medicines, by named authorised health professionals, to a well-defined group of patients requiring treatment of a specific condition.
PATIENT SPECIFIC DIRECTION: An instruction from a doctor, dentist or other independent prescriber for a medicine to be supplied or administered to a named patient after the prescriber has assessed that patient on an individual basis. e.g. written direction in patient’s notes or inpatient chart.