Medicines administration: avoiding the pitfalls

Many of the reported incidents of serious harm to patients are related to drug administration errors, particularly when medicines are injected. Our guide to safe administration provides comprehensive advice on avoiding common pitfalls

The administration of medicines is an important aspect of the professional practice of persons whose names are on the Council's register. It is not solely a mechanistic task to be performed in strict compliance with the written prescription of a medical practitioner [or an independent or supplementary prescriber]. It requires thought and the exercise of professional judgement...' (NMC 2010)¹

Of the 100 medication incidents of death or serious harm reported to the National Patient Safety Agency (NPSA) and published in the Safety in Doses report in 2009,² 41% were related to drug administration errors, and 61% of these involved injectable medicines. Thankfully, the majority of errors in primary care resulted in no harm to the patient, but without doubt these errors should not have occurred. More recently reports from both the Department of Health (DH) and the Medical Defence Union (MDU) in 2011 highlighted the prevalence of flu vaccine errors in children.³ So, being mindful of the amount of injectable medicines administered in primary care and the fact that medicine incident reporting in primary care is only at 14% (so prevalence is likely to be higher in reality), it is pertinent to review the process of all drug administration, reflect on why errors are made and consider measures that can be taken to prevent them.

INCIDENT REPORTING

It is vital that reporting takes place so consistent sources of error can be recognised and new ways of working identified to prevent them occurring in the future.

The NPSA, under the umbrella of the NHS, was initially created to monitor all patient safety incidents which included reporting of medication and prescribing errors. The NPSA was responsible for highlighting inaccurate medicines administration such as the devastating incidents of vincristine being administered via the intrathecal route, or enteral medication via intravenous lines and developing systems to ensure they could not happen again. From 1 June 2012 the key functions of the NPSA were transferred to the NHS Commissioning Board Special Health Authority, which will use the National Reporting and Learning System (NRLS)⁴ - a comprehensive database of patient safety information, to improve patient safety via root cause analysis and dissemination of good practice across the NHS.

The NRLS is currently working with healthcare organisations and the royal colleges to improve the reporting of patient safety incidents from general practice so that national learning can be developed. As a registered nurse it is important you are aware of when to report and the reporting process.

The recently-published PRACtICe report,⁵ commissioned by the General Medical Council (GMC) identified prescribing errors in 1 in 20 medicines issued to patients. The most common errors were missing information on dosage, incorrect dosage prescribed, and failing to instigate appropriate monitoring. Although this report looked purely at prescribing and not at the administration of medicines, it highlights the need for any primary care nurses to ensure that their knowledge is up to date, and that they are able to identify prescription errors before they administer medication.

It is pertinent to remember that ultimately the registered nurse who administers any medication takes full accountability and responsibility for it to be administered in its correct dose, via the correct route and in a safe manner. It is no defence to claim a medication was administered exactly as a prescription was written if that prescription has been written incorrectly for the patient it is being administered to. Indeed, in the same way a registered nurse who performs a chronic disease or medication review and fails to instigate appropriate monitoring and follow up would be held accountable for any actions or omissions in his or her practice.⁶

SUPPLY AND ADMINISTRATION

The NMC standards for medicines management¹ state that registrants must only supply and administer medicinal products in accordance with one or more of the following:

Patient specific directions (PSD) - a written instruction from a qualified and registered prescriber, for a medicine including the dose, route, frequency or appliance to a named patient who must be clearly identified on the PSD.

Patient medicines administration chart/medicines administration record (MAR) - this is not a prescription but a direction to administer a medicine; it should be signed by the prescriber. In administering from a MAR chart the registrant takes full accountability for safe and legal administration.

Patient group directions (PGD) - a specific written instruction to supply or administer a medicine to a group of patients who meet inclusion criteria. The patients do not need to be individually named but the registrant must have been assessed as competent to use PGDs and be named on the document.

Medicines Act Exemptions - this is a legal exemption allowing groups of healthcare professionals to sell, supply and administer specified medicines directly to patients.

Prescription forms - Secure stationary with anti-forgery features)⁶

If you use any of these methods to administer medicines then it is your responsibility to have a working knowledge of them and have undertaken the correct training to be able to use them.

Common drug administration errors

The NPSA reports the four commonest medication error themes in primary care are:

• Vaccinations
• Errors with the writing of the prescription
• Repeat prescribing, and
• Dispensing.

Vaccinations are a large part of primary care practice, and both the childhood immunisation programme and the annual influenza vaccination programme are usually nurse led services. The commonest errors made with vaccination administration are the incorrect vaccine being given, incorrect information being documented in the patient's record or delays in receiving immunisations. Other drug administration errors include administering to the incorrect patient, the wrong dose being given and the wrong route being used.

HOW CAN ERRORS BE PREVENTED?

Drug administration errors can be prevented if you follow the NMC standard for practice of administration of medicines, which clearly outline the steps you should take to safely administer a medicine. Using the 5 R's approach is a simple way of encompassing all the elements of the standard in an easier to remember format.

• Right patient
• Right medicine
• Right dose
• Right route
• Right time

The right patient

In hospitals, patient wear a wristband with identifying details, but in primary care this is not the case. It is important to remember that in a small population there may be many family members with the same surname, and forenames are often carried through as a family tradition. To prevent errors in administering to the incorrect patient ask them to tell you their name and to give you at least one other form of identifier such as their date of birth. Do not simply ask if they are 'Mr Smith'. You should be aware of being distracted when there are several members of a family attending together, and check carefully you have the right patient and are documenting information in the right set of notes when family members have the same name.

The right medicine

Carefully check if the patient can have that medication, have you looked at their plan of care? Have you checked their medical record carefully? Has the patient taken any other medications at home? Remember patients take over the counter preparations and herbal products.

You must know the therapeutic use of the drug, side effects, precautions and potential side effects: if you don't, you must NOT give it.¹

Ask yourself has anything changed since the patient last attended? Are there any new issues that mean this is no longer the right drug for this patient, such as a new pregnancy or diagnosis? If there is any reason it cannot be given you should report it immediately to the prescriber and clearly document this.

You should always ask a patient if they have any allergies each time they attend.¹ Ensure you must know both the generic and the proprietary name and the constituents of the medicines you are giving. The case of Teresa Innes in 2001 clearly highlights this. Teresa was severely allergic to penicillin, she wore a medic alert bracelet, her GP had written it on her admitting letter, she had informed the hospital and it was written on her medicine chart, yet she was prescribed and given co-fluampicil (Magnapen) as the doctor and nurse were not aware it contained penicillin; she later died. See box 7 that draws attention to the different potential allergens of the various different brands of influenza vaccine and which reinforces how difficult it can be.

Any prescription that is not clearly readable or a medicine that is not clearly labelled should not be given until it has been clarified and/or checked, in the same way that you should not be giving any medicine you have not prepared yourself.

Picking up the wrong medicine is perhaps one of the easiest mistakes to make.

Many medicines have similar sounding names:

• Sulfadiazine/sulfasalazine
• Chlorphenamine/chlorpromazine
• Repevax/revaxis
• Dopixol/clopixol

Many are in very similar looking packaging (Figures 1 and 2). Remember that you must be vigilant - it is easy to accidently pick up the wrong box if it has been placed in a different position to usual. Be aware also that it is easy to see what you expect to see on a label, especially if you are in a hurry. (Figures 3 and 4) And finally don't forget to check the expiry date.

The right dose

Is it the right dose for the patient? Don't be afraid to check the British National Formulary (BNF) or BNF for Children to clarify doses, this is good practice and prevents errors. Have you considered the patient's age and or weight? Do they have any concurrent conditions that may indicate dose adjustments such as in renal or hepatic disease? And has the prescriber considered this before writing the prescription?

Some medication brands have different dosing regimes for different age groups such as the influenza vaccines when administered to children. The DH and the MDU³ identified the many brands available, all with different dosing regimes, as the cause for many of the errors in influenza vaccine administration to children. (Table 1)

Some drugs need to be calculated according to the patient's weight, such as clexane; maintain your mathematics skills by undertaking regular calculations practice and 'if in doubt, check it out' - get another person independently to check a calculation with you, and don't be tempted to do it together as it can be easy to influence one another into making an error.

If administering oral liquids ensure they are measured accurately with a purple enteral syringe before administering.⁷

The right route

Has the correct route been prescribed for the drug? In primary care, this may include intravenous or subcutaneous medicines given in the community. If palliative care medications are being given via a syringe driver be aware of mixing criteria and potential interactions. Getting the right route would also encompass local guidance on giving and careful recording of multiple immunisations at one time. It allows easy identification of which immunisation was given into which site - essential for identifying the causative agent if a reaction occurs.

The right time

In secondary care or in a residential care home, getting the timings right usually relates to giving a medication dose at the time of day prescribed on the drug chart. However, in primary care it relates to the correct licensed regime, such as for paediatric immunisations or injectable contraception. It also encompasses medications that have to be given within a certain licensed time span such as emergency contraception. It is essential that these timings are adhered to, thus working within legislation and preventing adverse effects. The DH provides clear guidance on the childhood immunisation programme,⁸ ensure you check this for any changes regularly, and attend your yearly immunisation training update in accordance with HPA immunisation standards.⁹

OTHER WAYS OF PREVENTING ERRORS

The right education

Education is essential for safe drug administration, in addition to the above you should know the time it takes for each medicine to become effective, any advice you should give the patient on potential side effects, including any therapeutic drug monitoring that needs to be undertaken to monitor effect and toxicity and you should know appropriate emergency procedures and have regular resuscitation and anaphylaxis updates.

If you delegate medicines administration to other members of staff, remember you are accountable for delegation to a suitably qualified and competent individual or else you are just as liable as the person who administers incorrectly if they are not competent.

Be aware of the available medicines resources to get information should you require it such as the BNF, MHRA, NICE and the DH websites.

Questioning culture

Never be afraid of questioning a colleague, regardless of their seniority, if you are concerned that something is incorrect.

The NPSA is actively trying to encourage healthcare professions to report incidents so route cause analysis can be undertaken, lessons learned and guidance disseminated throughout the NHS. We should be encouraging the reporting of all 'near misses' and medication errors, regardless of whether the patient is harmed.

The future

The Department of Health announced on 3 July 2012 that it had approval for a common medicines directory, which would include a single drug terminology. NICE is also looking at developing generic national advice to support best practice in medicines management across the NHS. Both of these initiatives will help reduce the risks involved with medicines management especially when patients are moving between different healthcare sectors. These should begin to be published later in 2012.

CONCLUSION

As clinical risk management is developed within local clinical governance, the need for practitioners to work collaboratively to identify and reduce the risks associated with not only administering medications, but also prescribing and supplying of medicines is essential. Such collaborations should look at developing appropriate local guidelines, relevant changes in practice to enhance patient safety and the provision of regular education and training in medicines management issues.

REFERENCES

1. Nursing and Midwifery Council (2010) Standards for medicines management. NMC, London.
2. National Patient Safety Agency (2009) Safety in Doses, improving the use of medicines in the NHS. NPSA, London.
3. Medical Defence Union (2011) GPs urged to be cautious with child flu vaccines (Press release). Available: http://www.the-mdu.com/section_gps_and_primary_care_professionals/topnav_news_3/hidden_Article.asp?articleID=2386&contentType=Media+release&articleTitle=GPs+urged+to+be+cautious+with+child+flu+vaccines (accessed 12/7/12)
4. National Patient Safety Agency (2012) National Reporting and Learning System. Available: http://www.nrls.npsa.nhs.uk/ 5. General Medical Council (2012) Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study. GMC, London
6. Nursing and Midwifery Council (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. NMC, London
7. National Patient Safety Agency (2010) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes. Patient safety alert 19, NPSA, London.
8. Department of Health (2010) Childhood immunisations from November 2010. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_122401.pdf 9. Health Protection Agency (2010) National minimum standards for immunisation training. Available: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1196942164323 (assessed 14/7/12)