Recommendation 242

Administering medication

Accepted
In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated delegate. A frequent check needs to be done to ensure that all patients have received what they have been prescribed and what they need. This is particularly the case when patients are moved from one ward to another, or they are returned to the ward after treatment.

In the initial government response to the inquiry, Patients First and Foremost, the Department of Health gave strong support to supervisory roles for Ward Managers (including sister, charge nurse and team leader) in delivering oversight to all aspects of care on a ward and in a community, from cleanliness to allocation of staff. Nurse leadership at ward level provided by a ward manager is also important to the delivery of safe, high-quality care to patients. However, we wish to allow for local flexibility in delivering nursing care and so the Government is not mandating that ward nurse managers must operate in a supervisory capacity.

Having sufficient nurses trained and with the capacity to ensure the delivery of safe, patient focused care is currently a core standard requirement of the Care Quality Commission. Compassion in Practice, the vision and strategy for nursing in England, commits to ensuring we have the right staff, with the right skills in the right place. This includes supporting leaders to be supervisory, giving them time to lead action plans by December 2013.

In Patients First and Foremost, the government committed to draw up a new set of fundamental standards of care that will sit within the legal requirements that providers of health and adult social care must meet to be registered with the Care Quality Commission.

In June 2013, the Care Quality Commission issued A new start – Consultation on changes to the way CQC regulates, inspects and monitors care. This document started the public discussion on what the fundamental standards of care should be. DH has issued draft regulations for consultation, which set these fundamental standards of care in legislation as outcomes that must be avoided, as well as streamlining and improving the clarity of requirements which must be positively achieved in order for a provider to register with the Care Quality Commission. The Care Quality Commission, through its Chief Inspector of Hospitals, is engaging with providers, professionals and the public on what guidance it should publish on complying with these regulations and how they should relate to the Care Quality Commission’s broader assessments of the quality of hospital services. The new regulations setting out fundamental standards of care, and the Care Quality Commission’s associated guidance for providers on them, will come into effect during 2014, subject to Parliamentary approval. The final set of standards is likely to cover areas such as: care and safety of patients and service users; abuse, including neglect; respecting and involving service users, nutrition; consent; governance; cleanliness and safety of premises and equipment; staffing; fitness of directors; and duty of candour.

Local Healthwatch organisations are using their ‘enter and view’ powers to get a clear picture of how health and care services are meeting the needs of the public, and their place on every local health and wellbeing board will ensure that voices of people using services is at the heart of local planning and decision-making. Local Healthwatch will also enhance the new inspection regimes. They will make sure inspection teams get a comprehensive picture of local people’s opinions and concerns, and will maintain a focus on service quality issues after the inspection team has moved on.

Administration of medicines is one part of a system in hospitals designed to ensure patients have safe and effective access to the medicines they need. Other components of that system include safe prescribing and supply of medicines. The Nursing and Midwifery Council’s Standards for Medicines Management sets standards for safe practice in the management and administration of medicines expected of registered nurses, midwives and specialist community public health nurses. The General Medical Council’s guidance Good practice in prescribing and managing medicines and devices sets out expectations of registered medical practitioners. The General Pharmaceutical Council sets standards for registered pharmacists and registered pharmacy technicians. All of these members of the local clinical team contribute to safe use of medicines in an organisation.

However, the Royal Pharmaceutical Society’s Professional Standards for Hospital Pharmacy Services makes clear that the hospital chief pharmacist (or equivalent) leads on ensuring that all aspects of medicines use within its organisation are safe. Therefore local hospital pharmacy teams must ensure systems are in place to minimise risks to patients from medicines, and working with doctors, nurses and management colleagues, ensure those systems are robustly and regularly monitored and audited. Importantly, local organisations must also encourage a culture and system which supports reporting and learning from medication mistakes and errors. Such systems and processes must be set out in local hospital medicines policies, signed off by the hospital Trust Board, with the board receiving regular reports (eg annually) on implementation and areas for improvement, together with remedial action plans .

On occasion it is necessary for nurses to withhold medicines from administration. For example, when some medicines need to be temporarily halted before surgery, or is the registered nurse considers that administration of the prescribed medicine or dose would put the patient at risk.

The government’s Information Strategy outlined several elements which will be applicable to the administration of medicines. The Department of Health will continue to collaborate with key partners such as the National Care Forum, the Royal Pharmaceutical Society and key Royal Colleges, building on existing work, to improve the use of medicines in care homes, including considering the role of technological innovation and commissioning incentives in transforming safety and efficiency.

The Department of Health also set out in Transforming Care: a national response to Winterbourne View Hospital  a number of actions to address concerns raised about the prescription and administration of medications, including the overuse of anti-depressants and anti-psychotics for individuals with mental health conditions, learning disabilities, autism or behaviour that challenges and the use of rapid tranquilisation to restrain patients in crisis. The Department of Health is currently leading a cross-Governmental review of the Mental Health Act 1983 Code of Practice. This will include updating current guidance on the use of medications for individuals subject to the Mental Health Act. We will consult on a revised code early in the new year.

NHS England is also leading a review on the use of medications for individuals with a learning disability or behaviour that challenges. Working with NHS Improving Quality, NHS England is developing proposals for a collaborative to highlight and share best and safe practice in the prescribing, administration, dispensing and use of medications for individuals with a learning disability or behaviour that challenges. The proposals for the collaborative are currently being finalised and it will be launched shortly.

Update

The Care Quality Commission has 11 new fundamental standards will come in to force for all providers in April 2015. These new regulations are clearer statements of the standards below which care should never fail. One of these standards is ‘safe care and treatment’ which specifically outlines the need to protect service users from avoidable harm through the control and management of medications.