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Title: Instructions for NHS Grampian Staff on the In-Patient

Prescribing and Administration of Medicines using the NHS Grampian Prescription and Administration Record

Unique Identifier: NHSG/Guid/Inst/MGPG446 Replaces: n/a Lead Author/Coordinator: Medication Safety Officer and Pharmacist, ARI Subject: Prescribing and prescription Key word(s): Kardex, instructions, prescribing, administration, charts,

medicines, prescription record, administration record, Medication Administration Record, MAR, drug chart

Policy, Protocol, Procedure or Process Document:

Procedure/guidance

Document application: Whole of Acute Sector and community hospitals Purpose/description: To promote the safe use of the NHS Grampian Prescription

and Administration record. Group/Individual responsible for this document:

Records Standards Group

Policy statement: It is the responsibility of individual healthcare professionals

and their line managers to ensure that they work with the terms laid down in this guidance and to ensure that staff are working to the most up to date guidance. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect patient, staff or visitor safety and comfort will be reduced. Supervisory staff at all levels must ensure that healthcare professionals using this guidance act within their own level of competence

UNCONTROLLED WHEN PRINTED Review Date: August 2013 Identifier: NHSG/Guid/Inst/MGPG446 - i - Instructions For NHS Grampian Staff on The In-Patient Prescribing And Administration Of Medicines Using The NHS Grampian Prescription And Administration Record - Version 1 Approved August 2011

UNCONTROLLED WHEN PRINTED Review Date: August 2013 Identifier: NHSG/Guid/Inst/MGPG446 - ii - Instructions For NHS Grampian Staff on The In-Patient Prescribing And Administration Of Medicines Using The NHS Grampian Prescription And Administration Record - Version 1 Approved August 2011

Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo: Pharmacist Pharmacy and Medicines Directorate Lead Author/Coordinator: Medication Safety Officer and Pharmacist, ARI Physical location of the original of this document:

Pharmacy department ARI

Job title of creator of this document:

Medication Safety Officer, Pharmacist

Job/group title of those who have control over this document:

Records Standards Group

Responsibilities for disseminating document as per distribution list: Records Standards Group Responsibilities for implementation: Organisational: Acute Sector Operational Management Team and Acute

Sector General Managers CHP General Managers

Hospital/Interface services: Assistant General Managers and Group Clinical Directors Operational Management Unit: Unit Operational Managers Departmental: Clinical Leads Area: Line Managers

Review: This policy will be reviewed in two years or sooner if current

treatment recommendations change Responsibilities for review of this document: Lead Author/Coordinator: Medication Safety Officer and Pharmacist, ARI Review date: August 2013

Revision History: Revision Date

Previous Revision Date

Summary of Changes (Descriptive summary of the changes made)

Changes Marked* (Identify page numbers and section heading )

CONTENTS Page Number

Introduction ................................................................................................................................ 2

Prescription and Administration Record..................................................................................... 2

1. Writing the prescription ....................................................................................................... 3

1.1. Patient details ................................................................................................................... 3

1.2. Date of admission.............................................................................................................. 3

1.3. Prescription number .......................................................................................................... 3

1.4. Date rewritten .................................................................................................................... 4

1.5. Hospital/Ward.................................................................................................................... 4

1.6. Consultant ......................................................................................................................... 4

1.7. Weight and Height............................................................................................................. 4

1.8. Known medicine allergies/sensitivities .............................................................................. 4

2. Instructions for all prescribers............................................................................................. 5

2.1. ONCE ONLY PRESCRIPTIONS....................................................................................... 5

2.2. REGULAR THERAPY ...................................................................................................... 7

2.3. AS REQUIRED THERAPY ............................................................................................. 10

2.4. Patient Group Directions ................................................................................................ 12

2.5. Modification of an existing prescription ........................................................................... 12

2.6. Discontinuation of a prescription .................................................................................... 12

2.7. Cancelling a prescription written in error ......................................................................... 13

2.8. Other medicine charts in use .......................................................................................... 14

2.9. Medicines Care Issues ................................................................................................... 14

2.10. Prescriptions ordered by telephone................................................................................. 15

3. Recording the administration of medicines ....................................................................... 16

3.1. Steps in administration .................................................................................................... 16

4. Recording the non-administration of medicines/missed doses/doses given early or late . 20

4.1. Recording the non-administration of prescribed medicines............................................. 20

4.2. Recording the non-administration of medicines for reason(s) other than codes 1-12...... 21

4.3. Recording the administration of a previously missed dose.............................................. 21

4.4. Recording the administration of a dose given before or after the prescribed time of administration .......................................................................................................................... 21

5. Procedure in the event of error or suspected error in medicine administration................. 22

UNCONTROLLED WHEN PRINTED Review Date: August 2013 Identifier: NHSG/Guid/Inst/MGPG446 - 1 - Instructions For NHS Grampian Staff on The In-Patient Prescribing And Administration Of Medicines Using The NHS Grampian Prescription And Administration Record - Version 1 Approved August 2011


Instructions for NHS Grampian Staff on the In-Patient Prescribing and Administration of Medicines using the NHS Grampian Prescription and Administration Record

Introduction The prescribing and administration of medicines play an important part in the disease management of patients. In recent years, the number and variety of medicines available has increased dramatically. Also with the introduction of primary and secondary prevention and new drugs for second- and third-line treatment, individual patients now receive increased numbers of medicines. Many of these medicines are very potent and all are potentially dangerous if used incorrectly. The system for prescribing and administration of medicines has the following key objectives.

• To achieve and maintain a safe and effective system for prescribing medicines and recording their administration.

• To reduce errors

• To standardise and produce high quality records of the prescribing and

administration of medicines.

Prescription and Administration Record In hospital settings the main tool used to direct administration of medicines is the Prescription and Administration Record (often referred to as the ‘kardex’). The Prescription and Administration Record has been redesigned and the format has been changed with the aim of reducing errors and improving the interpretation of the recording of administration. The major changes which have been made are:

• the recording of administration is adjacent to each individual medicine • the regular therapy has been separated from the “as required” medicines • there is no separation for prescribing of different routes of administration, i.e.

all formulations are prescribed consecutively The Prescription and Administration Record is available in three formats to accommodate patients on varying numbers of medicines and lengths of stay in hospital: 2-page; standard; long stay. They are available from Central Stores:

• 2-page ZOP 112 • Standard ZOP 105 • Long stay (only to be used following discussion with Pharmacy Department).

This document describes the processes to be followed when prescribing and recording the administration of medicines on the new Prescription and Administration Record.


1. Writing the prescription Resources are available to support prescribing and prescribers should familiarise themselves with and refer to the local joint formulary (http://www.nhsgrampian.org/gjf) and non-medical prescribing policy (http://tinyurl.com/NHSGNMRx). Hospital prescribers must comply with current prescribing legislation, relevant NHS Grampian prescribing policies together with the procedures detailed in this document. All in-patients must have a Prescription and Administration Record. All Prescription and Administration Records must be filed in the patient’s medical records on completion/discharge whether or not any entries have been made. Prescription and Administration Records belonging to patients transferred within NHS Grampian may continue to be used in the receiving ward/hospital if staff are confident and familiar with the system. A new record must be used for readmitted patients regardless of the amount of time that has elapsed. Prescriptions must be written in block capitals, legibly, in black ink. 1.1. Patient details (Example A) A patient end-of-bed label should be used on the front sheet. If unavailable, patient identification details must be written on the front sheet prior to prescribing. Patient’s full name, date of birth and Community Health Index (CHI) number must be written at the top of each page prior to prescribing. Patient name: Full name in BLOCK LETTERS CHI: Patient’s CHI number (e.g. 0909321234). The full 10 digits must be used. Date of Birth: Written stating day, month and year, e.g. dd/mm/yy, 09/09/32 1.2. Date of admission The date the patient was admitted: full date including year must be entered to assist when medicines are being reviewed retrospectively (dd/mm/yy). 1.3. Prescription number The prescription number refers to the number of the record in use. If the patient requires more medicines than one record allows, a second record should be used and 2 of 2 should be entered in the space for prescription number. Prescription number 1 should be changed to 1 of 2. Patients should have a maximum of two Prescription and Administration Records at any one time.

http://www.nhsgrampian.org/gjf

http://tinyurl.com/NHSGNMRx


When records 1 and 2 are full, all prescriptions must be cancelled by writing REWRITTEN and the DATE of rewriting, diagonally across all pages. Those medicines still required are re-prescribed on new records numbered 3 and, if necessary, 4. The original dates on which the medicines were commenced should be written on the new records. The original date prescribed must be used to: • prevent confusion; • ensure medicines which are prescribed as a course can be discontinued on the

correct date, e.g. antibiotics; • ensure medicines which are being gradually increased/decreased are adjusted on

the correct date; • ensure medicines which are being assessed are reviewed at the correct time

interval. This procedure is repeated when further records are required, the new records being numbered 5 and 6, and so on. All cancelled prescription records must be retained in the patient’s medical notes. 1.4. Date rewritten This should only be completed when the previous Prescription and Administration Record is completed and a new record is needed, The date the records were rewritten should be entered in the space on the front sheet of the new record. 1.5. Hospital/Ward Abbreviations may be used here (e.g. ARI / 16). Update if patient moves ward or hospital. 1.6. Consultant Surname should be written in full. 1.7. Weight and Height Should be recorded using the metric system (kg and m/cm), and date recorded. 1.8. Known medicine allergies/sensitivities Prior to prescribing, any known medicine allergies/sensitivities must be recorded in the space provided. If confirmed patient has no known allergies write NKDA (i.e. No Known Drug Allergy), in Box 1. Some patients may have an acute sensitivity to a drug or medicine. It is vitally important to check this before prescribing or administering a medicine. Even if the boxes contain NKDA this does not mean that the patient can tolerate all drugs/medicines without adverse reactions occurring. Any adverse reaction during the patient’s stay in hospital should be recorded along with the name of the medicine in this section of the sheet. Doctors, nurses or pharmacists may enter this data. All serious adverse drug reactions should be recorded by the doctor on the Master Registration Card at the front of the patient’s case notes.

Suspected new adverse drug reactions should be reported directly to the Medicines and Healthcare products Regulatory Agency (MHRA) through the Yellow Card Scheme. Further information available at back of BNF or by accessing: www.yellowcard.gov.uk Example A:

2. Instructions for all prescribers All medicines other than those in the Nursing Formulary1 must be prescribed by an independent/supplementary prescriber. Responsibility for rewriting prescriptions rests with prescribers. Medicines should be prescribed consecutively; different routes should not be separated. All medicines, e.g. oral and injectables, should be written together. 2.1. ONCE ONLY PRESCRIPTIONS (Example B) Prescriber enters: date; time medicine is to be given (using 24 hour clock); name of medicine; dose; route; signature and printed name. ‘Ditto’ is not acceptable because it causes misinterpretation when previous prescriptions have been administered. Prescriptions must not be bracketed together because it causes misinterpretation when prescriptions are cancelled. 2.1.1. Medicine Print in full, clearly, in BLOCK LETTERS, names of medicines to be prescribed. Some medicines have similar names and printing the name helps to avoid confusion thus reducing the likelihood of errors in administration. Most medicines have approved (non-proprietary) names. The use of non-proprietary names is good practice and facilitates economical use of medicines, e.g. clopidogrel not Plavix®. Where bioavailability varies between brands or between formulations, the brand


1 The Nursing Formulary is a list of products that may be used by nurses without medical or dental prescription.

http://www.yellowcard.gov.uk/


name should be specified. For example beclometasone inhalers, lithium products, etc should be prescribed by brand name. Where appropriate, the strength of the medicine should be specified. 2.1.2. Dose The dose of a medicine must be expressed in terms that are explicit. This helps to avoid errors where strengths of tablets and capsules may vary. Prescribe dose of medicine using metric system. milligram = mg gram = g millilitre = mL Do not abbreviate micrograms or nanograms, ‘mcg’ and ‘μg’ are not acceptable. Doses of less than one milligram must be expressed in micrograms, e.g. 62.5 micrograms and not 0.0625 mg. A leading zero should be added for numbers less than 1, e.g. 0.5mL and not .5mL. Whole numbers should not be followed by a decimal point and zero, e.g. 1 and not 1.0. Serious errors have arisen from confusion between milligrams and micrograms when the latter units have been abbreviated. All other units such as nanograms must be written in full. Doses of liquid preparations should be expressed as milligrams or micrograms of the active ingredient. Doses in millilitres (mL) should only be used for multi-ingredient preparations. Where more than one strength combination of a multi-ingredient preparation exists, both strength and dose to be administered must be stated, e.g. co-amilofruse 5/40, 1 tab. 2.1.3. Route Enter route of administration. Use abbreviations as follows: When medicines are prescribed orally, ORAL must be written in full. ‘O’ is not acceptable. Sublingual = SL Subcutaneous = SC Intramuscular = IM Intravenous = IV Intradermal = ID Inhalation = INH Nebulised = NEB Topical = TOP Rectal = PR Vaginal = PV Gastrostomy = Gastros Nasogastric=NG Orogastric = OG Jejunostomy = Jej Nasojejunostomy = NJ Buccal = Buccal The route of administration must be appropriate to the medicine prescribed. The abbreviations listed are the only ones that may be used. All other routes must be written in full. Medicines should be prescribed consecutively; 2.1.4. Signature and Name Each individual prescription must be signed and name printed by an independent prescriber. Initials are not acceptable. Printed name allows prescriber to be contacted when there is a lack of clarity.

Example B

2.2. REGULAR THERAPY (Example C) Prescriber enters: medicine/form; dose; route; signature and printed name; start date; times of administration in appropriate boxes. The frequency box is only required for dosage regimens that do not follow a daily pattern. A duration and stop or review date may be appropriate for some medicines prescribed as a defined course. For all antibiotic prescriptions a duration and stop date or review date must be included. It is also recommended that for antibiotics the indication is noted in the additional instructions section. Example C

2.2.1. Medicine/Form Print in full, clearly, in BLOCK LETTERS, names of all medicines prescribed. Some medicines have similar names and printing the name helps to avoid confusion thus reducing the likelihood of errors in administration. Most medicines have approved (non-proprietary) names. The use of non-proprietary names is good practice and facilitates economical use of medicines, e.g. clopidogrel not Plavix®.



Where bioavailability varies between brands or between formulations, the brand name should be specified. For example beclometasone inhalers, lithium products, etc should be prescribed by brand name. Where appropriate, the strength of the medicine should be specified. Enter form in which medicine is to be given, e.g. tablet, syrup, injection. If the route of administration is to be via a tube, the appropriate formulation, e.g. dispersible tablet, syrup, should be specified. 2.2.2. Dose The dose of a medicine must be expressed in terms that are explicit. This helps to avoid errors where strengths of tablets and capsules may vary. Prescribe dose of medicine using metric system. milligram = mg gram = g millilitre = mL Do not abbreviate micrograms or nanograms, ‘mcg’ and ‘μg’ are not acceptable. Doses of less than one milligram must be expressed in micrograms, e.g. 62.5 micrograms and not 0.0625 mg. A leading zero should be added for numbers less than 1, e.g. 0.5mL and not .5mL. Whole numbers should not be followed by a decimal point and zero, e.g. 1 and not 1.0. Serious errors have arisen from confusion between milligrams and micrograms when the latter units have been abbreviated. All other units such as nanograms must be written in full. Doses of liquid preparations should be expressed as milligrams or micrograms of the active ingredient. Doses in millilitres (mL) should only be used for multi-ingredient preparations. Where more than one strength combination of a multi-ingredient preparation exists, both strength and dose to be administered must be stated, e.g. co-amilofruse 5/40, 1 tab. 2.2.3. Route Enter route of administration. Use abbreviations as follows: When medicines are prescribed orally, ORAL must be written in full. ‘O’ is not acceptable. Sublingual = SL Subcutaneous = SC Intramuscular = IM Intravenous = IV Intradermal = ID Inhalation = INH Nebulised = NEB Topical = TOP Rectal = PR Vaginal = PV Gastrostomy = Gastros Nasogastric=NG Orogastric = OG Jejunostomy = Jej Nasojejunostomy = NJ Buccal = Buccal The route of administration must be appropriate to the medicine prescribed. The abbreviations listed are the only ones that may be used. All other routes must be written in full.

Regular medicines should be prescribed consecutively; different routes should not be separated, e.g. all medicines oral and injectables should be written on one sheet. 2.2.4. Time of administration For medicines at regular times, circle the time in the time column, i.e. 08, 12, 14, 18, 20, 22. If another time is to be prescribed, enter the time in the adjacent time column and circle the entry. There may be instances when more than six administrations of a medicine are necessary. In these circumstances, the medicine should be prescribed in the box immediately below and the additional times added. The pre-printed times should be scored through and the administration times added in chronological order, see Example D. Latin abbreviations such as PRN must not be used. Latin abbreviations are no longer taught and are not universally understood. If the medicine is also prescribed in the As Required Therapy section a note of this must be made in the additional instructions. Example D:

2.2.5. Start date Indicate the date the prescription is to start. Prospective prescribing increases the potential for error and should only be used when necessary.


2.2.6. Frequency This box does not require to be completed routinely and is solely for medicines that are given weekly or anything less than daily. If the medicine is not prescribed on a daily basis, the days on which the medication is not to be administered should be scored through to prevent administration (see Example C). 2.2.7. Signature and Name Each individual prescription must be signed and name printed by an independent prescriber. Initials are not acceptable. Printed name allows prescriber to be contacted when there is a lack of clarity. 2.2.8. Additional instructions Instructions from pharmacist, doctor or senior nurse, e.g. administration in relation to food, special instructions, storage, maximum dosage, etc. 2.2.9. Pharmacy box For use by pharmacy staff, to indicate that the prescription has been checked. 2.3. AS REQUIRED THERAPY (Example E) Prescriber enters: medicine/form; dose; maximum dose in 24 hours; frequency and indication; route; signature and printed name; and start date, in appropriate boxes. Pharmacist/doctor/senior nurse may enter: additional instructions. The indication must be prescribed as some drugs are used for more than one symptom, e.g. codeine is used for pain, diarrhoea and cough. Also in 2.3.4. Example E

2.3.1. Medicine/Form Print in full, clearly, in BLOCK LETTERS, names of all medicines prescribed. Some medicines have similar names and printing the name helps to avoid confusion thus reducing the likelihood of errors in administration. Most medicines have approved (non-proprietary) names. The use of non-proprietary names is good practice and facilitates economical use of medicines, e.g. clopidogrel not Plavix®. Where bioavailability varies between brands or between formulations, the brand



name should be specified. For example beclometasone inhalers, lithium products, anticonvulsants etc should be prescribed by brand name. Where appropriate, the strength of the medicine should be specified. Enter form in which medicine is to be given, e.g. tablet, syrup, injection. If the route of administration is to be via a tube, the appropriate formulation, e.g. dispersible tablet, syrup, should be specified. 2.3.2. Dose The dose of a medicine must be expressed in terms that are explicit. This helps to avoid errors where strengths of tablets and capsules may vary. Prescribe dose of medicine using metric system. milligram = mg gram = g millilitre = mL Do not abbreviate micrograms or nanograms, ‘mcg’ and ‘μg’ are not acceptable. Doses of less than one milligram must be expressed in micrograms, e.g. 62.5 micrograms and not 0.0625 mg. A leading zero should be added for numbers less than 1, e.g. 0.5mg and not .5mg. Whole numbers should not be followed by a decimal point and zero, e.g. 1 and not 1.0. Serious errors have arisen from confusion between milligrams and micrograms when the latter units have been abbreviated. All other units such as nanograms must be written in full. Doses of liquid preparations should be expressed as milligrams or micrograms of the active ingredient. Doses in millilitres (mL) should only be used for multi-ingredient preparations. Where more than one strength combination of a multi-ingredient preparation exists, both strength and dose to be administered must be stated, e.g. co-amilofruse 5/40, 1 tab. 2.3.3. Maximum Dose in 24hrs Wherever possible the maximum dose in 24 hours should be entered. 2.3.4. Frequency & Indication For as required medicines, indicate the time interval that the medicine is to be given. The indication for the medicine should be entered; some medicines are used to treat more than one indication, e.g. codeine for pain or diarrhoea. If the medicine is also prescribed in the Regular Therapy section a note of this must be made in the additional instructions.


2.3.5. Route Enter route of administration. Use abbreviations as follows: When medicines are prescribed orally, ORAL must be written in full. ‘O’ is not acceptable. Sublingual = SL Subcutaneous = SC Intramuscular = IM Intravenous = IV Intradermal = ID Inhalation = INH Nebulised = NEB Topical = TOP Rectal = PR Vaginal = PV Gastrostomy = Gastros Nasogastric=NG Orogastric = OG Jejunostomy = Jej Nasojejunostomy = NJ Buccal = Buccal The route of administration must be appropriate to the medicine prescribed. The abbreviations listed are the only ones that may be used. All other routes must be written in full. 2.3.6. Signature and Name Each individual prescription must be signed and name printed by an independent prescriber. Initials are not acceptable. Prescriptions must not be bracketed together because it causes misinterpretation when prescriptions are cancelled. Printed name allows prescriber to be contacted when there is a lack of clarity. 2.3.7. Start Date Indicate the date the prescription is to start. Prospective prescribing increases the potential for error and should only be used when necessary. 2.3.8. Pharmacy & Additional Instructions Instructions from pharmacist, doctor or senior nurse, e.g. administration in relation to food, special instructions, storage, maximum dosage, etc. 2.4. Patient Group Directions (Example L) If medicines are being administered using a PGD, they should be documented in accordance with the instructions in the PGD. This may be to record in the ‘Once Only’ section of the prescription sheet. For some PGDs the medicine may have to be written in a section of the Regular Therapy and administration recorded against the entry by staff signed up to the PGD. 2.5. Modification of an existing prescription (Example F) If a prescription needs to be changed, for example a dose change or a change of frequency, cancel the existing prescription and rewrite a new prescription in a new section. 2.6. Discontinuation of a prescription (Example G) When a medicine is discontinued, draw diagonal line through section in which medicine is prescribed, vertical line through the rest of the day’s administration and double diagonal line through remaining boxes in administration section for that medicine. The authorised prescriber must then sign and date under this double line.

It is important that the lines delete the intended prescription and do not encroach on other prescriptions rendering them unclear and invalid. Example F

Example G

2.7. Cancelling a prescription written in error If a prescription has been written in error, the entry should be discontinued as in Example F. In addition, the words ‘written in error’ should be entered adjacent to the prescriber’s signature. NEVER alter prescriptions; always cancel and rewrite.


2.8. Other medicine charts in use (Example H) When any of these charts is brought into use, a tick should be entered opposite its title. If a chart is not listed use the space for ‘Other’ writing in the type of chart in use. Medications on other charts such as warfarin, insulin and PCA should be prescribed in the Regular Therapy section as shown in Example H as a reminder to staff. It is important for staff to be aware of the patient’s full medication regime. If any of these charts are discontinued a double line should be drawn across the tick. Example H

2.9. Medicines Care Issues (Example I) Enter details of issues which occur on admission or during the patient’s stay. Any member of staff may use this section to record care issues relating to the patient’s medicines. Examples would be: patients with poor inhaler technique; medicines requiring therapeutic drug monitoring; medicines which have been stopped on admission which may need to be re-instated prior to discharge; patients with swallowing difficulties. Actions taken to resolve the issues should be documented to ensure that all staff are aware of outcomes.



Details of presenting complaint and past medical history should be entered. Specific medicines are contra-indicated in certain medical conditions. Information on whether a patient has a compliance aid and whether they are resident in a care home should be entered. This will facilitate the discharge process. 2.10. Prescriptions ordered by telephone In VERY EXCEPTIONAL CIRCUMSTANCES, a medicine ordered verbally may be given, but the following procedure MUST be adhered to. A registered nurse takes the message, REPEATING it to the doctor to ensure accuracy. Where possible, a second nurse should also take the message, again repeating it to the doctor to ensure accuracy. An entry is made, by the nurse taking the message, in the Once Only Prescriptions section of the Prescription and Administration Record. The name of the prescribing doctor should be written in the nursing notes. The prescribing doctor MUST sign the prescription at the EARLIEST possible opportunity, in any event, within 24 hours. Note: In community hospitals because there is not always medical staff present it may be necessary to fax prescriptions using the “Temporary GMED/GP Prescription Sheet”. Only in very exceptional circumstances should a prescription be ordered verbally. Controlled Drugs must NEVER be prescribed by telephone, see Policy and Procedure for Secondary Care and Community Hospitals in NHS Grampian on the Safe Management of Controlled Drugs.

Example I

3. Recording the administration of medicines 3.1. Steps in administration 3.1.1. Identify the patient. Ask the patient to state their name and date of birth. Knowing the patients in your care contributes to the ease of identification. Check the identification bracelet. Where identification bracelets are in use they must also be checked each time a medicine is to be administered. Extreme care must be exercised with highly dependent patients and in locations where, for social reasons, there is an agreed policy not to use identification bracelets. Check that the patient’s full name, date of birth and unit number/CHI correspond with the name, date of birth and unit number/CHI on the Prescription and Administration Record. Where the identification bracelet is not used, the patient's identity must be established by some other means. Non-identification of the patient is a common source of drug error. 3.1.2. Allergies/sensitivities (Example A) Before administering any medicine, check the Known Medicine Allergies/Sensitivities section is complete. If in doubt or the section is blank, do not administer and refer to medical staff immediately. Adverse reactions to medicines are not common but can put patients at risk. It is essential that any known adverse reaction is recorded. UNCONTROLLED WHEN PRINTED Review Date: August 2013 Identifier: NHSG/Guid/Inst/MGPG446 - 16 - Instructions For NHS Grampian Staff on The In-Patient Prescribing And Administration Of Medicines Using The NHS Grampian Prescription And Administration Record - Version 1 Approved August 2011

3.1.3. Check that all aspects of the prescription are complete. If any aspect of the prescription is incomplete, e.g. doctor’s signature, refer to medical staff. It is important to note any comments which have been entered in the “Additional Instructions” column. 3.1.4. Identify the medicines due to be given.

3.1.4.1. Regular Prescriptions (Example J) Write in the date at the top of the first column at the first administration. Check the “date” row at the top of each Regular Therapy section. Find appropriate date and then look down the column in conjunction with the time row to establish which drugs are due to be administered. Check that the same medicine has not been prescribed in the As Required or Once Only section of the Prescription and Administration Record Example J

3.1.4.2. As Required Medicines (Example K) Check that the same medicine has not been prescribed in the Regular Therapy section or the Once Only section of the Prescription and Administration Record. Administer medicines as required for the indication identified. Take into account the prescribed frequency, maximum dose, date and time last administered. Check that this dose will not exceed the maximum for 24 hours. Where a choice of dose is prescribed, the lower dose should be selected first and the effects evaluated before increasing to the higher dose. Nurses who do not feel competent to make this decision should discuss with a senior colleague on the ward. If you are at all unsure of any aspect of the as required prescription, do not administer and refer to senior staff. UNCONTROLLED WHEN PRINTED Review Date: August 2013 Identifier: NHSG/Guid/Inst/MGPG446 - 17 - Instructions For NHS Grampian Staff on The In-Patient Prescribing And Administration Of Medicines Using The NHS Grampian Prescription And Administration Record - Version 1 Approved August 2011

Effects of as required medicines should be evaluated in the nursing notes. Example K

3.1.4.3. Once Only Prescriptions (Example L) Check the Date and Time column in the Once Only Prescriptions section. Check the prescription itself and check that the Given By column is blank. If there is any doubt about the prescription, an appropriate senior colleague should be consulted. Example L

3.1.5. Select the dose of medicine required. Check the medicine container with the prescription. Where there is outer packaging, for example strip packed tablets, the medicine must be removed from the outer packaging and checked against the prescription. Special care should be taken to ensure that the correct formulation is selected, e.g. m/r = modified release. • MEDICINE NAME • FORM (appropriate for route) • STRENGTH (appropriate for dose) • EXPIRY DATE If the patient’s own drugs are being used check that the patient’s name is on them. Whilst selecting the medicines required, it is essential to ask the patient if they are willing and able to take the medicines at that time. If the patient refuses or is unable to take a medicine, see 5: Recording the non-administration of prescribed medicines.



Once the process of administration has started it is important to complete all administrations for that patient. 3.1.6. Recording the administration of medicine(s) Check the patient’s identity again, administer the medicine(s) then record the administration. Record the administration as follows: 3.1.6.1. Regular Therapy Prescriptions (Example M) When the drug is administered to the patient, initial the top half of the box. The administration box should only be initialled after the patient has taken the medicine. In exceptional circumstances, where a choice of dose has been prescribed (e.g. dihydrocodeine 30-60mg), the actual dose given should be recorded in the lower half of the box.) This also applies to situations where a choice of route is available. The route used should be documented in the bottom half of the administration box If medication is not administered see section 4. The top of the box should be initialled and the appropriate non-administration code (on the Prescription and Administration Record, see Example N) should be entered in the lower half of the box and circled (Example M) see 5: Recording the non-administration of prescribed medicines. In exceptional circumstances, medicines may have been administered more than one hour before or after the prescribed time. This will be identified by entering the time in the lower half of the box corresponding to date and time below the administering person’s initials. 3.1.6.2. As required therapy Enter the date, time, dose and initials in each box (see Example K). 3.1.6.3. Once Only Prescriptions Initial the Given By column on the Prescription and Administration Record. Complete the Time Given column (see Example L). 3.1.7. Recording the administration of Controlled Drugs All Controlled Drugs must be checked, administered and recorded (as described in 3.1) in the presence of a witness. A high level of security/recording is applied to Controlled Drugs because of the potential for abuse. The details of any Controlled Drugs administered must also be entered in the Ward Controlled Drugs Record Book which must be signed in full both by the person administering the medicine and by the witness. Local procedures relating to Controlled Drugs must be adhered to. See – http://intranet.grampian.scot.nhs.uk/foi/files/CD_SecCare_0912.pdf.

http://intranet.grampian.scot.nhs.uk/foi/files/CD_SecCare_0912.pdf

Example M

Medication witnessed as taken by the patient

Medication refused by patient (code 1)

3.1.8. Recording the administration of a PGD medicine If a nurse is using a PGD to administer medicines to a patient, it should be documented in the Once Only or Regular Prescription section of the Prescribing and Administration Record, as appropriate, see Example L.

4. Recording the non-administration of medicines/missed doses/doses given early or late Medicine doses may be omitted or delayed in hospital for a variety of reasons. Whilst only a small percentage of these occurrences may cause harm or have the potential to cause harm, it is important to recognise that harm can arise from the omission or delay of critical medicines. If the administration of medication is delayed for whatever reason, for instance medication not available or the patient is off the ward, then it is the responsibility of the nurse leading on administration of medication for that patient to ensure that the medication is sourced as soon as possible, or if appropriate an alternative is prescribed or the medicine is administered as soon as is possible. Where necessary it is important to have a robust process to ensure this information is passed to colleagues and that they follow this up later. In some instances patients may refuse or be unable to take a medicine. When this situation occurs there must be discussion with the team caring for the patient to explore alternative forms of medication or to clarify why the patient can not take their medication, e.g. Nil by mouth. Patients should also be educated on why it is important that they take their medication and continued refusal must be documented in the nursing notes. 4.1. Recording the non-administration of prescribed medicines Regular Therapy Prescriptions (Example M) If a dose is not administered, initial and enter the appropriate code in the administration box with a circle around it. Codes for non-administration of prescribed medicines are listed in the Prescription and Administration Record.


Once Only Prescriptions (Example L) Write the code for non-administration in the Given By column. When recording a Once Only Prescription, the medicine may not be given later unless a new prescription is written by an independent prescriber. 4.2. Recording the non-administration of medicines for reason(s) other than codes 1-12 Regular Therapy Prescriptions and Once Only prescriptions (Example N) Use of codes 13 to 16 For reasons other than those stated in 1 to 12, enter the reason on the dotted line of the codes for non-administration of prescribed medicines section. Example N

4.3. Recording the administration of a previously missed dose Regular Therapy Prescriptions It is important to check that it is still appropriate to administer the medicine. In instances where a non-administration code has already been entered into the administration box,, the administration should be entered in the Once Only section Once Only Prescriptions A delay in administering a Once Only medicine may be unavoidable and when this happens, if the nurse considers the prescription still to be appropriate, the actual time that the medicine is given should be entered in the Time Given column. In all other cases, the prescription must be rewritten by an independent prescriber . 4.4. Recording the administration of a dose given before or after the prescribed time of administration In certain circumstances, it may be necessary to administer medicines before or after the prescribed time but only following consultation with an appropriate member of staff. Medicines will only be considered to be outwith the prescribed time if they are more than 1 hour outwith this time. Regular Therapy prescriptions Insert the time the medicine was actually administered in the lower half of the box Enter the reason for early/late administration in the nursing notes. UNCONTROLLED WHEN PRINTED Review Date: August 2013 Identifier: NHSG/Guid/Inst/MGPG446 - 21 - Instructions For NHS Grampian Staff on The In-Patient Prescribing And Administration Of Medicines Using The NHS Grampian Prescription And Administration Record - Version 1 Approved August 2011


Once Only prescriptions The actual time of administration of the medicine should be entered in the Time Given column. In order to avoid duplication of drug administration, it is essential that details of any exceptional situations are additionally communicated on a "need to know" basis both verbally and in the patient's nursing notes.

5. Procedure in the event of error or suspected error in medicine administration In the event of an error or suspected error in the administration of a medicine, the doctor and senior nurse on duty must be informed and the patient treated appropriately. An incident form (DATIX) should be completed. Medication errors unfortunately can and do occur. Understanding of and adherence to policies and procedures will greatly reduce the likelihood of errors. If, however, an error does occur, it is essential that, for the protection of the patient and the member(s) of staff involved, appropriate follow-up action is taken. Lessons can be learned by recording and analysing errors. Consultation Group - Records Standards Group Sue Danby, RACH. Morag Lyall, Clinical pharmacist, RCH. Janette McDonald, Principal pharmacist, ARI. Karen McKessack, Clinical pharmacist, ARI. Jenny Mosley, Paediatric pharmacist. Elaine Neil, LCHP Lead pharmacist, Aberdeenshire CHP. Sarah Noriss, Clinical effectiveness co-ordinator. Linda Press, Nursing Professional development, CHP. Jennifer Ross, Medication Safety Officer. Mandy Walker, Nursing professional development.

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