Standards for the administration of medicines within the trust

1 Aim

The aim of this document is to set down the standards for the administration of medicines within the trust; this should be read in conjunction with inpatient standard operating procedures (SOPs) (staff access only) (opens in new window).

2 Link to overarching policy and, or procedure

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

3 Medicines and the law

The Human Medicines Regulations 2012 controls the manufacture, distribution and importation of medicine and requires that medicines available only on prescription must be given as instructed by the authorised prescriber (a doctor, a dentist or a nurse or pharmacist or occupational health practitioner prescriber). Changing the dose or giving prescribed medicines to a different person without the authorised prescriber’s permission is against the law.
While the law states who can prescribe medicines it allows anyone to administer them provided they follow the authorised prescriber’s instructions.
Non-registered practitioners may only administer medicines after receiving appropriate training and assessment at local level in accordance with local guidance.
An epinephrine (adrenaline) injection, Glucagon, Naloxone, Aspirin, Glyceryl Trinitrate may be legally administered without a prescription for the purpose of saving life in an emergency (Section 19 of the Human Medicines regulations). This is in line with the Resuscitation Council guidance, however; it remains a prescription only medicine until such time as it needs to be administered.
The administering of a medicine authorised for a patient will occur by one of three ways:
- by an individual authorised to administer medicines
- by the prescriber
- by the patient or carer who meets agreed self-administration criteria
Where the authority to administer is of questionable legibility, incomplete, or ambiguous to the person authorised to administer, the medicine will be withheld until the instruction has been checked with the prescriber or a new authority issued. Guidance on omitted doses must be followed as to when to contact the prescriber.

A single person administration system is in place with the exception of the following instances:

calculation of complex dose, for example, doses expressed by weight or surface area. This is for the calculation only. It should be done prior to the first dose, and any subsequent changes of treatment. The details of the calculations can be recorded in to the patient’s treatment goals for future reference
administration to children under 16 years of age without parental consent, assessed not to be Fraser competent
administration of controlled drugs. In exceptional circumstances, such as lone workers in special schools, it may be necessary to administer controlled drugs such as Midazolam Buccal without witnesses. In these situations the medication is the patient’s own and not stock
intrathecal injections, hospice
with the exception of emergency medication in the circumstances as stated above medicines can only be administered in line with a valid prescription issued by an authorised prescriber:
- the prescription must be legible, signed, dated, and written in black ink or on an approved electronic prescribing system. The name of the drug, dose, form, route and maximum frequency, in hours, of administration should be stated
- any illegible or ambiguous prescriptions must be brought to the attention of the prescriber, and clarified
for any patients who are subject to Mental Health Act consent to treatment rules, under the mental health act, staff must check that the appropriate consent form is in place and that the treatment to be administered is recorded on the form prior to any medication being administered
where possible patients should only have one prescription chart in use at any given time. Where this is not possible all current prescription charts for the patient are to be marked with the total number of charts in use
the relevant allergy section on the prescription chart must always be completed. If the patient states none ‘none known’ is to be recorded

4 Who has the authority to administer medication?

Medical staff, registered nurses, and student nurses (under the supervision of a registered nurse), nurse associates, trainee nurse associates (Under supervision), pharmacy technicians, health care assistants, who have undergone trust approved training and are deemed competent.
Student nurses will be given every opportunity to become proficient in the administration of drugs under the supervision of a registered nurse. The registered nurse who supervises the student remains accountable for the correct administration of the drug. Both the registered nurse and student are to sign the prescription chart
In community settings a non-registered member of staff may prompt a patient to take their medication or supervise them removing medicine from labelled containers which have the patients name on, or a compliance aid. Under no circumstances are untrained staff to select the medicine(s) on the patient’s behalf
Health care assistants, who have undertaken trust approved training may administer medication to patients, unsupervised, in agreed circumstances, and must follow the same rules as qualified staff. Area’s where this has been agreed are community homes and supported living. Other areas wishing to utilise this must discuss this with their service managers and the chief pharmacist
Non-registered staff that are to be involved in the handling of patients medicines must undergo appropriate competency training.

5 Patient self-administration of medication

5.1 Inpatient services general self medication scheme

Patients in the inpatient services may only undertake routine self-administration of their medicines where a ward has in place a specific local procedure approved by the trust chief pharmacist, and medical director.

Where these are used there must be a regular assessment of compliance, this should be recorded in the patient’s record.

The benefits of such an approach include:

helping patients achieve or maintain a great degree of independence during their stay
identifying compliance issues prior to discharge
improving service user’s knowledge of prescribed medicines
promoting drug administration at the most appropriate time
reducing wastage of primary care derived medication
preventing medicine hoarding and consequent inappropriate resumption of discontinued treatment
minimising delay at discharge

SOPs can be found on the trust website:

self-administration of medication within open and locked rehabilitation and recovery inpatient services
management of medicines on hazel, hawthorn and magnolia wards SOP

6 Specific medicinal products

Where patients are prescribed Glyceryl Trinitrate (GTN) tablets and sprays for the relief of angina pain, or inhalers of β adreno-receptor agonist as bronchodilators, it is appropriate to allow the patient immediate access to the medicines when they are required.

An individual authorized to administer medicines may assess a patient as suitable for this type of self-administration provided the following conditions are met:

the patient understand what their medicines are for and the how to take them correctly
that the self-administration of such medicines has been considered as part of the patient’s multi-disciplinary risk assessment, and the consultant in charge of their care is in agreement
suitable safe keeping arrangements are available to prevent misuse by others. In this case this does not necessarily mean in a locked cupboard
the medicines are labelled with the patients name and instructions for use
a record of the dose and frequency of self-administered medicine is made on the inpatient drug administration chart

7 Community service

Within community services it is a patients right to self-administer their own medicines if willing and able to do so. However, some patients have difficulty managing their medicines safely and sometimes trust staff are the only people to see these patients who can therefore highlight the need for help.

7.1 Patients in the community who are unable to self-administer medication

Trust staff that are caring for or managing patients who are self-administering medication should be aware of factors which can affect a patient’s ability to self-medicate.
Self-administration from dispensed containers may not be possible for some patients and in such cases the advice of a community pharmacist or the patient’s GP must be sought. The most appropriate form of help can then be identified.
If a patient requires a compliance aid such as monitored dose container, this must be dispensed, labelled and sealed by a pharmacy If there is a delay in allocating a pharmacist to fill a compliance aid, staff must inform the patient that trust staff are unable to fill compliance aids due to the risk of error. This information must be clearly documented in the patient’s clinical record if the patient lacks capacity, then Best Interests guidance must be followed.

However, there may be occasions when to support the patient to take their required medication is vital and it is not possible to have the pharmacy fill compliance aids. This is the case with Tuberculosis (TB) medication which is prescribed and dispensed at the hospital. Therefore, community pharmacy will not undertake this task. The RDaSH colleagues within the TB team may need to support the patient and their family to build confidence with this task. If, in exceptional circumstances, when there is no family member who can support the patient with this, the TB nurse needs to dispense their TB treatment medications into a weekly compliance aid (provided by the TB team and contains only the TB medications) this will be undertaken by 2 persons (one of whom must be a qualified nurse) and for the shortest possible period of time. The qualified nurse will record in the electronic patient record the rationale, who filled the container and who checked with them for accuracy.

8 Principles of administration

The individual authorised to administer medicines will be responsible for ensuring they have an understanding of the use, action, usual dose, side effects and handling hazards of the medicine(s) being administered.
This person will ensure they are certain of the identity of the service user to whom the medicine is to be administered before initiating any administration activity, in line with the trust policy on patient identification.
The individual authorised to administer medicines will check that the authorisation for administration is within this policy.
Medication may only be administered against an authorised prescription chart in inpatient settings. The only exceptions to this are drugs covered by Section 19 of the Human Medicines Regulations 2012 for emergency use, medications authorized via verbal orders, and those covered by a patient group direction.

For routes of administration other than oral then the process as described in the Royal Marsden manual (staff access only) (opens in new window)

EPMA training on SystmOne is considered as “essential to role” for prescribers and inpatient staff who administer medication to ensure that:

they have received the prescribing or transcribing or meds administration (as appropriate) as part of their induction training prior to using SystmOne
exceptionally where the need is urgent, for example, urgent start for employed staff or agency staff that their use is through the temporary access card (TAC) available on the ward. Employed staff are to then complete the training at the first available opportunity

9 Action prior to administering medication

Prior to administering any medication the staff member must observe the following principles:

be able to confirm the identity of the patient:
- within an inpatient setting this will be confirming that the name and hospital number expressed on the authorization for administration corresponds with that on the patients identity bracelet or photographic ID, and wherever possible, verbally confirming this detail with the patient themselves
- within a community based setting, or where an inpatient is wearing an identity bracelet or there is no photographic ID, this will be verbally confirming the name, address and date of birth expressed on the authorisation for administration with the patient, or where appropriate, the patient’s carer
check the consent status of the patient and if the patient is subject to consent to treatment guidelines under the mental health act
check that the medicine has not already been administered
check that the drug to be administered has not past its expiry date
give the correct drug, check the label on the drug against the prescription
give the correct dose, if unfamiliar with the drug or dosage, verify before administration
give the drug in the right form, check whether tablets or liquid.
for oral liquid medication in non-standard doses, for example, not multiples of 5ml, approved oral syringes must be used
give the drug at the correct time, it is important to give medication as it is prescribed in order to maintain therapeutic levels of treatment
check that the drug is administered by the route specified, and that the formulation used is appropriate to that route. Administration by enteral feeding tube is covered by the enteral tube feeding adults policy
at no time are any medicines to be left unattended by the administering staff member
where more than one medicine is specified for administration, they will consider whether any of the medicines may dangerously interact with each other

10 Consent to treatment

This must be in line with the trust consent to care and treatment policy.

Wherever possible the proposed medication should be discussed with the patient in a way which gives them the opportunity to openly ask questions and express their agreement with the treatment.

“Consent” within the context of this policy is the voluntary and continuing permission of the patient to receive a particular medication.

However, for a patient to give valid consent or not, they must have capacity. Therefore, the authorised prescriber must first undertake an assessment of the patient’s capacity if they have any concerns, in line with trust policy.

This consent is based on the patient having been provided with:

adequate knowledge of the purpose, nature, and likely effects of the treatment
information as to any commonly known risks associated with the treatment
details as to the likelihood of the treatment succeeding
information about any alternative treatments which are available

Any agreement to proceed with treatment which is given under unfair or undue pressure is not consent (Mental Capacity Act Code of Practice 2005).

It is the duty of everyone proposing to give treatment to use reasonable care and skill, not only in giving information prior to seeking a patients consent, but also in meeting the continuing obligation to provide the patient with adequate information.

All discussions relating to consent to treatment are to be recorded in the patient’s clinical records. The appropriate Mental Health Act (MHA) consent to treatment forms should be completed, if applicable.

Information given to the patient by a pharmacist or other practitioner about the treatment is provided in addition to that given by the prescriber, not as an alternative.

11 Treatment of patient who lack the capacity to consent

Where there any concerns about the patients ability to consent an assessment of capacity should be undertaken.

Where an assessment of capacity has been undertaken evidence that the person lacks capacity must be documented on the appropriate MCA 1 questionnaire in the patient`s clinical record.

If the person lacks capacity a best interests decision under the Mental Capacity Act 2005 (MCA) should be made if treatment cannot be given under the MHA.

Decisions taken on behalf of a person who may lack capacity to make a particular decision for themselves must comply with the requirements of the Mental Capacity Act 2005 and the supporting code of practice in that, “An act done or decision made under this act for or on behalf of a person who lacks capacity must be done, or made in his or her best interest”. (Mental Capacity Act 2005, Code of Practice, page 66). The trust MCA Mental Capacity Act 2005 policymust be followed.

Any decision regarding medication given in a person`s best interests should be recorded on MCA2 questionnaire in the patients clinical record.

12 Treatment of patient detained under the Mental Health Act 1983 (amended by the Mental Health Act 2007)

The Mental Health Act 1983 (amended by the Mental Health Act 2007) (MHA) provides the prescriber with a 3-month period in which to develop a treatment program to meet the patient’s needs (for patients detained under a section of the act which legislates for consent to treatment provision). However, even though the act allows for treatment to be administered without the consent of the patient the prescriber should still adhere to the same principles of seeking consent as described above.

Note, the 3 month period starts from when treatment or medication is first prescribed.

For treatment after this 3 month period the responsible clinician will receive notification from the MHA Administrator within their locality that the patient’s consent to treatment needs to be reviewed and on receipt of this notification the responsible clinician must:

seek the patient’s consent for the treatment to continue beyond the 3-month period
record the discussion in the clinical notes including an assessment of the patient’s ability to consent
if the patient consents to continued treatment, complete a form T2
if the patient refuses consent or is deemed unable to provide a reliable consent, the responsible clinician must request a second opinion doctor (SOAD) visit from the Mental Health Act commission
if the SOAD agrees with the responsible clinician that treatment is necessary and should be given, the SOAD will complete a form T3. The responsible clinician must fill in a form Sn62 (in questionnaires on SystmOne) to cover the period until the SOAD completes the T3
a place holder must be prescribed on the drug chart, and a copy of the document should be available for staff to be able to read

Note, no treatment is to be administered to any patient detained under the Mental Health Act without a check being made that there is a valid T2 or T3 in place.

For further details staff should refer to the Mental Health Act Code of Practice (opens in new window).

13 Checking administration

It is good practice that, wherever possible, all medicines are prepared and administered in the presence of another practitioner. If this is not possible for any reason a single registered nurse may carry out administration, but not for the following:

schedule 2 controlled drugs (staff are to refer to the trust controlled drugs (with the exception of St John’s Hospice and RDaSH physical health community services) SOP)
prior to administration, the calculation of complex doses, including weight related doses, the administration itself may be done by a single practitioner
rapid tranquillisation policy and guidelines (pharmacological management of violence)

The purpose of the second person is as a check of the correct administration of the drug (for example, right patient, right drug, right dose, right route and dose, and form), and that the appropriate paperwork is completed.

Where the second person is a qualified professional they should also review the clinical appropriateness of the dose (this will exclude nurse assistants and pharmacy technicians for example)

It is the administering nurse’s responsibility to observe the patient taking any oral medication.

The following may be appropriate for counter-signatories or witnesses:

registered nurses
doctors
pharmacists
pharmacy technicians (directly employed by the trust)
appropriately trained healthcare professional
nurse associates
student nurses including trainee nurse associates under supervision by someone other than the first signatory
nurse assistants, health care assistants or clinical support workers

14 Complex calculations

These checks, such as for syringe drivers may take place away from the place of administration, such as the district nurse community base. These should only be done by staff competent to work out such calculations.

15 Controlled drugs

Following the administration of the medicine the staff member must sign the prescription chart or medicines administration record (MAR) sheet or make an appropriate entry on an electronic patient record system such as SystmOne. This signature signifies that the patient has taken or been administered the medication. Students administering medication should have their signature countersigned by the supervising practitioner. This should be done once the medication has been administered.

If any medication is not administered, the code must be recorded on the approved administration card or prescription chart using one of the trust’s recognised codes found on the drug chart and or electronic system, an entry made in the clinical records, and the prescriber informed where appropriate. Please see the omitted medication guidance (staff access only) (opens in new window).

Electronic charts, when the administering person does not have access to the SystmOne:

the chart should be printed prior to the member of staff coming on duty, the person administering will sign the paper chart
at the earliest opportunity a person with administration rights will record on the chart that there is a signature on the paper record, with a note to say administered by, for example, agency staff. The paper record should then be scanned into the patient record. The trust can assure the person completing the electronic record that they are only confirming that they have seen the paper record, this is to maintain the administration record on the electronic chart

16 Failure to record the administration or omission of a medication constitutes a medication incident and must be reported

If a patient is absent from the ward, or has missed a dose for some other reason, the delayed dose can be administered at a later time provided the prescriber has confirmed that it is appropriate to do so. If this is the case the actual time of administration is to be recorded on both the prescription chart, and in the patient’s clinical records.

Any patient who is classified ‘nil by mouth’ for any reason is to be given all their prescribed medication unless specifically advised otherwise by medical staff.

17 When a patient who does not receive the medication prescribed (omitted doses)

Inpatients and community patients should have a plan in place as to what to do in the event of them missing the medication for whatever reason; this should be based on the nature of the medication and the potential risks. The trust guidance on omitted doses (staff access only) (opens in new window) must be followed. It should include when to contact the prescriber and any remedial action required.

18 Covert administration of medicines

Covert medication refers to medication that is hidden in food or beverages. The covert administration of medication is the practice of hiding medication in food or beverages so that it will be undetected by the person receiving the medication. Pills may be crushed or medication in liquid form may be used, if it is safe to do so. This practice exclusively applies to patients who lack capacity to consent to the treatment. It is intended to ensure that patients refusing treatment as a result of their illness will have access to effective medical treatment.

As a general principle, by disguising medication in food or drink, the patient is being led to believe that they are not receiving medication, when in fact they are. This is not acceptable as the patient has not consented to its administration. However if the patient lacks capacity and the medication is deemed essential covert administration of medication can be given providing it is in the person best interests, after a best interests meeting has taken place and a covert medication plan is in place. see below for details

The decision and plan will be detailed in the patients care plan and case notes or SystmOne.

18.1 Process for the administration of covert medication

Legal authority to treat: If the MHA is not applicable the MCA Mental Capacity Act 2005 policy should be followed to assess the patient’s capacity to make decisions about their medication. If the person is deemed to have capacity then covert medication cannot be given.

If the person is assessed to lack capacity then a decision should be made in the persons best interests. The courts have said the best interests decision should be made via a best interests meeting involving all interested parties, this includes family, carers, attorneys and advocates as well as professionals.

Covert medication care plan, the method of giving the medication covertly is generated in partnership with a pharmacist. The pharmacy should be contacted to generate a care plan documenting the agreed method, along with any necessary dosage changes (appendix D, see safe and secure handling of medicines manual homepage to access).
Administration, each dose of medication is offered normally, if refused it may then be administered covertly.
Documentation, use of covert medication, and how it is given, should be documented explicitly on the prescription chart.
Safety, systems are in place for safe, optimal practice with a clear audit trail of events, including evidenced reviews.
Review, review by the ward manager and ward multidisciplinary team, on a planned and regular basis.
Supervision, nursing staff giving covert medication have ongoing training or clinical supervision.

The pharmacy service (staff access only) (opens in new window) offers support to all inpatient areas, giving advice on management with covert medication.

19 Use of patient’s own medicines

The trust has a duty of care to ensure that any patients own medicines used while they are under the trust inpatient care are both safe and fit for purpose. The trust acknowledges that medicines brought in are the patient’s property and staff require the permission of the patient to dispose of their medicines.

Medicines brought into hospital by a patient can be administered to them during their stay until new supplies can be obtained from pharmacy. These medicines must be assessed by pharmacy as being suitable for use, for example:

the medicine can be easily identified from the backing on the strip pack or markings on the tablet or capsule
the medicine has not expired and appears to be in a good condition
the medicine is prescribed by an authorised prescriber and is on the inpatient medicine card
the patient does not object to their own supply being used

Patient’s own medication is not to be used if:

there are any doubts about the identity or quality of the medicines
the patient objects, and has capacity, however if they lack capacity and the medication is deemed essential, then a best interests decision must be made in line with trust policy

Note, medicines brought into hospital by one patient must never be used for any other patient.

20 Monitoring arrangement

20.1 Recorded EPMA training of inpatient staff administering medicines

How: Inpatient audit.
Who by: Pharmacy.
Reported to: MMC.
Frequency: Annually.

20.2 Recording of administered doses against inpatient drug card

How: Inpatient audit.
Who by: Pharmacy.
Reported to: MMC.
Frequency: Annually.

20.3 Adherence to covert administration guidance

How: Inpatient audit.
Who by: Pharmacy.
Reported to: MMC.
Frequency: Annually.

Document control

Version: 2.2.
Unique reference number: 549.
Approved by: Clinical policy review and approval group.
Date approved: 6 February 2024.
Name of originator or author: Senior pharmacist.
Name of responsible individual: Executive medical director.
Date issued: 19 February 2024.
Review date: August 2025.
Target audience: Trust wide.
Description of change: An addition to section 7.1.

Page last reviewed: April 25, 2024
Next review due: April 25, 2025

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