Medication administration by nurses

APNA often receives enquiries around medication administration by nurses in general practice.

The difficulty in answering these questions lies in the fact that each state and territory has its own drugs and poisons legislation, with different guidelines for rural and remote areas and for certain sectors of the healthcare worker community. APNA recommends nurses check with their local authority on questions around drug and poisons.

We’re interested in your experiences. To start the discussion, we thought it would be helpful to share a typical enquiry we receive around medication administration.

Q. What should I do when a patient brings a prescription medicine dispensed from the pharmacy (e.g. a vitamin B12 injectable supplement) in to the practice for me to administer?

A. To answer this question, our discussion would address the following:

  • As with all procedures, consider what is within your individual scope of practice: what are you educated, authorised and competent to perform?
  • We normally discuss the way in which the prescribing GP might document the medication order for nursing staff in the patient’s clinical notes (i.e. this might coincide with writing the prescription or the GP may prefer to see them again on the day of administration).
  • We ask nurses to ensure the order is written and provides all of the required information, including authorisation for the nurse to administer the medication (i.e. dose, how often, pre and post follow up if required).
  • Verbal orders can be difficult to manage when there is only one nurse in the practice and should be reserved for urgent situations – discuss with your practice team how this might be managed.
  • We like to discuss the need for nurses to have a good understanding of the drugs they are administering. What are the potential side effects? Has the medication been stored appropriately prior to presentation? Is any pre-administration care required? What follow up is required? Is this a cytotoxic drug? If so, what appropriate measures need to be put in place to be able to administer this safely and within legislation in your practice?
  • We always recommend you refer to the ‘6 Rights’ of medication administration (or the 8 rights, if you prefer to include right reason and right response):
    • Right drug – check the order, medication and expiry date. If you don’t have another nurse to check the order and the medication, we recommend you check with the GP. Note that nursing students are NOT able to check medication with you.
    • Right individual/patient – use a minimum of two identifiers. Ask the patient to identify themselves by name and date of birth. Ask them for their understanding of the medication you are about to administer, and deliver medication information. If there is an alert on the patient file that there is a person with a similar name in your practice please use normal processes to provide additional checks.
    • Right dose – check the order and confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse or the GP calculate the dose as well.
    • Right time – check the frequency of the ordered medication. Double-check you are giving the ordered dose at the correct time. Confirm when the last dose was given. Confirm whether follow up or examination is required prior to or post medication being administered. Place a recall or reminder for next dose or follow up.
    • Right route – again, check the order and appropriateness of the route ordered. Confirm the patient can take or receive the medication by the ordered route.
    • Right documentation – document administration AFTER giving the ordered medication. Using the clinical software, you may develop ways to consistently document the medication administration which includes information about the drug, expiry date, time, route, site of injection, and any other specific information as necessary (e.g. any pathology test or observation which needs to be checked before or after giving the drug).

Have you developed an easy process in your practice to improve medication management that you would like to share? We would love to hear from you.

5 thoughts on “Medication administration by nurses

  1. If an injection was prescribed from outside the practice, I ask the patient to see one of our GPs first, then act on instructions from the GP.
    Monthly allergy injections I felt better about after some coaching from a visiting educator
    Injections prescribed by our GPs I have no problem with. If it’s a new medicine to me I will discuss withe the GP first. Most of the unusual ones (e.g. implants) they the responsibility for.
    Generally children are seen by the GP first before immunisation.
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  2. I would just like to clarify a few areas that I find are not well known in general practice or nursing generally.

    In Victoria it is legal for nurses to administer a medication from the written instructions on the medication packet. It is also legal to help someone to take their own legally prescribed medications if they are unable to do this for themselves. There is no legal requirement for two nurses to check schedule 4 medication this is something that is policy driven in hospitals.

    Practice policies should be written to encompass medication given in the settings described above to provide clarity and indemnity to nurses.

    The following is found on the drugs and poisons website
    Nurses and midwives – Key legislative requirements
    http://www.health.vic.gov.au/dpcs/reqhealth.htm

    Administration of Schedule 4 and Schedule 8 poisons
    Regulation 47 requires a nurse or midwife to refer to authoritative instructions before administering Schedule 4 or Schedule 8 poisons, namely:
    • Written instructions of an authorised prescriber (the most common option)
    • Oral instructions of an authorised prescriber if, in the opinion of the authorised prescriber, an emergency exists (e.g. telephone orders)
    • Written transcription (of emergency oral instructions) by the nurse or midwife who received those instructions
    • Directions for use on a container supplied by an authorised prescriber or pharmacist (e.g. when administering a person’s own lawfully supplied medicine)
    • In accordance with the provisions of regulation 5(2), namely when administering under the conditions of a Health Services Permit (e.g. the Standing Orders permit condition) or under an approval issued by the Secretary of the Department of Health (e.g. nurse immunisers, midwives)

    Note: Nurses can also be authorised to possess Schedule 4 and Schedule 8 poisons when acting in a role that is not specifically limited to nurses, as specified in regulation 5(1); for example:
    • Possession and self-administration of medicines that were lawfully supplied to the nurse (as a patient)
    • Possession of medicines, which were lawfully supplied (e.g. on prescription) to a patient for whom the nurse is caring, in the course of assisting that patient to administer their own medicines
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  3. This question came up through our nurses network. The legislation is different in SA regarding S4 medications – they do indeed have to be checked by two nurses. I beleive this will be discussed further at a meeting of SA ANMF later in November, as one of our network members pointed out to the ANMF that many GP practices only have one nurse. For my own practice, I now check ALL injectables with a GP before administering.
    o Another issue that prevents us from administering as per the label, is that most of the labelling on patient’s injectable medication at our practice says “to be administered by your doctor”. Our own Practice Policy (maybe outdated) necessitates a “signed” order by the GP.

    The answer we got from the ANMF:
     Yes we are in agreement with you that you are in need of a medication order to be able to administer the medication. The usual points eg patient , medication, dose route, need to be clear and some sort of signature. If everything is electronic well and good but there needs to be a way to confirm the order and , confirm administration (Duty officer ANMF)
    o For further clarification I took a screen snapshot of a medication page/script order which I explained corresponds with an electronic “signed” entry by the GP – to see if this was sufficient….. then the following response:
     We both agree that what you have sent as it stands is not sufficient however with modification in the Instruction column (outlining to be administered by nurse) it would then be sufficient if coupled with a column/place for the Doctors electronic signature. Perhaps a separate page modified to suit would be able to be developed using existing IT capabilities (this would not be practical or possible with our software although it is easy to see who has ordered the medication)
     Administration itself as injectable should still be checked by two people – this may be inconvenient for the Doctor, but would be sufficient as it would be checked by two authorised people (yourself and the MO)
    o For myself, I now document that the medication is given as per doctor’s prescription [datedxx]. Last dose given xx. Medication dosage and administration checked with Dr xx prior to administration. An alternative is for your GP to document in the patient’s progress notes on the day the patient presents for the medication “ xmediction dose of x to be administered IM by the nurse” (as Christine noted above) – although you still need to check the dosage, route etc with one other health professional.
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  4. I was a little surprised reading this article as it got me thinking as in General Practice we dont have the opportunity to have routine medications checked with another nurse or have the GP physically see the medication- prescribed by them and dispensed by pharmasist/or taken from our supply (in the case of vaccines or antiobiotics). I think we as Practice Nurses working alone do a more thorough check on the medication rather than relying on another person to check it. Of course if there is anything that I haven’t seen before or doesnt seem right I would have it checked and discuss and it with the GP or pharmacist. It is really about familiarising yourself with and learning the medications and patients and working within your own scope. I wouldnt expect a new nurse to do the same. Also as a policy of our clinic is that medications brought in prescribed by other doctors (or for the example of the OTC B12 inj) for the initial dose we would get them to see the GP and have the orders doccumented.
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