Microsoft word - appendix 07 injectable medicines policy v1.00.doc

INJECTABLE MEDICINES POLICY
Injectable Medicines Policy

1.0 Introduction 2.0 Scope 3.0 Purpose 4.0 Insertion of an Injectable Access Device 5.0 Care and Maintenance of Injectable Access Devices 6.0 Prescribing of Injectable Medication 7.0 Preparation and Administration of Injectable Medication 8.0 Audit and Review 9.0 References Appendix 1: Central Intravenous Administration Service (CIVA) Appendix 2: Intravenous Drugs Available in Mini-bag Plus System INTRODUCTION

The prescribing and preparation of injectable drugs and their administration, poses
many risks to patients. Safe systems of work are necessary to minimise these risks.
The National Patient Safety Agency (NPSA) Alert 20 “Promoting Safer Use of
Injectable Medicines” sets out to highlight processes to be implemented to minimise
these risks.

2.0

The policy covers all routes of injectable medicine administration within UHSM and
applies to all healthcare professionals authorised to administer to a patient via a
particular route.
3.0

This policy provides a policy and practice framework that promotes the principles of
the NPSA Alert 20 with the aim of reducing the risk to patients of injectable medicine
use within UHSM.
4.0
INSERTION OF AN INJECTABLE ACCESS DEVICE
There are seven main categories of injectable access devices in use within the Trust. These are: Peripherally inserted central venous catheters University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review Date August 2010 INJECTABLE MEDICINES POLICY
4.0.1 Before any healthcare professional inserts an injectable access device all the The performance of the task is agreed by the appropriate clinical manager/educational supervisor to be part of the clinical duties of the practitioner concerned and is included in their job description or is a pre-registration core competence. The practitioner has received appropriate training that conforms to the standards set by the Trust Clinical Skills Unit and approved by the Medicines Management Committee and Trust Education Committee. The practitioner has had these skills assessed and endorsed by an appropriate person within University Hospital South Manchester (UHSM). The practitioner can provide evidence of continuing competence via appraisal. 4.0.2 The insertion of all devices must be recorded on the patient’s observation Peripheral intravenous cannulae
4.1.1 Peripheral cannulae are the most commonly inserted vascular access device within the Trust. Peripheral intravenous cannulae may be inserted by: A registered medical practitioner or dentist. A registered nurse or midwife who must meet the competency requirements of the Royal College of Nursing “Standards for Infusion Therapy” June 2007. Healthcare Assistants, Assistant Practitioners and Medical Assistants if deemed competent by the manager of the clinical area in which they are working and included in their job description. Registered NHS Professionals (NHSP) and agency staff with a current professional registration who have received appropriate training to perform this task and can provide evidence of continuing practice and competence. Provisionally registered medical staff and medical students at an appropriate stage of their training under the direct supervision of a registered practitioner. 4.1.2 Guidelines for the insertion of these devices can be found in The Royal Marsden Handbook of Clinical Nursing Procedures 6th edition via the hospital Intranet. http://192.168.32.52/cd/rm/content/contents.htm Specific infection control procedures can be found in the South Manchester University Hospitals Trust Infection Control Policy Manual. Central Venous Catheters
May be inserted by: • A registered medical practitioner who has undergone appropriate training and assessment in the insertion of these devices. • An appropriately trained specialist nurse practitioner who has undertaken training and assessment in the insertion of these devices. University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review date March 2010 INJECTABLE MEDICINES POLICY
Peripherally Inserted Central (PIC) Catheters
May be inserted by: • A registered medical practitioner who has undergone appropriate training and assessment in the insertion of these devices. • An appropriately trained specialist nurse practitioner that has undertaken training and assessment in the insertion of these devices. Arterial Cannulae
Arterial cannulae must only be inserted by a registered medical practitioner who has undergone appropriate post-registration training and assessment in the insertion of these devices.
4.5 Subcutaneous Cannulae

A registered medical practitioner or dentist. Student nurses and medical students at an appropriate stage of their training under the direct supervision of a registered practitioner. Epipleural Cannulae
Medical staff can insert epipleural catheters under supervision with a record being kept in their personal log-book before competency is signed off by a consultant. 4.7 Epidural Cannulae
Medical staff can insert epidural catheters under supervision with a record being kept in their personal log-book before competency is signed off by a consultant. Implantable Devices
Must only be set up by a registered medical practitioner chronic pain specialist. CARE AND MAINTENANCE OF INJECTABLE ACCESS DEVICES
Devices should be maintained in accordance with the guidelines contained in the UHSM Trust Infection Control Manual. Devices should be labelled in accordance with the Medicines Policy Appendix 8 Invasive Line Labelling Policy. The administration of sodium chloride 0.9% 5mL flush to maintain the patency of a peripheral intravenous access device may be administered by a Healthcare Assistant, Assistant Practitioner or Medical Assistant. This must be signed for on the drug kardex by the assistant and the registered nurse who University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review Date August 2010 INJECTABLE MEDICINES POLICY
witnessed the administration. Administration of intravenous sodium chloride 0.9% 5mL flushes must only occur if intravenous cannulation is included in the job description of the assistant and they have received specific training and are deemed competent. PRESCRIBING OF INJECTABLE MEDICATION
All prescriptions for injections must clearly specify the following: The dose and frequency of administration Where relevant the prescription or protocol must specify the following: The brand name and formulation of the product e.g. a National Patient Safety Agency Requirement for amphotericin products Ambisome / Fungizone / Abelcet Concentration or total quantity of the medicine in the final infusion container or syringe, e.g. 1mg/mL or 200nanograms/50mL Compatibility with diluent and infusion fluid. The name and volume of diluent and/or infusion fluid The rate and/or duration of administration The type of rate control pump or device to be used The age and weight of any patient under 16 years of age The date on which the treatment should be reviewed. PREPARATION AND ADMINISTRATION OF INJECTABLE MEDICATION
7.0.1 Medicines should be given by injection only when the practicality and appropriateness of other routes of administration has been excluded. 7.0.2 Preparations for injection that require manipulation before administration must only be prepared by the healthcare professional that will be administering that preparation to a particular patient. 7.0.3 For the ward / clinic preparation of an injection that is not available in a “ready to administer” presentation, an aseptic, non-touch technique should be used. Ideally preparation should take place in an area dedicated to this process. The area in which the preparation is to be prepared must be as clean, uncluttered and free from interruption and distraction as possible. 7.0.4 For cytotoxic drugs, refer to the Trust’s Cytotoxic Medicines Policy. 7.0.5 Drugs for injectable administration may be given to the patient by the following healthcare professionals providing they have undergone the Trust’s Injectable Medicines Training (to include administration via intravenous and subcutaneous pumps): • A registered nurse or midwife. • A registered medical practitioner or dentist. University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review date March 2010 INJECTABLE MEDICINES POLICY
• A registered Allied Health Professional, e.g. radiographers, physiotherapists. • Registered NHSP and agency staff with a current professional registration and who have received training based on the Skills for Health competences and can provide evidence of continuing practice and competence. • On final placement, student nurses and midwives may prepare and administer drugs for injectable administration (intravenous, subcutaneous, intramuscular) under the direct supervision of a registered competent practitioner after attendance at the Trust’s Injectable Medicines training. 7.0.6 Before preparing and administering any injectable medicine all the following The performance of the task is agreed by the appropriate clinical manager/educational supervisor to be part of the clinical duties of the practitioner concerned and is included in the job description or is a pre-registration core competence. The performance of the task is considered to fall within the boundaries of the scope of the practitioner’s professional practice as defined by the relevant regulatory authority. The practitioner has received appropriate training that conforms to the standards set by the Trust Clinical Skills Training Officers and approved by the Trust’s Medicines Management Committee and Education Committee. The practitioner has had these skills assessed locally by a practitioner who has also undergone the Trust’s Injectable Medicine training. The practitioner can provide evidence of continuing competence via appraisal. INTRAVENOUS
7.1.1 The Trust has a Central Intravenous Additive Service (CIVAS) in the Pharmacy Department, which currently provides a service to nearly all wards within the hospital. These wards should obtain any intravenous drugs from this service where possible. (See appendix 1 for a list of wards provided with this service and the products available). 7.1.2 The majority of intravenous antibiotics can be prepared using the Minibag Plus system, which is available for use at ward level (see appendix 2). 7.1.3 Intravenous drugs that are not available from the CIVA service need to be prepared at ward level. These should be prepared for administration in accordance with the directions in the UCL Hospitals Injectable Drug Administration Guide (UCLH 2007) which must be available in all clinical areas of the Trust. If the drug is not listed in this guide then refer to the package insert of the product (Summary of Product Characteristics also available in the electronic Medicines Compendium), Appendix 6 of the current British National Formulary, or the Medicines Information department ext. 3331. 7.1.4. All syringes and infusions containing injectable medicines must be labelled with the Trust’s white drug additive labels or theatres pre-printed labels. See Appendix 8 of the Trust’s Invasive Line Labelling Policy. UHSM - Policy Documents University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review Date August 2010 INJECTABLE MEDICINES POLICY
7.1.5 Unpreserved injections must not be used for multiple use. Most injectable medicines are licensed for “once-only” use. Unless the manufacturer’s label specifically indicates that the injection contains a preservative, the product should only be used to prepare a single dose for a single patient on one occasion. 7.1.6 Drugs for intravenous administration must be prepared immediately prior to administration and should not be prepared in advance. For infusion products prepared in clinical areas, there is a 24-hour expiry (or less if specified in the Summary of Product Characteristics). The only exception to this is when the drug has been prepared by the Trust pharmacy CIVA service and it has been stored in accordance with the instructions provided on the label. 7.1.7 National Patient Safety Agency (NPSA) Alert 20 and The Nursing and Midwifery Council advocates double checking of all injectable medicines before administration. However, the Trust recognises that in exceptional circumstances, single person preparation and administration of intravenous medication is acceptable. If two people are involved in the checking of an injectable drug, each individual must be deemed to be competent and will be accountable for his/her part in the process. The use of calculators to determine the volume or quantity of medication should not act as a substitute for arithmetical knowledge and skill (NMC 2008). Where a second person is asked to check a calculation this should be done independently without reference to the work of the preparing practitioner. 7.1.8 Nursing staff/midwives must be familiar with the Trust Anaphylaxis Policy. Registered and appropriately trained nurses/midwives are permitted to administer any dose, including the first, of intravenous drugs. 7.1.9 Drugs must not be mixed together in infusion bags or administered together via Y-sites or 3-way taps unless compatibility of the drugs has been confirmed. The UCL Hospitals Injectable Drug Administration Guide (UCLH 2007) has brief information on compatibilities; further information may be obtained from Medicines Information (ext 3331). 7.1.10 The responsibility for monitoring a patient for adverse effects during intravenous administration is that of the practitioner administering the medicine. No practitioner should administer a drug unless: • They are aware of the therapeutic use of the drug or solution to be administered, the normal dosage, side effects, precautions and contra-indications. • They can prepare the drug aseptically and safely, they have checked the container and drug for faults, used the correct diluent and only prepared the drug immediately prior to administration. University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review date March 2010 INJECTABLE MEDICINES POLICY
• They are able to identify the patient and check their allergy status. • They have checked the prescription kardex. • They have checked and can maintain the patency of the vascular access • They have inspected the site of the vascular access device and can report / manage the complications where appropriate. • They can control the flow rate of the infusion and or speed of injection. • They monitor the condition of the patient and report changes. • They make clear and immediate records of all drugs they administer. Where an infusion is due to continue past the end of the practitioner’s shift or on transfer between different clinical areas, then the infusion should be handed over to the practitioner undertaking continued responsibility for the patient’s care. The condition of the infusion site and the status of administration must be documented on the patient’s drug kardex. Patients leaving the ward / department area with an infusion being administered via a volumetric pump must be risk assessed and the plan documented in the patient’s notes. 7.1.11 All intravenous drug and fluid infusions should be regulated using a volumetric infusion pump. Exceptions to this are: • Emergency situations were a rate is required that is higher than the maximum programmed rate of the infusion device. For all registered nurses and midwives that have attended and passed the Acute Illness Management course, following risk assessment of the patient the following rates of intravenous sodium choride 0.9% can be given for the acute management of hypotension whilst awaiting urgent medical review: 200mL over 5-10 minutes if cardiac cause of hypotension 500mL over 5-10 minutes if non-cardiac cause of hypotension The administration of this intravenous fluid must be retrospectively prescribed and signed for. • Medicine that the UCL Hospitals Injectable Drug Administration Guide (UCLH 2007) or Summary of Product Characteristics recommends to be given as a bolus.
• Fluids containing only sodium chloride, glucose or Hartmann’s may be
infused using an infusion line with integral manual flow control device providing that the patient concerned is not considered to be at high risk of developing systemic fluid overload. Situations where a suitable infusion pump is temporarily unavailable and the risks to the patient of not having the medication are judged to be greater than the risks caused by not using an infusion device. This must be documented in the patients notes and a HIRS report completed. 7.1.12 The use of the intravenous route should be regularly reviewed in favour of switching to oral administration as soon as clinically appropriate. University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review Date August 2010 INJECTABLE MEDICINES POLICY
7.1.13 For the management of extravasation, guidelines are available at http://192.168.32.6/Support/Clinical/Pharmacy/Formulary/smuht_extravasation_guidelines.pdf SUBCUTANEOUS ADMINISTRATION

7.2.1 Infusions

Hypodermoclysis is a technique used to administer fluids and electrolytes subcutaneously to achieve fluid maintenance or replacement in mildly dehydrated patients or in patients at risk of dehydration when the oral or intravenous routes are not available. It is not suitable for use for patients with severe dehydration. Normally 500mL of fluid is given over 8 hours up to a maximum of 2litre over 24-hour period. The following solutions are appropriate for administration in this way: potassium ≤ 40mmol/L in the above solutions Solutions are administered using a standard giving set and should always be gravity fed i.e. not via a pump.
7.2.2 Syringe drivers

All prescriptions for syringe drivers used in the palliative care setting must be prescribed on the South Manchester Palliative Care Team syringe driver chart. INTRAMUSCULAR ADMINISTRATION
Absorption following intramuscular administration can be erratic and therefore intramuscular administration is not normally the first line route for injectable therapy. The volume to be given at any one site must be limited to 5mL for the thigh (or 4mL if this is a depot injection) or 2mL for the deltoid muscle. Larger volumes are not effectively absorbed and may lead to abscess formation. If more than 5mL has to be given, then more than one injection site must be used. If a series of injections are to be administered, injection sites should be used in rotation and a record of these kept. The administration of intramuscular methotrexate must be in-line with the Cytotoxic Medicines Policy and the Gynaecology Assessment Unit guidelines. INTRA-ARTERIAL ADMINISTRATION
See Peripheral Arterial Thrombolysis Guidelines for the management of acute arterial ischaemia by interventional radiologists. University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review date March 2010 INJECTABLE MEDICINES POLICY
INTRA-ARTICULAR ADMINISTRATION
• Drugs for intra-articular administration can be given by a registered medical practitioner, specialist nurse practitioner or physiotherapist who have had appropriate training and are deemed competent. • A physiotherapist cannot mix two products together for single administration e.g. a local anaesthetic and corticosteroid. EPIDURAL ADMINISTRATION
See Protocol for Acute Pain Service Epidural Analgesia January 2008. EPIPLEURAL ADMINISTRATION
See respiratory system therapeutic guidelines “Doxycycline Pleurodesis.” INTRATHECAL ADMINISTRATION
UHSM is not an accredited site for the administration of intrathecal chemotherapy. In-line with the Pharmacy Aseptics Services Standard Operating Procedures intrathecal pumps for chronic pain management must be approved for release by two senior aseptic services pharmacists and signed for upon collection. REGIONAL BLOCK ADMINISTRATION

See Acute Pain Service protocols for sub-pectoral and brachial plexus blocks.
INTRA-VESICAL ADMINISTRATION

See Cytotoxic Medicines Policy for the administration of mitomycin.
The Mito-In device should only be used in situations where the pharmacy
aseptic unit is unable to make up the mitomycin. Mitomycin can be made up
to 4pm daily Monday-Friday.
Botulinum toxin must only be administered by Consultant Urologists that have
been trained in the injection technique for the management of overactive
bladder.
AUDIT AND REVIEW
The Trust will include an audit of medication practice with injectable medicines as part of the annual medicines management report. It will include a summary of risk assessment results, incident reports, compliance with NPSA recommendations and in-year actions and improvement. An action plan for improving any poorly performing aspects of the system will be included. The report will be presented to the Medicines Management Committee on an annual basis. University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review Date August 2010 INJECTABLE MEDICINES POLICY
REFERENCES
NPSA 2007 Patient Safety Alert 20 Promoting safer use of injectable medicines. Nursing and Midwifery Council 2008 Standards for Medicines Management. Royal College of Nursing 2007Standards for Infusion Therapy Royal Marsden 2004 The Royal Marsden Manual of Clinical Nursing Procedures South Manchester University Hospitals Trust Infection Control Policy Manual. UCL Hospitals Injectable Drug Administration Guide 2007, Blackwell Science, Oxford UHSM 2006 South Manchester University Hospitals Trust Formulary 2006/2007 University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee - 10 - Published March 2008; Review date March 2010 INJECTABLE MEDICINES POLICY
APPENDIX 1
Provision of CIVA Service to wards
at University Hospital South Manchester NHS Foundation Trust
Wards that receive a CIVA service
Wards that do not receive a CIVA
University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee - 11 - Published March 2008; Review Date August 2010 INJECTABLE MEDICINES POLICY
LIST OF PRODUCTS MANUFACTURED
NAME OF DRUG
PRODUCT TYPE
University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee - 12 - Published March 2008; Review date March 2010 INJECTABLE MEDICINES POLICY
LIST OF VIALS THAT ARE COMPATIBLE WITH
SODIUM CHLORIDE 0.9% 100mL MINIBAG PLUS ASSEMBLY
ONLY these vials listed are compatible with Minibag Plus
Amoxicillin 250mg
Amoxicillin 500mg
Amoxicillin 1g
Co-amoxiclav (Augmentin) 600mg
Co-amoxiclav (Augmentin) 1.2g
Benzylpenicillin 600mg
Benzylpenicillin 1.2g
Cefotaxime 500mg
Cefotaxime 1g
Cefotaxime 2g
Ceftriaxone 1g
Ceftazidime 1g
Ceftazidime 2g
Cefuroxime 750mg
Cefuroxime 1.5g
Flucloxacillin 500mg
Flucloxacillin 1g
Meropenem 500mg
Meropenem 1g
Omeprazole 40mg
Temocillin 1g
Vancomycin 500mg
LIST OF VIALS THAT ARE COMPATIBLE WITH
METRONIDAZOLE 500MG in 100mL MINIBAG PLUS ASSEMBLY
University Hospital South Manchester NHS Foundation Trust, Medicines Management Committee Published March 2008; Review date March 2010 INJECTABLE MEDICINES POLICY
CYTOTOXIC AND ANTIVIRALS DRUGS PREPARED
Name of drug
Product Type
University Hospitals South Manchester NHS Foundation Trust , Medicines Management Committee
Published March 08, Review date March 2010

Source: http://smuht.nwest.nhs.uk/services/P/policies/Trustwide%20policies%20operational%20policies%20and%20proced/MMP%20Appendix%2007%20Injectable%20Medicines%20Policy%20V1.00.pdf