Drug administration, handling and storage
The aim here is to provide an opportunity to review and revisit the main principles of drug administration and consider the midwife’s role in relation to medicine administration, handling and storage. Medicines should only be administered in pregnancy if the anticipated benefits for the mother are thought to outweigh the potential risks to the fetus, and all drugs should be avoided during the first trimester if possible.
The control of medicines in the United Kingdom is primarily through the Medicines Act (1968) and The Misuse of Drugs Act (1971). Legislation regulating the authorisation, sale and supply of medicinal products for human use is laid out in the Human Medicines Regulations (2012) (Table 72.1). There are three main classes of medicinal products for humans (Table 72.2) although some medicines can be classified under more than one category depending on factors including their formulation, strength and quantity.
Within their professional role, registered midwives can supply and administer medicines without the need of a prescription or Patient Specific Direction (PSD) when there is a Patient Group Direction (PGD) or Midwives’ Exemption (ME) for a particular drug. PGDs are written instructions for the sale, supply and administration of medicines to patients, usually in planned circumstances or an identified clinical situation. PGDs should be put together by a multidisciplinary group including a doctor, a pharmacist and a representative of any relevant professional group.
Midwives Exemptions refer to the medicinal products that midwives can supply and administer on their own initiative (without a prescription or PGD) provided it is appropriate and within the course of their professional midwifery practice. The list of medicines that midwives are able to supply and administer under the Midwives Exemptions legislation can be found on the Nursing Midwifery Council (NMC) website and was last amended in July 2011 to ensure that drugs commonly used within midwifery practice are included. It is important to note that if a medicine is not included in the ME list then a prescription, PSD or PGD will be required.
The NMC provides guidance and sets out the professional standards expected for the administration of medicines. These provide the benchmark by which practice should be conducted and measured. An overview of these main principles can be found within Box 72.1. It is of paramount importance that midwives use both their clinical judgement and professional accountability when administering medicines to ensure that they act safely at all times, involving the woman and putting the interests of the woman and her baby first. The process of drug administration can be fraught with potential errors. Healthcare organisations have a duty to ensure that clear protocols are in place for the administration of drugs and midwives must be proactive in following both organisational and professional guidance to ensure that the right patient receives the right drug, in the right dose, by the right route, at the right time. The NMC stipulate that where possible two registrants should check medication to be administered intravenously, one of whom should also be the registrant who then administers the IV medication. Student midwives should refer to the NMC guidance for details regarding drug administration and should only administer medicines under the direct supervision of their mentor.
Ensuring that drugs are administered by the correct route is vital in ensuring that the drug works in an effective and timely way. Table 72.3 provides an overview of the commonly used routes of administration that may be used within midwifery practice. It is important that midwives are competent in the administration method required and the NMC (2010) points out the midwife has to ensure that they have undergone the correct training with regards to the administration of medicines, including those for which they are exempt. Following registration, midwives are required to undertake additional local training to be able to safely administer drugs via the intravenous and epidural routes.
Medicines must be stored securely in an environment that will not affect their potency. All healthcare organisations should have Standard Operating Procedures and policies in place to ensure compliance with the manufacturer’s storage recommendations and the relevant legislation, for example the storage of controlled drugs. Drugs must be stored in a locked cupboard or medical fridge according to the manufacturer’s recommended temperature range. The appropriate temperature range should be monitored and both a room thermometer and fridge thermometer is required to enable this. Organisational policies should be available to ensure that medicines requiring storage within a medical fridge, for example Syntocinon, are stored appropriately when used within the community setting. Midwives must also follow organisational policy for the supply, storage, administration and disposal of controlled drugs that may be used in hospital and community settings.
Steps should be taken to prevent human error and potential harm. Drugs should be stored to minimise mix-ups between medications of a similar appearance, for example intravenous (IV) solutions bags and vials of sterile water, normal saline and lidocaine. Measures should also be in place to reduce distractions that may occur in a busy care environment during drug rounds and the making up of IV infusions. Midwives should never prepare substances for injection in advance of immediate use or administer medication drawn into a syringe or container by another practitioner when not in their presence.