Medicines Management
Are Registered Nurse Prescribers allowed to prescribe MDA/controlled drugs?
Yes. Registered Nurse Prescribers can prescribe controlled drugs independently, but they are subject to abiding by Schedule 8 of the Misuse of Drugs (Amendment) Regulations of 2007 for restrictions for MDA Schedule 2 and 3 drugs.
It should be noted that the Department of Health are currently reviewing the MDA Schedule 8 listing with a view for its expansion for RNPs. For further information visit this section of the Department of Health website.
Are registered nurses and midwives required by NMBI to double-check medications as part of their role in administering medications?
Firstly, it is appropriate to clarify what is meant by double-checking. An independent, double check of any medicines is termed independent verification. The nurse or midwife conducts their own calculation of the medicines and then compares with a colleague.
It is recognised that there are circumstances in care settings where the nurse or midwife is not working alongside other nurses or midwives – for example, working in the community, residential care units or on night duty. Double-checking the administration of medicines is not a statutory requirement. You may consider asking another nurse or midwife colleague to double-check a medicine if you determine that assistance is needed.
For patient safety and risk management purposes, health service providers may have a policy for independent verification of medicines, particularly for those that are considered high-alert (such as insulin, heparin and chemotherapy) or that require complex calculations in preparation for administration.
As a public health nurse, I usually work on my own and have to rely on clients or family members to check medication with us. I have concerns about patients who receive drugs through a syringe driver, especially MDA Schedule 2 controlled drugs. Are public health nurses supposed to have two nurses with us when dealing with these drugs?
There are a number of key points to consider in addressing your concern. Does your health service provider have a medicine management policy that includes the management of controlled drugs? If so it should be used in association with current medicines legislation and the NMBI’s guidance on medicine management to guide your practice.
NMBI acknowledges that local need may dictate specific Policies, Procedures Protocols and Guidelines(PPPGs) authorising the practices of individuals involved with medicines. The local health service provider policy may require two persons to conduct the administration of MDA drugs. The checking, preparation, administration or destruction of these drugs by two individuals may also be mandated for in the policy. However there is no legal requirement for controlled drugs to be checked and/or administered by two individuals.
In your situation, in the community, it may be apt for you to ask the client (if appropriate) or a family member to witness the checking of the prescribed medication. Clear and direct communication with the client and their family about your role and responsibilities for medicine management should be undertaken at the initial stage of caring for the individual.
If you identify concerns about medicine practices including MDA use, either from your point of view, the client or family it may be helpful to organise a team meeting to openly talk about these issues. Maintaining good clinical records are also essential in providing care safely and effectively. You should read the NMBI’s guidance for recording clinical practice.
Can I take a verbal or telephone order from a doctor particularly in an emergency situation?
The only acceptable time a verbal or telephone order should be taken from a doctor is in an emergency situation. Accepting a verbal or telephone order should not be considered a substitute for a comprehensive medication policy or protocol for routine medication management. The overall benefit to the patient and ensuring their safety should be prioritised in these situations.
The key considerations of responsibility, accountability, autonomy and competency should guide the individual nurse or midwife in determining their own scope of practice relating to emergency situations. These are outlined in the Scope of Nursing and Midwifery Practice Framework.
A registered nurse or midwife utilising the framework and the principles of the Code of Professional Conduct and Ethics in their provision of care would be considered to be practising in a safe and competent manner. You should also refer to our Guidance on Medication Management.
The development of policies and protocols to support verbal or telephone orders in emergency situations should be undertaken at a local organisational level which reflects this guidance.
I am a community nurse and my work supports clients with self-administration of medication. Sometimes I encourage clients to use a dosette box to help them organise their medications for the week. What should I be aware of for safe and appropriate practice?
Many individuals in the community may use a medication administration aid to assist them in organising and taking their medications. Various terms describe this type of system (e.g. compliance aids, dosette boxes, monitored dosage systems). Compliance aids are designed to aid self-administration by patients or clients.
The client’s individual requirements and needs should be assessed to ensure there are no contraindications related to using the compliance aid. Consultation with the client’s pharmacist and GP should be considered for guidance in assessing the need for using such a system and in supplying medicines in this manner. Systems for the on-going evaluation of the appropriateness of the compliance aid should be documented in local policy, based upon the client’s condition and their prescribed medicines.
Optimally, the compliance aid should be filled by the person’s pharmacist. NMBI’s guidance on the medicine management provides detailed advice to support you in the use of compliance aids. Additionally the regulator of pharmacists the Pharmaceutical Society of Ireland has prepared guidance for pharmacists on this topic.
I am a Director of Nursing of a community hospital and we are planning an update in medicines management. We plan to initially address this need by providing an in-service study day. What kind of resources we should consider for this topic?
Consider examining the concept of medicines management and its activities as first step. Sources from health care regulators include:
You should determine prior to the study day which topics and issues are most pertinent to your staff. Is it the general principles of medicines management that you want to review or more specific issues such as medicine reconciliation, dealing with medication errors, management of MDA controlled drugs?
Other resources for planning the in-service day that may compliment the above information provided are:
I am a nurse working in a nursing home. I am the only staff nurse in a ward. Administering medication is difficult for me to manage and I am concerned that residents are not receiving their medicines on time. Can I delegate the task of administering medicines to a healthcare assistant?
As a registered nurse, you are accountable to NMBI for your professional practice, which includes the safe administration of medications. Each situation should be reviewed individually as it arises. It is also important that you know what your employer's policy is for the staff responsibilities nurses and non-nurses - in the administration of medications.
The resident's best interests and safety should be the primary factors in making your decision while the nursing care plan for the resident should help to determine the assistance they require.
When considering delegation of this activity, you should ensure that the care assistant is an appropriate person to delegate to. You must consider the level of experience and competence of this person before assigning this task:
- Has the care assistant the necessary skill to administer the medication to the individual resident/patient?
- Are they familiar with the resident and aware of any special needs in assisting them to take the medication?
- Has the care assistant been informed of their responsibilities in taking on this task? For example, does the care assistant need to report any information back to you after completing the task? If so, this should be reviewed with the care assistant prior to the actual administration of the medication.
You as the registered nurse are responsible and accountable for ensuring that the delegation of medication administration is appropriate in each particular situation.
The NMBI guidance on delegation is covered in Principle 5 Collaboration with others of Code of Professional Conduct and Ethics. Also, the Scope of Nursing and Midwifery Practice Framework also contains detailed guidance on the issue of delegation and supervision. Working through the Scope of Nursing and Midwifery Practice Flowchart should assist you in considering whether or not you should delegate this activity of medication administration to a healthcare assistant in a specific and defined circumstance.
I am a staff nurse in a surgical clinic. A consultant has prescribed a medication and I am concerned about the dosage amount. Our pharmacist said although that the dosage prescribed was outside the license it would be considered ‘off label use’. What does this mean?
The term ‘off-label prescribing’ has been replaced by the term ‘authorised medicine prescribed for an unauthorised indication'. The Health Product Regulatory Authority* (HPRA). which was formerly called the Irish Medicines Board, defines this as an authorised medicine prescribed for an illness or condition that is not listed on the medicine’s summary of product characteristics.
There is no restriction in the relevant medicines regulations for a registered medical or dental practitioner to prescribe an authorised medicine for an unauthorised indication. The Medicinal Products (Control of Placing on the Market) Regulations 2007, as amended, do not prohibit the sale, supply, manufacture, possession or procuring the sale, supply, manufacture of an authorised medicine for an unauthorised indication.
Prescribing by a RNP of an authorised medicine for an unauthorised indication must be in accordance with Regulation 5A of the Medicinal Products (Prescription and Control of Supply) Regulations 2003 as amended. The Practice Standards and Guidelines for Nurses and Midwives with Prescriptive Authority provides detailed guidance on this topic.
A nurse or midwife has authority to administer an authorised medicine for an unauthorised indication once it has been prescribed by a registered medical, dental practitioner or nurse prescriber. It is important that you have an understanding of the reasons for administering the medications, particularly as it relates to your assessment and evaluation of the effectiveness of the prescribed medication for the patient.
It is advised that you speak with the medical practitioner who has prescribed the medication if you have questions regarding the indications including dosage, for its use for the patient.
I have been asked to update our documentation and medicine management policies and to include guidance on the use of abbreviations in the hospital setting. What should be considered?
A policy on the use of abbreviations within your practice setting is an excellent way of improving patient safety. NMBI’s Recording Clinical Practice addresses the use of abbreviations stating “Abbreviations should only be used if drawn from a list approved by the healthcare facility….The list should be periodically reviewed and, if necessary, updated”.
Collaborate with other members of the inter-professional team and departments such as risk management, quality and safety, pharmacy. Policies, Procedures Protocols and Guidelines (PPPGs) should be directed at all staff using abbreviations in their documentation and communication for patient care.
Other NMBI guidance that may aid your work include Medicine Management. If a nurse or midwife finds a medicine prescription to be unclear which may occur with use of abbreviations, they should seek clarification from the prescriber.
I work as a nurse in a nursing home which is introducing the practice of intravenous medication administration for residents. The majority of these IV medications are antibiotics. I am concerned about the safety aspect of this practice particularly possible adverse reaction and anaphylactic shock. What kind of resources should I refer to?
There are a number of resources NMBI can direct you to regarding developments in practice and best practice guidelines in relation to intravenous medication administration and therapy. Firstly NMBI has published guidance on medicine management Guidance to Nurses and Midwives on Medication Management which provides guidance for nurses and midwives. The accompanying eLearning programme which is available on HSELand.ie should also be reviewed. HSELand.ie also lists courses on peripheral intravenous cannulation.
Each nurse or midwife should take appropriate steps to develop and maintain competence with regard to all aspects of medicine management, ensuring that her/his knowledge skills and clinical practice are up to date. This point is significant for you in view of your nursing home initiating intravenous medication administration as an expanded service for residents. The Scope of Nursing and Midwifery Practice Framework is also a useful tool for you in considering your professional responsibilities.
Assistance and support from your employer should be sought. This should include emergency management of anaphylaxis and adverse events associated with IV therapy.
Also, there is an international speciality organisation for nurses interested in IV therapy called the Infusion Nurses Society which has an Irish chapter.
I’m working as a practice nurse. One of the GPs wants me to see all women who come in for repeat prescriptions for the oral contraceptive pill. He does not want to see them unless they have a problem. Is it OK to do this?
The Scope of Practice Decision-Making Flowchart is good tool for you to use to reflect on this question and to assist you in identifying your concerns. By working your way through the flowchart one of the issues to consider is the legislation that governs the issuing of prescriptions for medicines. Only a doctor, dentist, registered nurse prescriber or veterinary surgeon can legally write a prescription. The issuing of a repeat prescription is the responsibility of these professionals and they may are accountable for that decision.
As the practice nurse, it may be appropriate for you to be involved in the assessment of the woman that informs the decision-making process. You must communicate the findings of your assessment to the GP so that the decision to issue the repeat prescription is based on informed consultation process. You must document all the findings of your assessment and the consultation with the doctor.
For reasons of patient safety and risk management, you should not write out the repeat prescription and present it to the GP for signing.
In such a case, how should a practise nurse go about assessing a patient?
Again, you should refer to the Scope of Practice Decision-Making Flowchart. This encompasses considering if the woman will derive an overall benefit from your actions and whether it fits with the definitions and values that underpin nursing.
You must also assess your own level of competence in relation to the assessment of women requiring repeat prescriptions for the oral contraceptive pill. Do you have the necessary knowledge and clinical skills to carry out the appropriate assessment? If not, you should not carry out the assessment. You need to take steps to acquire the necessary knowledge and skills.
Ultimately, you have to make a judgement about your own level of competence and what you will undertake. You, and not the GP, are accountable for your actions. You should also apply the standards set out in the Professional Responsibility and Accountability section within the Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives.
You should also note the Medical Council of Ireland has given direction to doctors about their responsibilities for prescription writing and patient assessment.
Should the nursing home’s policy on medicine management be updated in the light of the decision to introduce intravenous medication administration for residents?
Yes. Your nursing home’s policy on medicine management should be updated with regard to intravenous therapy and IV medication administration including the areas of:
- Infection control and safety observance
- Site selection and placement for IV access
- Site care and maintenance
- Staff education
- Patient education
- Infusion equipment
- Documentation/communication standards and IV related complications treatment and reporting.
This list is not exhaustive and consultation with other members of the health care team is suggested for policy development and monitoring.
What other bodies apart from NMBI should I refer to in relation to the use of abbreviations.
The HSE has published guidance in drawing up an approved list of abbreviations. This is included in a document Code of Practice for Healthcare Records Management document.
Internationally there is much guidance on the use of abbreviations within healthcare settings. The Institute for Safe Medication Practices (ISMP) compiled a list of more than 60 commonly used abbreviations, symbols, and dose designations that have been implicated in medication errors. The Joint Commission on Accreditation of Healthcare Organisations (JCAHO) is another useful resource.
ICAHO has conducted research finding the use of abbreviations in health care may be efficient, however this may be at the expense of patient safety by contributing to medication errors. In addition to publishing a list of approved abbreviations the JCAHO has published lists of approved and prohibited abbreviations.