Medicine Management in Nursing

Introduction
Finding an interesting and challenging subject for second year transition was not an easy task, as there where many things that I wanted to know more about. Much of the work we had undertaken within university had been focused on long term conditions and the process for patients being discharged from the hospital to home. With this in mind and a great experience on my community placement I wanted to learn more about the role of the community pharmacist. I felt that this would build on my knowledge base, from university, of the discharge process and the management of peoples conditions within the community. I felt that a better understanding of the role of the community pharmacist, would give me greater insight when, in the future, I am involved in discharging patients back into the community.

What I did
I was able to work with both the pharmacist and the pharmacy assistants during the transition. I had the opportunity to observe the checking process in dispense, storing and ordering of medication and was able to observe consultations. The importance of the laws surrounding the dispense and storing of drugs was on of the first things that I learnt. My only experience of this had been in a hospital setting, where all drugs where stored in lockable trollies or bedside cabinets, with those drugs classified as ‘controlled drugs’ being stored in more secure locked cupboards.

The Laws
The Misuse of Drugs Act (1971) prohibits certain activities in relation to ‘Controlled Drugs’ the most important are the manufacture, supply and possession of these. These drugs are graded and defined into one of three classes; Class A, Class B or Class C. The grading is done broadly and the penalties applied according to the ‘harmfulness attributable to a drug when it is misused’ (BNF 2012).

The Misuse of Drugs Regulations (2001) defines the classes of a person who are authorised to supply and possess controlled drugs while acting within their professional capacities and lay down the conditions under which these activities may be carried out (cited BNF 2012). The five schedules, which these drugs are divided into, each specify the requirements governing certain activities, for example the export, import, production, supply, possession, prescribing and record keeping of these drugs. Within the pharmacy the drugs are stored and dispensed in accordance to their schedule classification.

Role of the Pharmacist
The majority of the work at a pharmacy is to take in and dispense prescriptions. These can be from a number of different NHS areas as well as private prescriptions. In accordance to the BNF’s general guidance ‘ Medicines should be prescribed only when they are necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risk involved’ (BNF 2012 p1). The Department of Health has guidelines on the responsibility for prescribing between hospitals and general practitioners and they state that the responsibility for prescribing lies with the doctor who signs the prescription (DH 2013).

Nurse prescribing is an important step in the ease of access for patients to medications and it could also reduce waiting times for some patients wanting to see a GP. There are strict rules controlling what a nurse prescriber can prescribe, these items are within the speciality of the nurse. Nathan (2005) explains that nurse prescriber can also ‘.. prescribe a limited number of non-prescription medicines listed in the Nurse Prescribers’ Formulary’ (Nathan 2005 p42). The RCN states that from nurse prescribers ‘Patients gain improved access to information and advice, which helps with understanding of decisions made about their health and care.’ These nurses will, for example, have been trained to explain to the patient what the medicine is and how it should be taken, enabling more time for the patient to ask questions increasing compliance (RCN 2013).

Prescriptions must be completed fully to be legal including the name and address of the patient, the date and preferably the date-of-birth and age (BNF 2012). A pharmacist will not dispense the medication if the prescription is not filled out correctly and legal. I witnessed this happen a few times and realised the importance of clear writing, and the factor of human error when completing prescriptions. Prescribing errors may not be reported officially in an error report as with hospital drug charts, nurses will often take it to the doctor to determine the drug name or correct a mistake if these are noted, then can complete the dispensing process (Wright 2013).

From my transition experience I found many members of the public use their local pharmacy for advice on a number of health issues or problems with their medications as well as the dispense of medications. The pharmacists depth of knowledge was astounding to me. They regularly, for example, gave advice on which over the counter medications could alleviate symptoms for a number of conditions, advice on the complex contraindications of multiple drug therapies. Local people came in worried and anxious, but left, feeling satisfied, after being given the advice and support. I found that many of these people found it easier to first talk to the pharmacists first, rather than going to their GP. This role of the community pharmacist, I feel, is vital to building good relationships with the local community to facilitate drug compliance and the management of patients long term conditions. A better understanding of this role, means I will take in to account the importance of a good relationship with the community pharmacist in the long term management of my patients once they have been discharged from my care.

Why I chose it
The experience I had lead me to find out more about the administration of medications to patients, and focusing more on factors surrounding the safe administration of medications and also medication errors. We had been taught pharmacology as part of our biology course in second year, and also completing a drug calculations test. I wanted to use this base of knowledge from university, to better my skills and understanding of the laws of drug administration and what factors effected drug errors. This awareness will aim to give me a solid grounding for my final year of study as I take on more responsibility for administering and calculating medications. As Downie et al (2003) says that ‘The importance of establishing a firm basis of learning during pre-registration training is well recognised, as is the need to progress to wider aspects, as part of professional development.’ (Downie et al 2003 p29).

Griffith et al (2003) states that ‘Administration of medicines is a key element of nursing care’, Downie et al (2003) agree saying that ‘.. the safe and effective management of medicines remains a high priority for all practicing nurses’ (Downie 2003 p29). I would also say that the management of medicines should be a priority for nursing students too.

Medicines Management
“The clinical, cost-effective and safe use of medicines to ensure patients get the maximum benefit from the medicines they need, while at the same time minimising potential harm.” (MHRA 2004 cited NMC). The Medicines and Healthcare products Regulatory Agency (MHRA) review products and issue them a license only if they meet its criteria for safety, quality, efficacy and manufacturing practice (Nathan 2005).

Nurses are required, by law, to administer medicines to the right person, at the right time, in the right form, with the right dose and via the right route (Griffith et al 2003). This is taught to nursing students at university and in practice settings, often being known as the ‘5 right’s’.
Within drug therapy a broad summary of what nurses may be required to do are; observe and report any side effects or drug interactions, act to alleviate unavoidable side-effects, educate and guide patients and families with regard to medications, promote patient compliance and importantly to follow the recognised procedures for the control of pharmaceutical products (Downie et al 2003).

The Nursing and Midwifery Council (NMC) sets out its own policies and procedures, with expectations for the standards of nurses administering medications. The NMC’s standards for medicines management is a comprehensive guide which aims to provide the minimum standard that practice should be conducted and provides a bench mark against which practice is measured (NMC 2010).

An awareness of the benefits as well as the potential dangers of drugs is important for the practicing nurse as well as students. The NMC code says that nurses are not only accountable for their actions, but also their omissions (NMC 2010). For the safe administration of medicines nurses must have a solid understanding of basic pharmacology and physiology as well as a knowledge of the medicine used and their management (Downie et al 2003). This is also true to be able to advise patients and give information or special instruction to facilitate successful management of drug therapy (Greenstein 2004).

The Department of Health (DH) produced reports, over ten years ago, which highlighted the high number of medicine administration errors (DH 2000, Kohn et al 2000, Wright 2013). Wright (2013) found that this lead to research into these errors, the types and causes, leading to the evaluation of strategies to reduce rates of errors. Wright (2013) goes on to highlight that from the results of the research the focus should not be on the individual error but a ‘whole system approach’ should be used to reduce medication errors. A knowledge of these strategies is important for my future study, as these will inform and guide me to be a safe administrator of medications to my patients.

Medication Errors
There is no one simple definition of a drug error as it can depend on the type of study undertaken to determine the error (Wright 2013), the standard definition, when using observational studies, is the administration of a medication that differs from the prescription (Han et al 2005, Lisby et al 2005, cited Wright 2013). Although others include administrations which differ from manufacturing guidelines or hospital policy (Taxis and Barber 2003, Wirtz et al 2003 cited Wright 2013).
Medication errors should be reported, but this is not always the case. I do not know the protocol of who to report a medication error too for my local trust, I have identified that this is an area in which I need to increase my knowledge. Not all medication errors result in adverse events resulting in harm to the patient (JBI 2006).

Causes
It is important to identify any causes for medication errors to be able to implement potential action plans to reduce these occurrences in the future (Wright 2013). The most common causes that Wright (20013) identified in her article was drug omissions and the wrong rate or time of administration of specifically IV fluids (Barker et al 2002, NRLS 2009, Han et al 2005 cited Wright 2013). It is also identified by Wright (2010) that even though these errors where highlighted, no clear reason for why the error occurred is given. This lack of information cannot lead to improvements in drug errors. Other reasons for medication errors, identified by Greenstein (2004), include patient focused errors, for example the patient failing to understand self-administration systems and not recognising any adverse effects; poor compliance; taking alternative medications which interact with prescribed ones. Errors accountable to nurses could be a failure to take a full drug history; not identifying the patient correctly; lack of knowledge of the properties and actions of the drug; confusing drug names; and poor drug calculation skills leading to errors in dose. Greenstein (2004) also highlights organisational reasons for example, inadequate stock control and ordering; poor labeling and inaccurate prescribing; failure to identify previous errors and take preventative steps.

Drug Administration
When completing medication rounds with a qualified member of staff, in accordance to the NMC Standards for Medicines management (NMC 2010), I was taught a number of strategies to increase drug safety. Some of these where highlighted by Greenstein (2004); a prescription chart must be used, no drugs should be given from memory; drugs must be given only from correctly labelled containers; do not give drugs prepared by anyone else, the drug trolly or cupboard must be kept locked. Being able to reflect back on the task of drug administration will enable me to learn from it; ensure evidence based practice; maximise learning opportunities; and identify my learning needs (Jasper 2006).
In a pharmacy drugs can only be dispensed to the public if a qualified pharmacist is on site.
The administration of medications in a hospital is complex with many factors affecting it. A busy, noisy environment can cause distractions, the structures and systems in place as well as those working within the healthcare environment. Some areas have a dedicated nurse who dispenses medications to the whole ward, but from my experience nurses just administer medications to their allocated patients. This method means that they will know their patients better and will have greater control over the timings of administration (Greenstein 2004). Through research a number of other interventions, to reduce error, where evaluated, such as nurses completing single checks verses those who did double checking, and the use of a jacket to distinguish that nurse was not to be disturbed (Joanna Briggs Institute 2006). However, the Joanna Briggs Institute (JBI) (2006) found that there was a low level of evidence to support these, due to small sample sizes poorly reported or inconclusive results (JBI 2006).

Medicines
There are many different types of medication, and the number of these is ever increasing. The medications can be produced and supplied by different drug companies, with different packaging and brad names, further increasing the complexity of administration. This is particularly problematic with drug names which sound similar (Wright 2013).
There are many routes through which medication can be administered. The oral route is often the most common, but other commonly used routes I have seen include, intramuscular or subcutaneous injections, intravenous and central lines and dermal patches.
In a busy setting care must be taken that oral solutions and IV ones are not confused and administered via the wrong route (Wright 2013). Within the trust I work in, the use of purple syringes for oral medication is implemented, as these cannot be attached to the taps on the end of IV lines, thus reducing the incidences of mixing up prepared medication.

Future in Nursing
Being able to reflect back over the transition activity I undertook, will inform my practice for the future. I will learn to make decisions based on my knowledge and experience resulting in evidence based practice and also being able to identify deficits in my skills and knowledge and opportunities to develop these further (Jasper 2006). From this transition activity I have gained a lot more knowledge on the laws and procedures surrounding the administration and storing of medications. Although, during practice, I have been carrying out many of the checks which have been previously highlighted, I have a better evidence based knowledge as to why these are in place. Being more involved in the care of patients, improving on my skills and learning new ones is vital to make me a competent medicines administrator.

With experience of both a hospital and community setting I have learnt the importance of good communication during discharge. The JBI (2006) highlighted that the continuity of care between the hospital and the community during discharge can contribute to whether there are any medications errors, as there can be different prescribing practitioners. The use of pharmacists during discharge, to check the drug chart and dispensed medications can help to reduce errors (JBI 2006). In my future training and once qualified, I will ensure I use pharmacists ,within the hospital, for advice and to check medications.

My awareness of the most common types of drug error, omissions, IV rates and timings, will push me to focus on these during placement and the future. Correctly filling out forms to clarify why there may have been an omission of a drug, and an emphasis on working out drip rates and time management, I will avoid making these most common of mistakes. I hope to pass on what I have learnt about these to my student colleagues. Professional development as a student is about learning to be a safe and competent practitioner with the skills and knowledge to be fit for practice (Jasper 2006).

The complexity of drug administration has lead to the need for nurses to further their skills and knowledge in the safe administration of medications. Morrison-Griffiths et al (2002) and Ndosi and Newell (2008) (cited Wright 2013) have identified in studies that student nurse education needs further emphasis in pharmacological education. A pharmacological knowledge of the complex process of administering drugs is required to support the process and the clinical decisions needed in medicines management (Wright 2013).

The NMC’s Standards for medicines management (NMC 2010) is set out to give nurses the best practice for administration of medications. From this experience I will ensure I am more familiar with it and use what it has set out in my daily practice. It was only through doing this assignment that I became aware of it, and I feel that all student nurses should be made aware and have a copy, which would inform them of best practice.