VIEWS: 446 PAGES: 5 POSTED ON: 5/1/2010
MEDICATION PROCEDURE NAME OF SERVICE OR ESTABLISHMENT:____________________________ NB This template is deigned to shape the written procedure for the administration of medication in individual establishments and will therefore be different for each service. However, all of the points below must be covered in each service policy and the manager concerned must refer back to the generic Departmental Medication Policy to ensure that the service policy complies with it. Local service procedures must be reviewed annually or more often if changes to practice occur. STANDARDS 1) State the CSI standards to which your service is working (delete as appropriate) Domiciliary (day services to follow these standards) Residential Adult Placement ADMINISTRATION 2) State the method of administration used in your services Drug trolley Monitored Dosage System (blister packs) Pharmacy containers State your procedure for administering medication, to include the following where applicable e.g: Who administers medication – which grades of staff, how many, where in the building? Any special arrangements – e.g. wear a tabard/take off bleep Medicines not to be left unattended Give at correct time (and any leeway allowed) Stay with client until taken Do not give to a third party to administer Sign only after safely taken Make sure there are no gaps left on chart Report any concerns or anomalies to…(who)...and record…(where)… Report any medication errors – near miss/SOVA/internal recording All of these points should be checked during administration. PRN MEDICATION State if your service administers PRN medication. State your procedure for PRN medication to include the following where applicable. Where recorded e.g. care plan, support plan, medication agreement. Instructions for PRN medication should list exact circumstances when drug should be given with evidence e.g. GP letter, Consultant’s report Times and dose of administration of PRN medicines should be recorded. State where else administration of PRN medication should be recorded e.g. daily notes, individual file, handover sheet. CONTROLLED DRUGS State the procedure for administering controlled drugs, to include: Who can do this Where the drugs are stored How keys are assigned, handed over and accounted for How to count and record controlled drugs How to record and report any concerns or anomalies eg near miss/SOVA/manager on call. RECORDS 1) State the records kept at your service in respect of medication, as appropriate from the list below Medication agreement Medication Administration Record (MAR) sheet Risk Assessment COSHH data sheets Capacity Assessment for self-medication, refusal of medication etc. Entry on individual care/support plan Signed records of receipt/disposal of medicines Photo of service user Level of assistance required by service user (CSCI 3 levels) 2) The following information must be recorded in respect of each individuals medication Name and age of resident/client including any nickname Month and year Name and strength of medicine The dose Route of administration The frequency and time of administration of each dose The commencement date of prescribing if known Any special information, e.g. Before food, when required Any known drug hypersensitivity (in red) Indication that the dose has been administered and by whom Indication that a new container has been opened. GP name and address Any other information relevant to the service. Codes should also be listed to record non-administration of medication, as follows: T = Tracked – this code can only be used by someone in a management role and is used to record that medication had not been signed for at the time of administration but has been proven, on investigation, to have been given. R = Refused A = Absent S = Sleeping F = Administered by Family L = Leave (can also be used for short trips out) O = Other – if this code is used a note must be made on the MAR chart specifying the reason why the medication was not given. SERVICE USERS GOING OUT State how to record medication taken out ie as ‘leave’. State how medication is accounted for and handed over when going out. STORAGE/SECURITY State where drugs are stored e.g. trolley in locked room, service users room etc. State where to store drugs that need to be refrigerated. State where to store controlled drugs. State who can hold keys for drug cabinets and how these are assigned, handed over and accounted for RECEIPT/DISPOSAL OF MEDICATION State if your service is responsible for checking the receipt of medication State what to check when receiving medication into the service as appropriate: 1. Name and strength of medication 2. Name of person medication has been prescribed for 3. Dose and frequency 4. Date the medicine was dispensed 5. Quantity dispensed. 6. Name and address of dispensing pharmacy State how this is recorded and who/how many people sign for this. State the special arrangements in respect of controlled drugs State how medicines should be disposed of and how to record this. NON-PRESCRIBED MEDICATION State if your service administers non prescription medication. State what records are needed: GP letter Agreement from pharmacist Risk assessed Capacity assessment Entry on support plan State procedure in your service to administer non-prescription drugs. State how you check whether medicines are appropriate for this person e.g. interactions, allergies, contra-indications. MEDICATION ERRORS State how medication errors/anomalies/concerns should be recorded e.g. Case notes Daily logs Handover sheet Near miss forms – must be done SOVA AP1 form – must be done State who is to be notified of any error or anomaly e.g. on call senior, unit manager, next of kin. State who to contact for advice in the event of overdose/under or missed dose, medication given to wrong person, e.g. NHS Direct, GP, Pharmacist. AUDIT MONITORING State the audit/monitoring systems for medication in the establishment e.g. who monitors, how often, how is this recorded, who is this reported to? APPENDIX 1 STAFF GUIDE FOR THE ADMINISTRATION OF MEDICATION (to be read in conjunction with Luton Borough Council policy and procedures for your work area / setting) Administration & Recording Check that the medication you are administering is clearly labelled with the clients name, medication name, date prescribed or expiry date, dose, frequency, and date opened. Check these details against the MAR chart or prescription. Refer to care plan or information on the MAR chart to confirm route of administration. Sign the MAR chart once the medication has been administered. Charts must indicate if the client was absent or refused medication. Medication labelling This should be a pharmacists printed label (unless it’s a home remedy/ bought over the counter). Do not administer medication if the label has been tampered with or is missing. Seek advice from the prescribing doctor or dispensing pharmacist Do not administer medication unless you have been part of the process of checking MAR charts and preparing the dose to be administered Report to manager and complete a near miss form and other forms appropriate to your work area e.g. SOVA, Cause for Concern under Care Homes Regulation 37. Other Do not give medication to anyone else, other than the person it has been prescribed for Do not administer a different dose than what has been prescribed unless there is written authorisation from the prescribing doctor or nurse Do not give invasive treatment e.g rectal diazepam, gastrostomy, injections etc, unless you have been trained to do so Do report any incidents e.g. overdose, missed dose etc to your manager and record these incidents on the appropriate record. Do not leave medication laying around, ensure it is securely stored Advice on any aspect of the administration of medication or on any other medication issues is available from the pharmacist, GP, Advanced Practice nurse or Community Nurse.