Standards for administering, ordering or storage and prescribing of specific medications

1 Aim

The aim of this document is to set down the standards for administering of specific medications within the trust.

2 Link to overarching policy and, or procedure

This document links to the overarching safe and secure handling of medicines manual.

3 Scope

This document covers medications where specific guidance exists, such as medicines and healthcare products regulatory agency (MHRA) guidance. It applies to all areas where these medications are used.

4 General

This document must be read in conjunction with standard 2 administration of medicines within the safe and secure handling of medicines manual.

The Royal Marsden procedures (staff access only) (opens in new window) should be used for guidance on procedures of how to administer medication.

5 Parenteral (injectable) medicines

Guidance on specific parenteral medication can be found in the Medusa injectable medicines guide (staff access only) (opens in new window), along with The Royal Marsden procedures (staff access only) (opens in new window).

All staff administering Injectable medications must have:

up to date anaphylaxis training, along with access to adrenaline
be competent in administering medication through this route
have access to all the necessary equipment needed to administer the medication
knowledge of the medication being administered

Staff administering parenteral medication must have completed approved training and be judged competent by a competent practitioner, being signed off by their line manager prior to reconstitution and administration of an injection.

When administering intravenous (IV) antibiotics in the community the first dose must have been administered in hospital prior to transfer into the community.

The standards outlined in standard 2 administration of medicines must be followed, along with standard 1 prescribing of medicines including clinical trials. Along with standard information the prescription must also include:

use of any diluent
use of any flushes (the relevant PGD can be used, either Heparin sodium to line lock a vascular access device administration (PGD) or Sodium chloride 0.9% injection as a flush administration PGD dependent upon the clinical scenario)
rate of infusion, if not a bolus injection

5.1 Community services including the hospice

For medicines administered via syringe driver or palliative care, staff should follow the syringe driver administration of drugs via the CME medical T34 syringe driver SOP.

For all other injections technical information and risk assessments can be found at Medusa injectable medicines guide (staff access only) (opens in new window).

Under medicines legislation, except in very restricted circumstances, mixing drugs together, where one is not a vehicle for the administration of the other, creates an unlicensed medicine. The person undertaking this preparation, unless an exemption applies, must hold a manufacturer’s license.
Regulation 20 of the Human Medicines Regulations 2012 exempts nurse and pharmacist independent prescribers as well as supplementary prescribers from these restrictions (the manufacturing restrictions do not apply to doctors and dentists, regulation 3 refers.). It allows these prescribers to mix medicines themselves or direct others to mix. Directions must be in writing
The list of acceptable combinations can be found on the Health Improvement Scotland website (opens in new window).

5.2 Administration of IV antibiotics to children in the community

Eligibility criteria:

all referrals for IV medication administration in the community must be discussed with the Community Children’s Nursing (CCN) team before planned discharge. Acceptance may be dependent upon available capacity within community resources; however, wherever possible referrals will be prioritised
the child or young person or their carer or guardian must consent to treatment being continued in the home environment
referrals must be correctly completed on the appropriate CCN team referral form:
- the CCN team reserves the right to decline a referral until the correct information is provided or if the suitability of the home environment compromises the safe administration of the prescribed medication. Referrals will not be accepted on a Friday afternoon for medication on a Monday
the child’s or young person’s health condition must be stable
a treatment review or completion date has been set and documented by the responsible prescriber.
the child or young person must have received the first dose of any medication in a hospital setting prior to discharge
the child or young person must have patent IV access and secure, clean, transparent, adherent dressing applied (UK DH, 2007)
the child or young person must be discharged with the required medication and drug chart or authorisation sheet for CCN team staff to administer the required medication in the community
all medication, including diluents and flushes, needed to complete the course of prescribed treatment will be prescribed and provided by the referring source. Along with enough consumables for the first week of treatment in the community (except a sharps bin). Flushes can be used by employing the patient group directive (PGD) where appropriate
the time of administration and completion of the required medication dose must be within the operational hours of the service (Monday to Friday, 9am to 5pm). Outside of these times these will be agreed with the CCN. During a weekend the child will need to attend the children’s observation unit at Doncaster Royal infirmary and the CCN will arrange this
the IV medication requested must be clinically suitable for the safe administration outside of a hospital setting, for example, consideration of the risk of adverse effects and specific monitoring requirements
the requested medication must be on the RDaSH formulary (Unless specifically requested by microbiology). Consultation with the team leader or nurse consultant for the CCN team must be undertaken if the medication is outside of this list and is clinically indicated
a clean area within the home will be available for the safe preparation of medication and that a home assessment will be conducted by the CCN at the first home visit. Should a suitable area not be available at the time of the home visit the family must be made aware that the CCN will not be able to administer the medication and the child will be required to return to the ward

Exclusion criteria:

eligibility criteria cannot be met
safeguarding concerns
the risk assessment completed at the first home visit highlights areas of concern
there is a known allergy or risk of allergy to the medication or device. History of previous allergic reactions to medication being prescribed or similar group of medicine
administration of antibiotics via intramuscular injection
administration of blood or cytotoxic medication
treatment regimens exceeding once or twice daily doses will only be considered in exceptional circumstances depending on the child’s condition and service capacity, for example, middle day doses where child is still required to attend hospital for early morning or late evening doses

5.3 Nursing or medical responsibilities

The child and family must be discharged with all the medication and equipment for one week. If the CCN team are not informed within enough time to co-ordinate visits or the treatment sheet and, or referral form is not completed appropriately the child will return to the ward for the dose until these are correct.

The CCN or registered children’s nurse administering medications will have completed the trust approved training and be deemed competent to administer IV. Access to injectable medicines guidance will be available at all times via Medusa (staff access only) (opens in new window).

The CCN or registered children’s nurse administering the IV medication will ensure they have the knowledge and understanding of the medication to be administered prior to the home visit. The nurse must confirm:

the indication for use and that there are clear instructions for use, including any monitoring

After a referral to the team has been accepted the CCN will calculate the medication dose, the infusion rate and check recommendations within the current British National Formulary (BNF/C). The adrenaline dose will be calculated and documented within the clinical record and checked by a second registered nurse.

The CCN or registered children’s nurse administering the IV medication will ensure the prescription is:

not for a substance to which the patient is known to be allergic or otherwise unable to tolerate
based, whenever possible, on the patient’s or the patient’s parent or carers’ informed consent and awareness of the purpose of the treatment
clearly written, typed or computer-generated and indelible
specifies the substance to be administered, using its generic name and its stated form, together with the strength, dosage, timing, frequency of administration, start and finish dates, route of administration, flushes, and diluents as necessary and final infusion volume
is signed and dated by the authorised prescriber (NMC, 2010)
that the dose is appropriate for the child or young person’s age, weight and condition
when a calculation of the dose needs to be undertaken to either prepare or administer the medication, these should be done and checked with another qualified nurse. Following assessment of the clinical risks this will be facilitated with a two person visit for the initial visit and should there be no further changes a one person visit thereafter. Where the dose requires complex calculating or there has been a change or is a small dose, for example, 3.3mls. Then there will be a two registered nurse visit each time

5.4 Prescribing

Prior to any administration the nurse must ensure they have a valid prescription or authorization to administer along with all the necessary equipment and medication, which must be in original containers, and stored in accordance with the summary of product characteristics (SPC).

6 Clozapine

Any patients who are prescribed clozapine will be monitored through the clozapine clinics, which are within each of the trust’s localities. For further details staff should refer to the trust Clozapine clinic protocols, or contact their Clozapine local clinic.

Key points:

it is very important that compliance is assured due to the strict requirements for re-titration if it is missed for more than 48 hours
follow the initiation and re-titration guidance in the Clozapine clinic protocols
regularly assess side effects using the clozapine side effect questionnaire on the clinical record

7 Administration of rapid tranquillisation

The trust’s rapid tranquillisation policy and guidelines (pharmacological management of violence) provides guidance on the use of rapid tranquillisation and clinical staff employed in areas where rapid tranquillisation may be used should be familiar with its contents.

They should be aware of when it should be used, and the importance of monitoring.

For further details staff should refer to the rapid tranquillisation policy and guidelines (pharmacological management of violence).

7.1 Flumazenil

The trust has taken the decision, on advice provided by the medicines management committee and the resuscitation committee, not to carry Flumazenil, the antidote to benzodiazepine overdose. This is due to the requirement for it to be given by an intravenous route, and only by specialists, for example, Anaesthetists. Therefore, the use of the grab bag and ringing for an ambulance must be used. The risk assessment that under-pinned this decision will be reviewed annually.

8 Lithium

The prescribing of Lithium to patients will be in line with the trust Lithium monitoring via nurse led clinic policy, and staff should refer to this for further details on treatment and monitoring, including National Patient Safety Agency (NPSA) guidance.

Key points:

regular monitoring of levels and physiological markers
prescribing by specific brand rather than generically
shared care where in use

9 Oral anticoagulants

The prescribing of oral anticoagulants should be in line with the local district formulary.

10 Cytotoxic or cytostatic chemotherapy or medication

An increasing number of patients will be receiving chemotherapy in the community, as the provision of care is moved from secondary care to primary care.
Practitioners administering these drugs parenterally must be deemed to be competent to do so. The Royal Marsden should be followed or the specific directions from the originating prescriber should be sought. They should have a written prescription clearly stating:
- the drug name
- dose rate (if appropriate)
- frequency and timing
- route of administration
- where appropriate, a review date of the treatment
- this should be signed and dated by a prescriber
An assessment should be made of the suitability of the patient’s home environment including telephone access in case of emergency or anaphylaxis.
Administering oral cytotoxic or cytostatic medication in inpatient settings:
- these are identified on the medication chart with the words cytotoxic or cytostatic, which is automatically inserted by SystmOne
- pregnant women should not physically administer these medications, staff should be double gloved. The medication form must not be altered, for example, crushing, prior to administration. If the patient spits out any medication this must be disposed of in the cytotoxic purple lidded bin, ideally without touching it directly
Cytotoxic waste must be disposed of in a cytotoxic waste bin or other receptacle, which should be supplied by the hospital at the same time as the supply of the drug. For further information please refer to the trust’s waste policy, and the poster which is in treatment rooms by the disposal bins

11 Antimicrobials

Authorised prescribers should follow the local integrated care board (ICB) policy for the prescribing of antimicrobials.

As a minimum when prescribing antimicrobials staff must ensure:

clinical indication and duration complies with local guidance
antimicrobials for suspected urinary tract infections should not be prescribed based purely on a urine dipstick
clearly documented in the clinical record and should comply with community guidance in locality for drug selection, dose, and duration of treatment
swab or culture (if indicated). Sample taken prior to initiation or in response to empirical 1st line failure as per guideline, and evidence of review of results
a review of continued appropriateness should be completed within 48 to 72 hours by the treating team, ideally a review can be added to the chart on SystmOne, to remind staff
mark clearly duration or review date or stop date and indication on the drug chart

12 Naloxone ampoules 400mcg

Naloxone injection is an antidote to opiate-induced respiratory depression and should be available in all clinical locations where opioids, such as diamorphine or morphine injections are stored or administered, in line with NHS Commissioning Board Special Health Authority guidance.

12.1 Ward and department

All areas where morphine or diamorphine ampoules are stock items, they must also have naloxone 400mcg ampoules as a stock item.

Naloxone is covered by section 19 of the Human Medicines Regulations covering the emergency use of drugs, and as such can be administered without a prescription; dosing guidance found with the medication must be adhered to.

12.2 Community

Naloxone ampoules will be a stock item at base points and available for use by community nurses when dealing with patients using diamorphine or morphine injections.

Naloxone prefilled syringes may be made available via the substance misuse clinics where agreed, in line with national guidance, identified staff may supply this medication in line with local guidance widening the availability of naloxone (opens in new window).

13 Administration of medication via a percutaneous endoscopic gastrostomy (peg) tube

Patients with PEG tubes may receive medication via this route. The tube should be flushed before and after administration of medication with tap water, inpatients who are immunocompromised then recently boiled water should be used.
Medication should never be mixed with the feed. A chemical or physical reaction may occur, which may adversely affect the drug, food, or both. Guidance should be sought from the prescriber and acute trust, alternatively the use of NEWT guidelines (opens in new window) can be used.

Medication should be prescribed in liquid form to prevent tube blockage. If a drug is not available in liquid form, advice must be sought from a pharmacist or medical practitioner as to whether it can be crushed and flushed down the tube

For details see enteral tube feeding adults policy.

14 Medical gases

The medical gases committee has overall responsibility for reviewing guidance on the use of and training requirements for medical gases

Additional guidance can be found on the intranet (staff access only) (opens in new window), please scroll down to the “clinicalskills.net” section.

With respect to the safe storage of medical gases the following precautions must be observed:

oxygen is mainly available in cylinder form; however, it is also available in piped form in some areas, staff must be aware:
- the source of oxygen in their area of work
- how to use the equipment
- how and when to order further supplies
- need for servicing
the number of cylinders held as stock in any department should be kept to a minimum
cylinders must be firmly secured at all times to prevent them falling over
they should be stored under cover, preferably inside and not subjected to extremes of heat
naked lights must not be allowed within the immediate vicinity of a cylinder
no oil or grease should be applied to the cylinder or tap connector
- allow for segregation of full and empty cylinders and permit separation of different gases within the store
have warning notices posted prohibiting smoking and naked lights within the vicinity of the store
allow for a strict rotation of full cylinders to enable the cylinders with the oldest filling date to be used first
the storage should be designed to prevent unauthorised access and to protect cylinders from theft
excessive force or any tools must not be used to open or close a cylinder valve
cylinders with damaged valves and defective equipment must be labeled appropriately and withdrawn from use
estates must inform the emergency services of the location and contents of the medical gas cylinder store
contact suppliers for more specialist advice where necessary The arrangements for the maintenance and repair of medical devices (which includes flow meters and oxygen regulators) within the trust localities are as below

14.1 Doncaster

A combination of in-house and service level agreements with the Doncaster and Bassetlaw Hospitals NHS Foundation Trust.

14.2 Rotherham

A combination of in-house and service level agreements with the Rotherham NHS Foundation Trust.

14.3 Scunthorpe

Medical physics at Scunthorpe General Hospital, North Lincolnshire, and Goole NHS Foundation Trust.

14.4 Oxygen administration

Patients should be correctly assessed for the use of oxygen. A risk assessment must be included in relation to safety and recorded in the clinical records. Medical grade oxygen is regarded as a drug and may only be prescribed by a doctor or appropriately qualified practitioner. The prescription should include the type of appliance to be used, the appropriate percentage of oxygen, the flow rate, and the duration of administration.
Patients and carers must be educated in the safe use of oxygen in relation to smoking and hygiene of tubing and mask. Concentration of oxygen and duration of administration should be the minimum required for efficacy, and patients and carers should be educated in its safe usage.
Safety guidelines must be adhered to, and appropriate warning notices displayed on vehicles in which oxygen cylinders are transported.

15 Flammable liquids

Flammable liquids are issued from pharmacy and labelled “flammable” COSHH data sheets must be available for all flammable liquids kept on the premises. The data sheets must be kept in a central point available to all staff.

To reduce the risk of combustion or explosion:

keep stock levels to a minimum
avoid spillage
keep bottle closed. Replace the screw cap immediately after use
keep well away from naked flame or electrical apparatus
do not store in a refrigerator
store all flammable liquids in a locked metal cupboard that displays an appropriate hazard notice

15.1 Alcohol gel

It should be noted that as alcohol gel is also a highly flammable substance the precautions as stated above must be followed.

If nursing staff need to store alcohol gel in their car it must not be stored anywhere where it would be subject to direct sunlight. Alcohol gel must therefore be stored in nursing bags, pockets and, or in the boot of the car, when not being used.

15.2 Emollients

These contain paraffin and can be highly flammable; MHRA drug safety alerts (opens in new window) must be followed.

16 Dressings

Doncaster community nursing staff will provide dressings in line with the wound care formulary Doncaster
On wards non medicated dressings should routinely be ordered either from the local dressing store in Doncaster or through Regional Supplies

17 Insulin

All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device appropriate to the insulin. Intravenous syringes must never be used for insulin administration.
The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or ‘IU’, are never used.
When community nursing staff are requested to administer insulin, they must have either a prescription or letter of instruction including the brand, dose, and time of each dose. Prior to administration they must assure themselves that the insulin is in date and has been stored appropriately, and that it has not already been given at a duplicate visit.
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.
All healthcare staff involved in prescribing, administering, or monitoring insulin must undertake the online training safe use of insulin, available on ESR. For those senior healthcare assistants and nurses who work within the trust’s physical health community nursing service they must also undertake the Six Steps to Insulin Safety training (opens in new window) (staff will need to register first, it takes about 45 minutes). Evidence of completion should be shared with the staff member’s line manager.

18 Adrenaline

Adrenaline can be administered without a prescription when used in an emergency situation, as listed in schedule 19 of the Medicines Act 2012, staff must be competent to administer adrenaline, in line with life support training.

18.1 Inpatient

Must have Adrenaline accessible in the event of anaphylaxis occurring.

18.2 Clinics

Where injectable medicines are being administered, for example, depot clinics or vaccine clinics adrenaline must be available.

18.3 Community visits

Staff administering long-acting injections (depots) must carry adrenaline with them for the first two injections, and it is advised they carry it routinely.
Community nurses administering injections, such as antibiotics must carry adrenaline with them.

Adrenaline shock packs are available from the trust pharmacy.

Document control

Version: 2.
Unique reference number: 550.
Approved by: Clinical policy review and approval group.
Date approved: 3 October 2023.
Name of originator or author: Senior pharmacist.
Name of responsible individual: Executive medical director or medicines management committee.
Date issued: 26 October 2023.
Review date: 31 October 2026.
Target audience: Trust wide.
Description of change: Title change, update on adrenaline, addition of administering children’s intravenous medication

Page last reviewed: April 24, 2024
Next review due: April 24, 2025

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