Chapter 11. Administration of medicines
Background
There are fundamental differences between the self-administration of medicines in our own home and the provision of prescribed drugs to clients in our care. Clients place themselves in our trust. If they are in pain, frightened or ill they will often take the medicines we offer or suggest, without question. Our procedures for administration of drugs need to be robust, to ensure that we give the right drugs to the right person at the right time.
Also, when a woman takes two paracetamols at home, she has probably done this on many occasions, throughout her adult life. She knows that she is not allergic to them and that they usually take away her headache. If she is generally fit and well, she probably does not take any prescribed medications on a routine basis, that might react with them. She may also know that if she has just taken a dose, she must wait 4 hours before taking any more.
However, when she comes into the care of maternity services, there are many alternative drugs available. She may take a drug that she has not previously been exposed to and does not know how her body might respond to it. Individuals react differently to the same type and dose of drug. Pethidine is an example of this, with some women feeling little effect and others becoming sedated. She might be offered a drug that could potentially interact with another she has already taken. This will be significant for those women who regularly use ‘natural’ forms of medicine, such as homeopathic remedies, and midwives should be aware of these women (Tiran 2006). There might be someone else on the ward with the same name with the potential for the wrong drug card to be used for the administration of her drugs.
Between January 2005 and June 2006, 60000 medication incidents were reported to the National Patient Safety Agency (NPSA 2007), illustrating the need for care in how drugs are administered.
National guidance
Acts of parliament
There is a detailed legal framework that supports the administration of drugs. The drugs are divided into three categories for the purpose of supply:
■ General sales list drugs can be bought without the supervision of a registered pharmacist in a general store
■ Pharmacy only drugs must be purchased under the supervision of a pharmacist in a pharmacy
■ Prescription only drugs must be obtained by prescription from an eligible practitioner dispensed by a registered pharmacist (Jordan 2002).
The legal framework for the supply and administration of medicines is in the Medicines Act 1968 and The Misuse of Drugs Act 1971. The Medicines Act states that prescription only medicines can only be obtained from a registered doctor, dentist or vet. However, midwives have some exemptions from the restrictions in the Act, as some drugs usually available on prescription may be supplied for use in practice, on provision they have notified intention to practice.
The Misuse of Drugs Act 1971 covers the legislation surrounding drugs that may be misused, which are often called ‘controlled drugs’. Midwives are included in the amendment to the law of The Misuse of Drugs (Amendment) Regulations 2005 (Statutory Instrument 2005 No. 271) which covers the possession and disposal of drugs. Following the Shipman Inquiry, systems for managing the dispensation of controlled drugs have been strengthened by The Controlled Drugs (Supervision of Management and Use) Regulations (Statutory Instrument 2006 No. 3148) underpinned by the Health Act (2006). These changes are explained in guidance by the Department of Health (2007) and it is now a requirement that Trusts must have an ‘Accountable Officer’ responsible for managing their safe use and management. It is reinforced that a midwife’s records related to the administration of medicines should be audited by their named supervisor of midwives on a regular basis and any concerns reported to the Accountable Officer and the Local Supervising Authority (LSA) Midwifery Officer.
Patient Group Directions
Patient Group Directions are:
written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.
This means that there is a detailed document that allows medicines to be given to a particular group of clients, without an individual named prescription. This is particularly useful in the maternity settings as it enables drugs to be given to a woman by midwives, without having to wait for a doctor to physically come and individually prescribe it.
In order to protect the safety of the client and the practice of the midwife, Patient Group Directions (PGDs) are carefully compiled by a multidisciplinary group (Department of Health 2000) and must conform to guidance outlined in the Health Service Circular (HSC 98/051). This HSC summarized the recommendations of A Review Of the Prescribing, Supply and Administration of Medicines under group protocols, the Crown Report (Department of Health 1999) stating that current protocols should be reviewed. Meticulous guidance was given in the Report regarding the criteria for group protocols, under the following headings:
1. Clinical condition or situation to which the protocol applies
2. Characteristics of staff authorized to take responsibility for the supply or administration of medicines under a group protocol
3. Description of treatment available under a group protocol
4. Management and monitoring of group protocols (DoH 1999, Appendix A).
In order to ensure that PGDs comply with the law regarding prescription only medicines detailed in the Medicines Act 1968, various Amendment Orders were made which came into force in August 2000, allowing drugs to be administered to an unnamed individual. The exemptions of the Medicines Act (1968) that apply to midwives were unaffected by the new provisions (HSC 2000/026).
Professional guidance
As a registered midwife, you will be personally accountable for your practice (NMC 2004) and this includes the drugs you administer, even though a doctor may have written the prescription. As a student you will be supervised by a registered midwife, who should countersign your records. However, when you qualify, ‘you are accountable for your actions and omissions’ (NMC 2008:01) and must have an underpinning knowledge of the many different drugs that you will administer to a woman and how they should be given. Following qualification the legislation mentioned in the previous section enables a midwife to supply and give out specific drugs without a prescription, if it is part of their own professional practice (NMC 2007). The Standards for medicines management (NMC 2007) and Standards of proficiency for nurse and midwife prescribers (NMC 2006) cover all the principles in relation to professional practice. Midwives are also accountable for the records that they keep (NMC 2004), including those of the administration of drugs and they are subject to audit by their supervisors of midwives.
Drugs and pregnancy
It is recommended that all drugs should be avoided in early pregnancy if possible and only used if known to be safe during the rest of pregnancy (BNF 2006). As the use of some drugs can result in malformation in the developing fetus, it is essential that caution is used in the prescription of drugs to women of childbearing age. Even if the woman is not thought to be pregnant, but has had unprotected sexual intercourse since her last period, there is a possibility that there may be a vulnerable embryo embedding in the endometrium. Midwives should also be aware that this includes the use of complementary therapies, and women should be advised to avoid their use in pregnancy (NICE 2008).
Drugs and breastfeeding
Care should continue to be taken following the birth of the baby regarding the drugs it may receive via its mother’s breast milk. The BNF has a comprehensive section detailing drugs and their use during lactation.
Types of drugs
There are many types and forms of medicines and some of their forms of administration are discussed later in this chapter. The issue of injectable forms of medicine will be explored in the next chapter. As indicated previously midwives should also be aware of the use of alternative forms of medicine that may be thought to be innocuous, such as aromatherapy oils , herbal or homeopathic medicine (Tiran 2006).
Controlled drugs
We have used pethidine as an example throughout this chapter. Pethidine is a controlled drug which means that its use is carefully monitored under legislation by the Misuse of Drugs Act 1971. This act grades drugs according to the harm that their misuse could cause so that penalties can be issued for offences in relation to their abuse.
■ Class A drugs include pethidine, morphine and methadone
■ Class B drugs include amphetamines, codeine and barbiturates
■ Class C drugs include cannabis, anabolic steroids, valium and tranquillizers.
The Misuse of Drugs regulations 1985 categorizes controlled drugs into five schedules (Jordan 2002); see Table 11.1.
| Schedule | Description | Example |
|---|---|---|
| 1 | No health purposes. Possession and supply is prohibited except with Home Office authority. Dose of drug must be in words and figures. Bound register record of supply/administration. Kept in a locked cupboard within a locked cupboard | Lysergic acid (LSD) |
| 2 | Opiates and major stimulants. Dispensed on prescription only. Dose of drug must be in words and figures. Bound register record of supply/administration. Kept in a locked cupboard within a locked cupboard | Pethidine |
| 3 | Barbiturates and minor stimulants. Dispensed on prescription only. Dose of drug must be in words and figures. Invoices must be kept for two years | Temazepam |
| 4 | Benzodiazepines and anabolic steroids. Not subject to safe custody requirements | Chorionic gonadotrophin (HCG) |
| 5 | Weak preparation with little risk of abuse. Not subject to above arrangements. Invoices must be kept for two years | Cough mixtures |
As Table 11.1 highlights, controlled drugs such as pethidine have additional controls on the way they are administered. Their individual use is recorded and witnessed by two people, one of whom is a registered midwife or nurse. They are kept in a locked cupboard within a locked cupboard and the keys should be held be a registered midwife. Keys should not be given to other personnel, even doctors.
The administration of drugs
The student midwife should always be supervised when she administers drugs. Some trusts may have local policies regarding the practice of students who are already registered nurses, but care should be taken regarding the interpretation and formulation of such guidance, as the context for the administration of drugs to childbearing women and their babies is complex.
When a student midwife enters the domain of the administration of drugs to clients, s/he must become familiar with a whole new language. There is a plethora of legislation, governmental and professional guidance to understand and apply in practice. The student midwife must ensure that s/he is closely supervised in relation to this aspect of professional and practice development. The principles of drug administration are outlined in Box 11.1.
Box 11.1
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Procedure for administration of prescribed oral medication
■ Consult the woman’s plan of care
Rationale To ensure accurate and timely administration of drugs
■ Consult the drug card, identify the drug, dose, route and time of administration, prescriber’s signature
Rationale To conform with legal requirements and professional guidance
■ Confirm and identify any known allergies
Rationale To prevent the risk of allergic reaction in response to contact with known allergens
■ Assess the possibility of confounding factors
Rationale To reduce the risk of drug interaction, contraindication, potentiation or overdose
■ Select the correct drug and check the expiry date
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