MEDICATION ADMINISTRATION POLICY

FOR NURSES, MIDWIVES AND UNREGULATED HEALTH WORKERS

The Medicines and Poisons Act 2014 and Medicines and Poisons Regulations 2016 came into effect on 30 January 2017. The transitional provisions of this legislation ensure the continuity of arrangements outlined in this policy.

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Effective: 25 January 2018

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TITLE: MEDICATION ADMINISTRATION POLICY FOR NURSES, MIDWIVES AND UNREGULATED HEALTH WORKERS

TABLE OF CONTENTS 1. BACKGROUND .......................................................................................................... 3 2. LEGISLATIVE REQUIREMENTS ............................................................................... 4 3. DEFINITIONS .............................................................................................................. 4 4. ROLES AND RESPONSIBILITIES ............................................................................. 5

4.1 Registered Nurse and Midwife ............................................................................ 5 4.2 Direct Entry Midwife (who is not a registered nurse) ........................................... 6 4.3 Enrolled Nurse .................................................................................................... 7 4.4 Enrolled Nursing or Registered Nursing or Midwifery Students .......................... 8 4.5 Unregulated Health Worker ................................................................................. 8

5. PRINCIPLES OF MEDICATION ADMINISTRATION ................................................. 9 5.1 Administration Standards .................................................................................... 9 5.2 National Inpatient Medication Charts ................................................................ 10 5.3 Medication History and Management Plan ........................................................ 10 5.4 Patient’s Self Medication ................................................................................... 11 5.5 Withholding Medication ..................................................................................... 12 5.6 Correct Documentation ..................................................................................... 12 5.7 Discharge, Transfer, or Non-admitted Patient Medication Planning .................. 13 5.8 Fees and Charges for Medication ..................................................................... 13 5.9 Patient Education ............................................................................................. 13

6. MEDICATION ERRORS ........................................................................................... 14 7 MEDICATION PRESCRIBERS ................................................................................. 15

7.2 Labelling of medications other than starter packs ............................................. 15 7.3 Registered Nurse’s Legal Responsibility ........................................................... 16

8. VERBAL ORDERS ................................................................................................... 16 9. DESIGNATED REMOTE AREA NURSING POST ................................................... 17 10. APPROVED STARTER PACKS ............................................................................... 17

10.1 Approved Starter Pack Supply .......................................................................... 17 10.2 Before Giving an Approved Starter Pack .......................................................... 18 10.3 Provision of a Psychiatric Starter Pack ............................................................. 18

11 NURSE INITIATED NON PRESCRIPTION MEDICATIONS ..................................... 18 12. NURSE INITIATED STI TREATMENT CODE .......................................................... 19 13. GUIDELINES FOR USE OF OXYGEN ..................................................................... 19 14. VACCINATIONS/IMMUNISATIONS ......................................................................... 19 15. COMPLEMENTARY MEDICINES............................................................................. 20 16. PRESCRIBING NUTRITIONAL SUPPLEMENTS..................................................... 20 17. HIGH RISK MEDICATIONS ...................................................................................... 20

17.1 Anti infective agents. ......................................................................................... 20 17.2 Guidelines for Midazolam for Adult or Paediatric Sedation .............................. 19 17.3 Potassium Chloride ........................................................................................... 22

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17.4 Insulin ................................................................................................................ 22 17.5 Narcotics (opioids) ............................................................................................ 22 17.6 Chemotherapy................................................................................................... 22 17.7 Heparin and other anticoagulants ..................................................................... 22 17.8 Systems ............................................................................................................ 23

17.8.1 Intrathecal Medication .......................................................................... 23 17.8.2 Epidural Therapy .................................................................................. 23 17.8.3 Medication Restrictions to Nurse Administered IV Bolus Treatment .... 23 17.8.4 Infusion Pumps..................................................................................... 23

18. RECORDABLE DRUGS INCLUDING CONTROLLED DRUGS/ DRUGS OF ADDICTION .............................................................................................................. 24 18.1 Schedule 4 Restricted Medications ................................................................... 24 18.2 Schedule 8 Medications .................................................................................... 24 18.3 Administering Schedule 4 Restricted or Schedule 8 medications from dose

administration aids in hostel and aged care facilities. ....................................... 25 18.4 Patient Discharge and Schedule 8 Medication .................................................. 26 18.5 Storage, transfer or disposal of medication refer to section 20 .......................... 26

19. INTRAVENOUS (IV) ADMINISTRATION .................................................................. 26 19.1 Intravenous therapy and infusion and bolus medication administration ............ 26 19.2 I V Flushes ........................................................................................................ 28 19.3 Intravenous Additives and Bolus Dose .............................................................. 28 19.4 Infusion Pump Safety Information ..................................................................... 29 19.5 Labeling, Changing Infusions and Intravenous Lines ........................................ 30

20. STORAGE OF MEDICATIONS ................................................................................. 30 20.1 Bedside Storage ................................................................................................ 30 20.2 Storage of Patient’s Own Medication ................................................................ 31 20.3 Storage of controlled drugs ............................................................................... 31 20.4 Keys and Access to Controlled Drug Keys ........................................................ 32 20.5 Transfer of controlled drug keys ........................................................................ 32 20.6 Transfer of recordable medication including Controlled Drugs. ......................... 33 20.7 Disposal of Drugs of Addiction and Poisons Included in

Schedule 4 Restricted and Schedule 8 ............................................................. 33 20.8 Reporting Of Schedule 4 Restricted and 8 Medication Stock Discrepancies 34 20.9 Medication Fridge .............................................................................................. 34

21. EVALUATION ........................................................................................................... 35 21.1 Compliance ....................................................................................................... 35 21.2 Mitigation strategies .......................................................................................... 35

REFERENCES ................................................................................................................. 36 APPENDIX 1 Starter Pack Approval Site List ................................................................. 39 APPENDIX 2 “Approved Starter Packs” as at 18 September 2013 ................................ 42 APPENDIX 3a Nurse Initiated Medications Non-Prescribed Schedule 2 and 3

Medications for Adult Patients .................................................................. 44 APPENDIX 3b Nurse Initiated Non-Prescribed Schedule 2 and 3 Medications for

Paediatric Patients .................................................................................... 45 APPENDIX 4 Designated Remote Area Nursing Posts .................................................. 46 APPENDIX 5 Supply by Registered Nurses at Remote Area Nursing Posts .................. 47 APPENDIX 6 Drug and IV flow calculations ................................................................... 48 APPENDIX 7 Anaphylaxis Flowchart .............................................................................. 49 APPENDIX 8 Policy Review Contributors ....................................................................... 50

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1. BACKGROUND

The Medication Administration Policy – Nursing Practice Standard is for application across WA Country Health Service sites (adult and paediatric), including hospital in the home, community health and public health settings, sub-acute care, mental health and aged care facilities, and remote area nursing posts. Contributors to this policy review are listed in Appendix 8. Nurses and midwives are accountable for their own practice and must only undertake medication management activities which are within their scope of practice and for which they are legally entitled to perform; educationally prepared for and competent to undertake. The scope is outlined in the: • Australian Nursing and Midwifery Council: A national framework for the

development of decision-making tools for nursing and midwifery practice 2007 • WA Health Operational Directive OP 1988/05 Scope of Enrolled Nursing

Practice and Enrolled Nurse Competencies The nurse or midwife must consult appropriate resources and references when unsure of details of the prescription, preparation or administration of medications. These include but are not limited to: • Australian Medicines Handbook • Australian Injectable Drug Handbook • Australian Medicines Handbook - Children's Dosing Companion • eMIMs • eTG (Electronic Therapeutic Guidelines) • Royal Flying Doctor Service (RFDS) • product information • WACHS Regional Pharmacist.

WA Health Operational Directives and Operational Circulars hyperlinked in this policy are to be read, understood and adhered to by WACHS nurses and midwives and health workers at all times. Reference to some guidelines via the HealthPoint website may also be necessary for approved WACHS protocols including some South Metropolitan Health Service (SMHS) Nursing Practice Standards, the Princess Margaret Hospital (PMH) Nursing Practice Manual or King Edward Memorial Hospital (KEMH) clinical guidelines also endorsed for use in WACHS. This Medication Administration Policy – Nursing Practice Standard is to be read in conjunction with the National Standards in Quality Health Service Standard 4 (NSQHSS) National Inpatient Medication Chart (NIMC) Standardised Charts and Guidelines (2008) endorsed for use in WACHS (Medical Record series 170s) (e.g. adults, paediatric, neonatal, residential care and adult anticoagulant).

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2. LEGISLATIVE REQUIREMENTS The WA Country Health Service (WACHS) provides safe medication administration in accordance with the national and state legislative requirements as per the: • Health Practitioner Regulation National Law (WA) Act 2010 • Australian Health Practitioner Regulation Agency (AHPRA) Code of Ethics and

Professional Code of Conduct for Nurses August 2008 • Carers Recognition Act (WA) 2004 • Poisons Act (WA) 1964, Poisons Regulations (WA)1965 and Poisons

Amendment Regulations (No 5) (WA) 2010 • Therapeutic Goods Act 1989 • Occupational Safety and Health Act 1984.

3. DEFINITIONS

Administration May be defined as the actual giving of a medication orally, by

injection, per rectum or other route.

Approved health service

Those listed in the Starter Pack approval list Appendix 1.

Authorised person

The designated controller (RN/midwife) of the Schedule S4R and S8 keys has knowledge at all times of who is carrying the keys. i.e. may delegate keys to another RN/Midwife but remains responsible for the S4R and S8 keys.

Competency Possess the knowledge, skills and behavioural attributes to perform a task.

Competent Demonstrate the minimum nursing or midwifery standard for effective work performance.

Direct supervision

Direct supervision is considered to be in the company of a RN.or medical practitioner or visually via the Emergency Telehealth Service.

Dispense Means supply the medicine or poison on and in accordance with a prescription given by a medical practitioner, nurse practitioner or dentist.

Dosage Administration Aid

A medication aid is a pre-packed medication dose in a container identified for a specific individual. It is used to support safe administration of medications. The client/ resident/ patient’s name, medication name, dose and time the medication is to be given is to be clearly labelled on the preparation dispensed by the pharmacist. May also include a pharmacy filled aid e.g. Webster Pak®.

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Dosage unit Means an individual dose of a poison and includes a tablet, capsule, cachet, single dose powder, or a single dose sachet of powders or granules.

Medication support for UHWs

Medication prompting is described as assisting the client/ resident/ patient with self-medication and involves:

i. reminding and/or prompting the client to take the medication ii. assisting (if needed) with opening of medication containers

for the client, and iii. other assistance not involving medication administration.

Standing Orders

A written document that contains instructions for the administration of medications in a defined clinical situation. Standing orders specify the condition for which the orders apply and stipulate the medication to be given, dosage and route of administration. Their use is limited to the treatment of identified acute medical conditions at designated remote area nursing posts.

Supply Includes distribute and sell but not the administration to a patient of any substance specified in any of the Schedules to the Act by a medical practitioner, nurse practitioner or dentist, or by a registered nurse or registered midwife when acting under the direction of a medical practitioner, shall not be deemed to be supplying within the meaning of these regulations.

Time-critical medicines

Medicines where delayed or early administration by more than 30 minutes may cause harm or sub-therapeutic effect.

4. ROLES AND RESPONSIBILITIES

It is a role of the registered nurse (RN), nurse practitioner (NP) and midwife, eligible midwife and in limited situations, enrolled nurse (EN), to administer medication in accordance with legislative requirements. All nurses and midwives must undertake the National Inpatient Medication Chart (NIMC) and Medication Safety Course. This is a once only assessment via WACHS Learning and Development (L&D) unit unless medication errors occur requiring individual performance review. 4.1 Registered Nurse and Midwife

4.1.1 The RN and midwife are responsible for medication administration which also includes the medication history (see section 5.3).

4.1.2 A RN or midwife may administer unrestricted Schedule 2, 3 or 4 medications including oral, topical, vaginal, rectal, sublingual, buccal, intranasal, transdermal and oxygen therapy alone.

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4.1.3 Vaccinations may be administered by some RNs and Midwives. Refer to section 14

4.1.4 A RN or midwife may administer intramuscular, intravenous, subcutaneous injections medications alone when checked by a second nurse, medical officer or pharmacist.

4.1.5 A first year RN must administer intravenous drugs under the supervision of a more senior RN. This requirement ceases once the 1st year RN has been assessed as competent in intravenous medication administration.

4.1.6 In some circumstances, e.g. Multipurpose sites (MPS), community clinic, small hospital or nursing post, the ability to check the medication with a second nurse may not always be possible. In this instance the second checker is not required.

4.1.7 Schedule 8 medications when checked by an RN or midwife must be administered by two nurses, one of whom must be a RN or midwife. Refer to section 18.

4.1.8 The RN or midwife may administer Schedule 8 IV narcotic bolus and infusion when deemed competent in the administration. Refer sections 18, 19.

4.1.9 A RN working in a designated remote area nursing post: i. must attend training and assessment and maintain competency in

Pharmacotherapeutics for Remote Area Nurses (refer to learning and development site (or provide evidence of recognition prior learning in pharmacotheraputics e.g. successful completion of pharmacotherapeutics Nurse Practitioner units of study) to administer medications in accordance with Appendix 5 Standing Orders A

ii. in accordance with the Poisons Reg 36(1)(c)(i), may provide up to three days' supply of a Schedule 4 medication.

iii. may supply S2 and S3 medications refer to WA Health, Operational Instruction OP 0302/93 Supply of 2nd Schedule and 3rd Schedule Medications from Remote Area Nursing Posts to guide best practice for designated remote area nursing posts.

4.1.10 The only medications that may be charted by a RN or midwife are those designated as:

i. ‘Nurse initiated’ as described in this policy - see Appendix 3 ii. ‘Verbal orders’ as described in this policy - sections 8

4.2 Direct Entry Midwife (who is not a registered nurse)

4.2.1 The Poisons Regulations allow a midwife (who is not an RN) to

administer a Schedule 4 medicine on the prescription of a medical practitioner, NP or dentist. However midwives need to work within their scope of practice and only administer medications to women and neonates during the peri partum period. Medication administration in any other circumstance must be under direct supervision of a RN.

4.2.2 A midwife (who is not an RN) is not permitted to supply a patient with an ‘approved starter pack’ (Poisons Regulations (WA) 1965 Regulation 36AA), or psychiatric starter pack.

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4.3 Enrolled Nurse

4.3.1 All ENs are expected to have relevant medication administration competence. Those ENs who have not yet completed the required units

will have the following notation against their name on the Nursing and Midwifery Board of Australia Register ‘Does not hold a Board approved qualification in medication administration’.

4.3.2 The EN can administer medications alone within their scope of practice including oral, transdermal, topical, ear, eye, inhaled, nebulised, vaginal, rectal, sublingual, buccal, and intranasal unrestricted Schedule 2, 3 or 4 medications.

4.3.3 The EN can administer intramuscular, subcutaneous injections when these have been checked by a second person who must be an RN, medical officer or pharmacist.

4.3.4 An EN may administer medications to paediatric patients, but the medications must be checked by an RN, and must be checked at the bedside by both parties.

4.3.5 To administer intravenous therapy and medications, the EN must complete an intravenous (IV) medication training and competency program. The EN may only administer intravenous therapy via peripheral devices, excluding Peripherally Inserted Central Catheters and Central Venous Lines.

4.3.6 An EN without an IV medication competency may be allocated to patients who have IV infusions, but will not be responsible for the IV therapy delivery.

4.3.7 An EN with an IV medication competency (refer to 4.3.5) may administer IV therapy, including setting the rate; add to a mini bag and administer a bolus dose

4.3.8 An EN working within their scope of practice in a renal dialysis unit may administer intravenous therapy, under RN supervision.

4.3.9 An EN may take care of a patient receiving IV narcotic infusion, cytotoxic or epidural therapies however these therapies are the exclusive responsibility of a RN or midwife.

4.3.10 An EN may not care for unstable patients who are receiving high risk drug infusions with low therapeutic index that are dependent on monitored drug levels or dose adjusted dependant on frequent patient observations.

4.3.11 An EN may check Schedule 8 medication but cannot administer a Schedule 8 medication. The exception being an EN may administer a dosage administration aid containing a Schedule 8.

4.3.12 Under no circumstances is the EN to hold the Schedule 8 keys.

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4.4 Enrolled Nursing or Registered Nursing or Midwifery Students

A student EN, registered nursing or midwifery student may check and administer medications under the supervision of an RN or midwife, provided the student is directly supervised at all times by an RN or midwife. 4.4.1 A student can sign the medication chart; however this must be

countersigned by the supervising RN or midwife. 4.4.2 The student must have completed the relevant theoretical preparation. 4.4.3 Where there is a requirement for two nurses in medication

administration, the student cannot be one of those two unless the second nurse is only required to check the medication.

4.4.4 A registered nursing student is able to administer Schedule 8 medication and complete the Schedule 8 register but this must be countersigned by the supervising RN or midwife and second RN or midwife who is the checker.

4.4.5 Student midwives who are RNs can administer drugs as per RNs. Only administration of maternity specific drugs and epidurals by a student midwife require direct supervision of a midwife.

4.4.6 An EN student may be the third checker of a Schedule 8 medication and complete the Schedule 8 register but cannot administer a Schedule 8 medication.

4.4.7 An EN student cannot be supervised by another EN 4.5 Unregulated Health Worker

An Unregulated Health Worker (UHW) includes: patient care assistant (PCA); assistant in nursing (AIN); Home and Community Care (HACC) support worker and an aboriginal health care worker (AHW). 4.5.1 Unregulated health workers are individually accountable for their own

actions and are accountable for undertaking activities as delegated by an RN or midwife and their employer for delegated actions (ANMC 2007).

4.5.2 The UHW is required to provide evidence of completion of a Care Worker Medication Administration Competency Package to their employer from an approved registered training organisation or from an approved WACHS assessor (e.g. HACC Community West Inc.), prior to undertaking medication administration.

4.5.3 A delegated UHW who has been deemed competent can assist with medication support and administration as per the example HACC Medication Support and Administration Policy (read “this organisation = WACHS”), including documentation e.g. medication signing sheet.

4.5.4 If medication prompting support is being provided the client/resident/patient retains all responsibility for their medications.

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4.5.5 If a dose administration aid includes Schedule S4R or S8 the contents

of the aid may be given by the UHW (see section 18.3 In Hostel and Aged Care Facility).

4.5.6 In a community setting the UHW is supported by the example HACC Medication Support and Administration Policy (3.5.3) to provide medication support (see section 3 for definition) as delegated. Medications are only given and signed for: i. if there is a client assessment, and ii. consent is signed by the client and HACC provider on a WACHS

form refer to Aged Care Residential Manual - RC 26 Ability to Self-Medicate (page 298), and

iii. a medication plan is documented. 4.5.7 The UHWs who provide care to Department of Veterans Affairs Clients

(DVA) community care clients are not permitted to manage or administer prescribed medications as per a care plan, as outlined in the Community Nursing Guidelines 2010 (Section 6.3.2.4 page 34).

5. PRINCIPLES OF MEDICATION ADMINISTRATION

5.1 Administration Standards

The following standards apply to the administration of medication:

5.1.1 Prior to administering any medication a RN, midwife, NP or EN must: i. know the legislation relating to medication administration ii. know the medication, its therapeutic purpose, usual dose,

frequency and route of administration, specific precautions, contraindications, monitor for side effects and adverse reactions

iii. know the correct storage conditions of medications iv. ensure the medication order is legible, complete, correct and has a

legible signature of the medical practitioner. The RN, midwife and EN must not, under any circumstances amend a prescription written by a medical practitioner or nurse practitioner. However the RN or midwife may change the administration time on the medication chart.

v. adhere to the following six (6) principles of medication administration: 1. Right medication 2. Right individual (in accordance with WA Health, Operational

Directive OD 0312/10 Western Australian Patient Identification Policy

3. Right dose 4. Right time 5. Right route 6. Right documentation

vi. consult appropriate resources and references. (refer to section 1)

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vii. Refer to the Australian Commission on Safety and Quality in Health

Care Recommendations for Terminology, Abbreviations and Symbols used in Medicines Documentation.

5.1.2 All medication including unscheduled medicines such as vitamins and

complementary medicines, Schedules 2, 3, 4 and 8, and oxygen must be written on an approved WACHS 170 series Medication Chart.

5.1.3 A RN, midwife and EN can only administer medication to a patient in a hospital if the medication is authorised in writing on the approved WACHS MR170 series Medication Chart or a WACHS approved electronic prescribing system. The documentation exceptions are aged care and MPS where an alternative approved chart may be used e.g. Webster Pak ® signing sheet.

5.1.4 Assess for efficacy of the medication and document in patient notes. 5.1.5 Report to the prescriber any side effects or adverse reactions

experienced by the patient and document the episode and nursing actions in the patient's medical record (Refer to section 7.1.3).

5.1.6 Administration of medications involving routes such as peripherally inserted central catheter or infusion port, intrathecal, epidural or regional blocks (e.g. femoral nerve block) is an advanced practice role (Refer to section 17.7). Administration of medications via these routes must be subject to providing demonstrated evidence of attainment of WACHS endorsed self-directed learning packages and/or competencies.

5.1.7 Administration of oral, enteral or nebuliser solutions - use of oral syringes. Refer to WA Health High Risk Medication Policy, WACHS High Risk Medications Procedure and section 16

5.2 National Inpatient Medication Charts

Use of the National Inpatient Medication Charts are a national standard for both prescribers and staff to enable safer prescribing and administration of medications. Guidelines for use of the National In-patient Medication Charts in WA are provided. In Western Australia these currently include WACHS medical record 170 series charts for: short and long stay adult and paediatric charts; anticoagulant medication and residential aged care. 5.2.1 Medication charts due to expire in the following 48 hours, are to be

brought to the medical practitioner’s attention by nursing staff caring for the patient to enable revision and rewriting.

5.2.2 All anticoagulant therapy is to be administered via the WACHS Anticoagulant Medication Chart (Refer to section 17).

5.3 Medication History and Management Plan

Nurses and midwives in partnership with the hospital pharmacists and/or medical practitioners complete a medication history, to inform care planning and documentation.

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Nurses and midwives are guided by the Medication Management Plan principles outlined in Pharmaceutical Benefit Scheme Reform in accordance with the Australian Pharmaceutical Advisory Council Guidelines for Continuity of Medication Management. Where a pharmacist is not available on site, the guidelines require nursing staff to ensure medication reconciliation occurs, and patients are charted for correct medications on admission. Discharge medication information should be included in the patients discharge summary by the pharmacist or medical practitioner.

5.3.1 Document an accurate medication history for all inpatients by an

appropriately qualified professional, as soon as possible but within 24 hours of admission. Only use the front of a WACHS MR170 series Medication Chart or a Medication Management Plan (where available).

5.3.2 Medication history is the documentation of all medications (including over-the-counter medications and complementary therapies) that a patient is taking at the time of hospital admission or presentation and includes any recently ceased or changed medications.

5.3.3 On admission, check any known allergies or drug sensitivities and document previous adverse drug reactions and allergies. Ensure correct identification e.g. red wrist band, alert labels. Document any adverse drug reactions (ADR) that may arise during admission.

5.3.4 Ensure the patient and family/ carer understand why the medication has been prescribed.

5.4 Patient’s Self Medication 5.4.1 The medical practitioner is to document on the medication chart if the

patient can self-medicate. 5.4.2 If the medical practitioner has documented such, the patient is to be

advised by the EN, RN or midwife of the safety plan for the storage of medications at the bedside, such as the medications are to be kept on the person of the patient or stored in their bedside locked drawer, not in plain view of other persons.

5.4.3 The EN, RN or midwife is to confirm all self administration medication and document on the medication chart using the appropriate code.

5.4.4 Schedule 4Restricted and Schedule 8 medications must not be left with patient (refer to sections 18 and 20).

5.4.5 Legal responsibility remains with the hospital or facility for the correct administration of patient medication.

5.4.6 Nursing and midwifery staff need to exclude evidence of delirium or temporary confusional state in situations where patients are usually self-medicating such as in a residential setting e.g. low care hostel (For community aged care settings also refer to section 4.5.5).

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5.5 Withholding Medication

Guidelines for use of the National In-patient Medication Charts in WA - Appendix A provides information on withholding medications. 5.5.1 A RN or midwife may withhold the administration of a medication if:

i. the order is not legible ii. there is some doubt about the medication order or dosage iii. it is not possible to identify the prescribing doctor iv. an identified side effect occurs or has occurred previously, or v. a change in the patient’s condition warrants doing so.

5.5.2 If the medication is withheld due to above, the RN or midwife must seek clarification of the order as soon as practicable, and must document this on the medication chart and patient progress notes.

5.5.3 When patients are fasting, it is the responsibility of the RN or midwife to check with the medical practitioner which medications should continue to be administered unless indicated on the medication chart.

5.6 Correct Documentation

Time-critical medicines (refer to section 3 Definitions) must not be delayed or administered early by more than 30 minutes. Non-time-critical medicines will depend on the frequency of dosing.

i. For medicines administered more frequently than daily but less frequently than four hourly – may be administered within 60 minutes of the scheduled time;

ii. For medicines administered daily or less frequently – may be administered within two (2) hours of the scheduled time.

5.6.1 The person who administers the medication must document the exact time of administration and sign the medication chart (e.g. medication due 0800 and given at 0830; the time of 0830 must be recorded and signed).

5.6.2 When two people have checked a medication, both are required to sign the medication chart after administration (see section 13 & 16 S4R and S8).

5.6.3 Where alternative routes (oral/ PR) or a dose range (e.g. 5 -10mg) are ordered, the route chosen and the dose given must also be documented on the MR170 series medication chart.

5.6.4 When PRN medications are given, the reason why they are given and the results obtained are to be documented in the patient progress notes.

5.6.5 If a medication is not given, the reason is to be documented on the medication chart and patient progress notes using only the codes supplied on the WACHS medication charts.

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5.7 Discharge, Transfer, or Non-admitted Patient Medication Planning

Discharge planning ensures medication or a prescription change to a medication is available in a timely manner on discharge and facilitates responsible supply of patient medications. 5.7.1 It may be necessary for the medical practitioner to dispense, where a

pharmacist or retail pharmacy is unavailable, sufficient medication on discharge until a discharge prescription can be filled. The medical practitioner is to make a written record of the medication dispensed at the time of supply. The medication is to be labelled in accordance with the Poisons Act 1964 and Poisons Regulations 1965.

5.7.2 A NP is authorised to prescribe and dispense a range of medication within their scope of practice, in accordance with Poisons Reg 40 (1) (aa).

5.7.3 Nurses and midwives are not authorised to “dispense” medications to a patient leaving the hospital. This does not include the administration of prescribed starter packs as described in section 10.

5.7.5 The supply of starter pack medication to non-admitted patients is to take place, when necessary, through the Emergency Department or a Designated Remote Area Nursing Post.

5.7.6 If the patient is transferred to another ward, their admission medications are to be transferred with them.

5.7.7 After discharge, any unclaimed medications are to be forwarded to the pharmacy department for disposal.

5.8 Fees and Charges for Medication

Medication and supply for inpatients and outpatients are in accordance with the following Department of Health Operational Directives:

i. WA Health Administrative Circular A 7652 Supply of Drugs and Medications.

ii. WA Health Operational Instruction 0280/93 Drug Supplies To Outpatients of Health Department Of Western Australia Government Non-Teaching Hospitals And Nursing Posts

5.9 Patient Education

5.9.1 Discharge education is to be documented in the patient’s health record

by the medical practitioner, RN, midwife or pharmacist providing discharge medication education. Ensure the patient/carer:

i. understands what the medications are for, how and when to administer them.

ii. receives Consumer Medication Information (CMI) sheets or other drug information leaflets as appropriate. (Refer to eMIMs online CMI sheets)

iii. have own medication brought to hospital, returned by a RN or midwife if indicated, on discharge, except S4R and S8 medications (refer to section 20 Schedule 8 and Schedule 4R).

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5.9.2 The patient/carer must be given information on the storage, preparation,

measuring and administration techniques for medications that they will be administering at home.

5.9.3 If administration devices are required, instructions for use, cleaning or maintenance must be given.

6. MEDICATION ERRORS 6.1 All medication incidents and near misses must be reported immediately to the

medical practitioner and shift coordinator/ line manager. The patient is to be immediately assessed and monitored for any adverse effects of incidents or errors. Also refer to sections 7 and section 21 Evaluation.

6.2 An incident occurs when any of the following occur: i. there is a deviation from a documented standard (policy, procedure), ii. a medication is omitted and the appropriate code has not been used, as per

the medication chart codes, iii. a medication is not signed for iv. medications are not given within 30 minutes for time critical medications, or

two (2) hours for all others of the specified time, except where there is a planned change due to patient circumstances,

v. a medication is given on the wrong date, vi. an incorrect medication is administered, vii. an incorrect dose is administered, viii. the medication is given by the incorrect route, ix. a medication is administered to the wrong patient, x. an intravenous infusion is administered at the wrong rate, and/or xi. where an adverse reaction requires treatment or cessation of the drug.

6.3 The medication given and/ or adverse drug reaction must be properly

recorded in the patient’s health record. In the case of an adverse drug reaction, an appropriate Adverse Drug Reaction Alert card may be completed.

6.4 Documentation must be completed as soon as practicable and be reported via

the clinical incident management system (refer to section 21 Evaluation).

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7. MEDICATION PRESCRIBERS

7.1 The governance of monitoring authorised prescribers (NSQHSS 4 Medication

Safety 4.3.2) is the responsibility of the regional medical and nurse directors.

7.1.1 Prescribing medications is the responsibility of health professionals who are endorsed to prescribe medications in line with their APHRA registration e.g. medical practitioners, nurse practitioners, There are also a limited number of nurse initiated medications schedule 2 and 3 medications that can be prescribed by any RN (See Appendices 3a and 3b and section 11) and remote area nurses (see section 4.1.9)

7.1.2 Eligible midwives may prescribe in accordance with the NMBA National Prescribing Formulary for Eligible Midwives with a scheduled medicines endorsement - NMBA Prescribing formulary for eligible midwives.

7.1.3 The clinician responsible for the patient is required to report adverse drug reactions in collaboration with the Regional Pharmacist to the Australian Government, Department of Health and Ageing, TGA, Adverse Drug Reactions Advisory Committee (ADRAC) in accordance with ADRAC requirements.

7.2 Labelling of medications other than starter packs

7.2.1 A medical practitioner, NP or a RN working at a remote area nursing post (section 4.1.9) is to label a supplied medication in accordance with Poisons Reg 21 in “English” with: i. the words “Keep out of reach of children” ii. the name and strength or amount of each poison in the preparation,

or the trade name and strength of the preparation (unless the trade name also uniquely identifies the strength, in which case only the trade name need be given)

iii. the name of the patient iv. date of supply, and a number identifying the prescription or supply

which corresponds to the patient’s records v. the name and address of the designated health site or remote area

nursing post, from which it is supplied vi. the directions for use vii. the total quantity contained, and viii. in an approved and appropriately safe container.

7.2.2 External use: where the medication is for human external use only, it must include the words “Not to be taken”.

7.2.3 Where a medication is included in Poisons Standard 2010, Part 2 Sub-paragraph 14(2) Appendix K of the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP), in accordance with Poison Reg 21A, the package must bear the statement: “This medication may cause drowsiness. If affected do not drive a motor vehicle or operate machinery. Avoid alcohol.”

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7.2.4 Plain Packaging

The Poisons Reg 19AA prohibits the use of envelopes, plastic bags, paper bags or cardboard boxes for supply of medication unless the medication is also strip packaged (in foil or in individually sealed amounts). The risk associated with supply of loose tablets in an envelope, bag or box is high. The use of a container with a name previously embossed or permanently marked is also prohibited (refer also to storage and transport section 20).

7.3 Registered Nurse’s Legal Responsibility 7.3.1 Should an RN be required to assist a medical practitioner in the

dispensing of a Schedule 4 or Schedule 8 medication to a non-admitted patient, the dispensed item is to be handed to the medical practitioner for supply by him/her to the patient or prepared under the direct visual supervision of the medical practitioner.

7.3.2 Nothing in the above precludes an RN from administering a medication to a non- admitted patient when acting under the direction of a medical practitioner.

8. VERBAL ORDERS

8.1 An RN (including a remote area nurse), midwife or NP may receive a

medication order for an inpatient or a non-admitted patient from a medical practitioner, NP or eligible midwife verbally, by telephone or other electronic means. The nurse who receives a ‘verbal order’ must:

i. confirm and record the identity of the prescriber ii. records the prescription in writing on the medication chart and repeat the

prescription back to the prescriber iii. second checker (RN, midwife, NP or EN, or pharmacist) confirms the

order with the prescriber. iv. both nurses must ensure the verbal order is recorded and signed on the

medication chart. v. exemption of second checker (see section 4.1.8).

8.2 The verbal order must be signed on the medication chart, or otherwise

confirmed in writing, within 24 hours by the prescriber. If the prescriber does not sign the original verbal order within a 24 hour period:

i. If order required beyond 24 hours must be reordered, or ii. In some instances where a health service may be covered utilising an on

call doctor in a single location or telehealth, telephone orders may be electronically transmitted via fax, email, or endorsed electronic system e.g. MMeX to the doctor’s location for signing and then faxed back for inclusion in the medical record in accordance with WA Health Information Circular IC 0179/14 Guidelines for the Transmission of Client Identifiable Health Information by Facsimile Machine.

iii. If electronic transmission occurs the hard copy document with the doctor’s original signature MUST be kept at the site from which the doctor authorised the medication order.

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iv. If the medication order is required to be continued beyond 24 hours it

must be reordered within the relevant section of the National Inpatient Medication Chart (NIMC)

9. DESIGNATED REMOTE AREA NURSING POST An RN working at a Designated Remote Area Nursing Post is authorised to supply a poison, not being a psychoactive poison in accordance with the Poisons Reg 36(1)(d):

i. Three (3) days medication supply, or ii. Where the poison is supplied in prepacked individual packs, one individual

standard pack iii. For the treatment of an acute medical condition in compliance with the

written standing orders of a medical practitioner which have been as approved by the CEO, or

iv. For the treatment of an acute medical condition in compliance with oral instructions of a medical practitioner for that particular patient.

10. APPROVED STARTER PACKS An RN at an approved health service (Appendix 1) as per Poisons Reg 36AA may give an approved starter pack (Appendix 2) to a non-admitted inpatient, if verbally instructed to do so by a medical practitioner or nurse practitioner, who need not be present at the health service. 10.1 Approved Starter Pack Supply

10.1.1 An approved starter pack is centrally prepared by WACHS Pharmacy and contains a medication supplied in a prepacked individual pack and does not exceed three days' worth of medication in accordance with Poisons Reg 36AA.

10.1.2 Within 72 hours of giving a starter pack instruction, a medical

practitioner or NP must provide to the health service a signed, written confirmation of the instruction including the following, (Poisons Reg 36AA) the: i. name of the medical practitioner or NP ii. name of the RN to whom the starter pack instruction was given iii. name of the patient iv. date and time when the instruction was given v. details of the approved starter pack vi. any relevant directions for use that were to be given to the patient,

and vii. any other information that the medical practitioner considers relevant.

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10.2 Before Giving an Approved Starter Pack 10.2.1 Before giving an approved starter pack to a patient, the RN must label it

with the patients name, date provided and name of prescribing medical practitioner or nurse practitioner.

i. keep the Supply Book for at least two years after the last entry is made, for accountable auditing and

ii. the name and address of the patient iii. the approved name and strength or amount of the poison or iv. if the brand name uniquely identifies the strength of the poison, that

brand name v. the date and time at which the approved starter pack is to be given

to the patient vi. the name of the medical practitioner vii. any directions for use given by the medical practitioner viii. a unique number identifying the entry in the Supply Book, and ix. the RN’s name and signature. x. document dispensing of starter pack in the patient’s MR5 or in

MR170 series medication chart. 10.3 Provision of a Psychiatric Starter Pack

Currently, there are no sites designated within WACHS for provision of psychiatric starter packs in accordance with the Poisons Regulations.

11. NURSE INITIATED NON PRESCRIPTION MEDICATIONS

11.1 An EN (under RN delegation), RN or midwife may administer a non-prescription

medication (Appendix 3 Nurse Initiated Medications). 11.1.1 The medication is recorded on the patient’s medication chart by an RN

or midwife in the adult nurse initiated medication section or the paediatric once only section.

11.1.2 The medical practitioner is advised as soon as possible (and a record made in the MR170 series medication chart.

11.1.3 If required on a regular basis, the medication is to be countersigned by the medical practitioner, and subsequently written up by the medical practitioner in the medication chart. (Refer Appendices 3a and 3b.)

11.2 If the patient requires two or more doses of these medications, the medical

practitioner is to be requested to review the patient. 11.3 Topical unscheduled products are not required to be individually listed in

Appendices 3a and 3b and may be given at the discretion of the RN. These products must be charted in the relevant section of the patient’s medication chart.

11.4 Supply of nurse initiated non-prescribed medication is subject to availability on

the regional formulary. 11.5 The WA Country Health Service supports the use of Nicotine Replacement

Therapy for inpatients. Refer to: Clinical Guidelines and Procedures for the Management of Nicotine Dependent Inpatients.

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12. NURSE INITIATED STI TREATMENT CODE

12.1 The WA Country Health Service nurses – STI and trachoma located at

Department of Health Structured Administration and Supply Arrangement website under CEO of Health SASA establishes the competencies which must be achieved and criteria to be met by a RN to administer single dose combination therapy (e.g. ZAP Pack) for chlamydia and gonorrhoea in accordance with the Poisons Regulations 1965.

12.2 A combination therapy pack may be administered for the treatment of chlamydia

and gonorrhoea in the Goldfields, Kimberley, Midwest and Pilbara regions and in accordance with the treatment indications and guidelines of the Silver Book and relevant recommendations in Silver Book Supplement. 12.2.1 A RN must only initiate treatment of adult clients and mature minors

aged fourteen (14) years or older, and 12.2.2 The ZAP Pack must be administered under direct observation of the

RN. The RN must not supply a ZAP Pack for an unsupervised client to self-administer.

13. GUIDELINES FOR USE OF OXYGEN

The WA Health, Operational Directive OD 0397/12 Use of Acute Oxygen Therapy in Western Australian Hospitals provide guidelines for the management of patients requiring acute oxygen therapy. 13.1 No patient should be denied oxygen therapy in an emergency. 13.2 Patients commenced on acute oxygen therapy should be assessed and

reviewed promptly, carefully and regularly as per the oxygen orders. 13.3 Once the patient is stable, oxygen therapy must be prescribed on a dedicated

oxygen prescription sticker by a doctor or NP and reviewed daily. Refer to the WACHS endorsed SMHS Respiratory Devices NPS or Princess Margaret Hospital (PMH), Oxygen Therapy, Section 7.2.1, 7.2.2 and 7.2.2.1, nursing standard of practice within the practice context and clinical equipment available for the WACHS sites.

14. VACCINATIONS/IMMUNISATIONS A WACHS RN fulfilling the requirements specified in the Vaccination Administration Code 2012 are authorised to administer vaccines in accordance with Regulation 37B of the Poisons Regulation 1965. 14.1 Vaccines are a Schedule 4 medication and can be administered by:

i. RN or midwife under the direction of a medical practitioner, or written prescription

ii. RN or midwife (e.g. community health nurses/ infection control nurses/ occupational health nurses) working within WACHS who have completed an accredited immunisation training program, as outlined in the Vaccination Administration Code 2012

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14.2 Key areas of competence are outlined in 2012 Vaccination Administration

Code.

14.3 Vaccinations /immunisations may be administered as per WA Health, Operational Directive 0415/13 Guidelines for Department of Health Vaccination Programs – School and Community Health Immunisation.

14.4 Refer also to the WACHS endorsed Australian Immunisation Handbook.

15. COMPLEMENTARY MEDICINES

Complementary medicines may contain active substances. Administration of any complementary-type medicines must be authorised by the medical practitioner and accurately documented on the medication chart. Complementary therapies will not be supplied, but patients own medication may be administered if charted.

16. PRESCRIBING NUTRITIONAL SUPPLEMENTS Care is required when administering oral nutritional supplements. The same requirements for safer prescribing and administration of medicines apply to nutritional products. A separate order chart is required for oral nutrition supplements and enteral feeding products. Also refer to WA Health High Risk Medication Policy and WACHS High Risk Medications Procedure. Refer to section 5.1.7 Administration of oral, enteral or nebuliser solutions - use of oral syringes.

17. HIGH RISK MEDICATIONS

Medication safety alerts and notices are issued from the Australian Commission on Safety and Quality in Health Care website and WA Department of Health operational directives in response to reported incidents or for medicines with known high risks. Medication safety alerts advise action to prevent future adverse medicine events or to lessen the risk of such events occurring. High risk medicines include:

i. those with a low therapeutic index; and ii. the following categories (A PINCH): Anti-infective agents, Anti-psychotics,

Potassium, Insulin, Narcotics, Chemotherapy, Heparin and other anticoagulants. iii. those that present a high risk when administered by the wrong route or when

other systems error occur.

17.1 Anti-infective agents 17.1.1 Antibiotic selection

Antibiotic selection, dose and duration should follow the antimicrobial creed:

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M. Microbiological Guides where possible (Therapeutic Guidelines Antibiotic current edition refer to section 1.)

I. Indications should be evidence based N. Narrowest spectrum D. Dosage appropriate for site and type of infection M. Minimize duration of therapy (see 17.1.2.1) E. Ensure monotherapy where possible.

17.1.2 Automatic Stop Order for Antibiotics An automatic stop-order may apply to the administration of intravenous, oral and topical antibiotics. 17.1.2.1 Wherever possible, a specific termination date is to be

written on the medication chart. If no specific date is given: i. an oral or topical antibiotic order has a seven (7) day

stop-order ii. an IV antibiotic order has a minimum third daily review

unless otherwise documented iii. if continuation required the prescription has to be re-

written if further administration is required 17.1.2.2 The prescriber is to be informed immediately prior to the

implementation of the automatic stop-order. If the antibiotic is to be continued, and the prescriber is unavailable to rewrite the prescription, the prescription should be recorded as an interim medication order

17.1.2.3 Where long term antibiotic administration is indicated, a specific endorsement to this effect is to appear on the medication chart, together with the date on which administration is to be reviewed.

17.2 Guidelines for Midazolam for Adult or Paediatric Sedation

Refer to WACHS specific adult and paediatric sedation procedures. Also, where appropriate, refer to the Sedation for Mental Health Patients Awaiting RFDS Transfer from Remote Regions Guideline and related documents in HealthPoint. 17.2.1 Intravenous Midazolam for adult sedation should only be used in

situations where there is: i. continuous cardiorespiratory monitoring, and ii. resuscitation equipment, and iii. availability of the specific antidote, and iv. registered nurses with the appropriate competencies, and v. a medical officer readily available per phone, in person or on the

Emergency Telehealth Service. 17.2.2 Paediatric patients prescribed intravenous Midazolam in anticipation

of a seizure require the above with the exception of continuous cardiorespiratory monitoring unless the patient is already sedated. Refer to PMH guidelines endorsed for use in WACHS for paediatric seizure management.

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17.3 Potassium Chloride Intravenous potassium chloride is to be stored, prescribed and administered in accordance with the Western Australian Guidelines for Use of Intravenous Potassium Chloride. Refer to WA Health High Risk Medication Policy and WACHS High Risk Medications Procedure.

A rapid potassium replacement/administration must only be administered in exceptional circumstances (i.e. resuscitation) under direct supervision or direct verbal prescription during a medical emergency by a senior medical consultant (FACEM, intensivist or paediatrician).

17.3.1 Paediatric administration of Molar potassium (10 mL ampoules of 10mmol of potassium chloride); rapid potassium replacement/ administration must only be prescribed and administered in exceptional circumstances under the direct supervision of the consultant. Refer to: PMH Pharmacy IV Potassium Chloride Policy.

17.4 Insulin

For all WACHS insulin guidelines refer to WACHS Ward Imprest Insulin Guideline; Insulin Infusion Guidelines and Insulin Infusion Order Chart (adults) MR157A.

17.5 Narcotics (opioids) For safe and appropriate pain management in WACHS sites consult medical staff, regional anaesthetist or Acute Pain Service. Also refer to the WACHS endorsed clinical practice policy: Emergency Care Acute Pain Management Manual. 17.5.1 Refer to Section 18 Schedule 8 17.5.2 Patient Controlled Analgesia. To ensure the prescription, administration

and monitoring of patients receiving intravenous patient controlled analgesia (with the main focus on opioids) is safe and appropriate refer

to OD 0416/13 Prescription and management of intravenous patient controlled analgesia.

17.5.3 Paediatric intermittent Morphine bolus protocol. Refer to the PMH Acute Pain Service Intermittent Morphine bolus protocol for infants greater than 6 months, children and adolescents.

17.6 Chemotherapy

17.6.1 Staff administering chemotherapy in WACHS utilise the endorsed Cancer Institute NSW - Standard Cancer Treatments - eviQ for use in clinical practice. Chemotherapy infusion rates must be verified by referring to the WACHS endorsed Cancer Institute NSW - Standard Cancer Treatments - eviQ for use in clinical practice (see also section 19.1.2).

17.6.2 Vincristine is neurotoxic and must only be administered intravenously. Sentinel events associated with the inadvertent intrathecal administration of vincristine result in a fatal outcome in 85% of cases with devastating neurological effects in the few survivors. Refer to WACHS Chemotherapy Administration - WACHS Clinical Practice Standard.

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17.7 Heparin and other anticoagulants

Refer to the WACHS endorsed NHMRC Prevention of Venous Thromboembolism Guidelines which contains the VTE Prevention Guideline and Clinician Summary and WACHS MR170C Anticoagulation Medication Chart.

17.8 Systems

This includes extra precautions for reducing oral medication wrong route or use of infusion pumps (refer to section 19). 17.8.1 Intrathecal Medication The administration of medication via the intrathecal route is considered

an advanced practice skill to be undertaken only by an intrathecal qualified RN. Refer to WACHS Chemotherapy Administration - WACHS Clinical Practice Standard

17.8.2 Epidural Therapy Administration of medications via the epidural route is considered an

advanced practice skill to be undertaken only by a WACHS certified competent RN or midwife.

17.8.3 Medication Restrictions to Nurse Administered IV Bolus Treatment An RN or midwife may prepare and administer a bolus IV medication,

in accordance with the prescriber’s instructions (including initial doses) - with the exceptions of the following groups of medications listed below, unless under the direct supervision of a medical practitioner, or direct verbal prescription by a medical practitioner during a medical emergency.

A patient is to be on cardiac monitor for both the administration of

Inotropes and Cardioactive drugs with a defibrillator in close proximity.

Medication Group

Examples (NOT to be administered by a nurse as an IV bolus)

Inotropes Dopamine, dobutamine, adrenaline, noradrenaline Cardioactive agents

Beta blockers, phenytoin, adenosine, verapamil, flecainide, digoxin, amiodarone

Anaesthetic agents Propofol, ketamine,

Paralysing agents (only applies to paediatric patients)

This list is not exhaustive and other agents are potentially dangerous in paediatric situations. Refer to section 1 links. Also PMH Paediatric Nursing Practice Manual section 2.1 Prescribing and Administering Medications

17.8.4 Infusion Pumps Refer to section 19

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18. RECORDABLE DRUGS INCLUDING CONTROLLED DRUGS / DRUGS OF ADDICTION

18.1 Schedule 4 Restricted Medications The Operational Directive OD 0528/14 Storage and recording of Restricted Schedule 4 (S4R) medicines provides guidance for the management of Schedule 4 restricted (S4R) medicines. Also refer to WACHS specific procedure for Requisitioning and Receipt of Schedule S4R and 8 Medications and Ordering of Pharmacy Imprest Supplies Procedure. Some S4R medications are open to abuse, such as benzodiazepines and tramadol, and the traditional storage and record keeping requirements for a Schedule 4 medicine are inadequate to provide the level of accountability required within the public health system.

18.1.2 Recording of Schedule 4 Restricted Medication All transactions of S4R medications are to be recorded in the respective

drugs register or software approved by the hospital or Chief Pharmacist.

18.1.2.1 Administration of a S4R medicine requires one nurse and a single signature in the register. (Department of Health WA, 2014, Operational Directive OD 0528/14 Storage and recording of Restricted Schedule 4 (S4R) medicines. (see section 4) However, some regions may have a local site procedure which requires two nurses to check and sign the register.

18.1.2.2 A minimum daily stock check of each item is required (OD 0528/14) with names and signatures of two people or more frequently if instructed by a local site procedure. Some regions also require two nurses to check with two signatures in the register). The exception is single nursing post if the staff member has not changed where S4Rs will be checked weekly. Checks will also occur when change of staff occurs as part of the handover process. Refer to WACHS specific procedure for Requisitioning and Receipt of Schedule S4R and 8 Medications and Ordering of Pharmacy Imprest Supplies Procedure.

18.1.2.3 Exemption to second checker refer to 4.1.8.

18.2 Schedule 8 Medications

18.2.1 Only a medical practitioner, nurse practitioner or dentist can prescribe/order a Schedule 8 (S8) medication (refer to section 7).

18.2.2 A medical practitioner, pharmacist, dentist, RN, midwife or NP (see section 4) can administer a S8 medication on a prescription in accordance with Poisons Reg 42.

18.2.3 Intravenous Schedule 8 Medication. Refer to section 19 Intravenous Infusion and Intravenous Additive and Bolus Dose.

18.2.4 All patients presenting for emergencies who require a S8 medication are to be examined by a medical practitioner (in person or via Telehealth); a nurse practitioner (in person only); or admitted on the instruction of a medical practitioner as an inpatient and examined as soon as practicable (not more than 24 hours) Refer to OD 0141/08 - Code of practice for the handling of Schedule 8 medicines (drugs of addiction) in hospitals and nursing posts, and OD 0142/08 - Administration of Schedule 8 Medicines to Patients Attending for Emergencies. Refer also to section 8 Verbal Orders.

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18.2.5 Ongoing prescription for a Schedule 8 medicine within the ED In hospitals without on-site medical staff and where a medical

practitioner, practising at the hospital, has decided that a patient is to receive an ongoing prescription for a S8 medicine within the ED, then this must have prior approval of the Regional Medical Director, and this plan must be reviewed every 12 months by the medical practitioner or WACHS medical health service provider Department of Health WA, 2008, Operational Directive OD 0142/08 - Administration of Schedule 8 Medicines to Patients Attending for Emergencies.

18.2.6 Dispensing of Schedule 8 medication to a non-admitted patient This may only be undertaken by a medical practitioner. Only the amount

of medication required to treat the patient until a community pharmacy re-opens is to be provided. The medical practitioner is to make a written record of the medication dispensed at the time of supply. These must be labelled in accordance with the Poison Act and Regulations and be dispensed in an approved container. Details of Schedule 8 medications dispensed to patients must be reported to the Pharmaceutical Services Branch of WA Health Department.

18.2.7 Recording of a Schedule 8 Medication

18.2.7.1 An RN or midwife must record each transaction involving a drug

of addiction in the register in accordance with the Poisons Reg 44 (3) as per the requirements of the approved S8 register HA14.

18.2.7.2 In accordance with Poisons Reg 44B (6), an authorised person (see definitions), where a pharmacist is not available may correct an error in a register – if on paper, by making a marginal or foot note and initialling and dating the note.

18.2.7.3 An inventory of drugs of addiction held in stock must be made in accordance with the Poisons Reg 45 as follows:

i. When about to relinquish control of drugs of addiction, or ii. Where a health care facility has an authorised person

present 24/7 a minimum of one full inventory is completed every 24 hours, or

iii. By any person who assumes control (see definitions) of drugs of addiction, and the result of that inventory is to be recorded in the Register.

18.3 Administering Schedule 4 Restricted or Schedule 8 medications from

dose administration aids in hostel and aged care facilities.

18.3.1 The resident’s medication aid signing sheet (provided by the packing pharmacist) must be signed by the person providing medication support i.e. UHW (refer to section 4.5)

18.3.2 All dose administration aids containing S4R or S8 medications need to meet auditable accountability requirements. They must be securely stored, balance recorded and disposed of in accordance with the usual storage / recording / disposal requirements for S4R or S8 medications.

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The auditing requirements include: i. where medication support is provided by an UHW only, a site

procedure exemption may be required from OD 0528/09 and OD 0141, respectively, from checking the S4R or S8 when contained in an individual patient’s dose administration aid.

ii. the UHW providing medication support must report any inappropriate breach of integrity of the medication administration aid. Refer to section 20 Reporting of Medication Stock Discrepancies.

18.4 Patient Discharge and Schedule 8 Medication

Dispensed S8 discharge medications not given to the patient on discharge can be collected by a person nominated by the patient or sent by courier at the discretion of the pharmacist or senior nurse on duty. Medications must be placed in a plain, unmarked packaging such as a brown paper bag for transport in accordance with this policy (see Packaging section 7.2.4).

18.5 Storage, transfer or disposal of medication refer to section 20

19. INTRAVENOUS (IV) ADMINISTRATION

19.1 Intravenous therapy and infusion and bolus medication administration

19.1.1 A valid prescription is required for intravenous (IV) therapy, infusions and bolus medications. A valid prescription contains the following: i. name of drug ii. dosage iii. rate of administration iv. any diluent volume v. frequency of dosage, and vi. method of administration.

19.1.2 It must be ordered by the medical practitioner and charted on: i. The Intravenous Fluid Chart, including infusion rates. Refer to:

Appendix 6 Calculating Rate of Flow for IV Infusions; ii. Intravenous Additives section of WACHS 170 series medication

chart, or iii. A specific chemotherapy order chart. (refer to section 17.6)

19.1.3 Intravenous therapy, infusions and bolus medications are to be checked at the bedside by two (2) nurses, one of whom must be an RN or midwife, except in the case of section 4.1.8. It is the responsibility of the second nurse checker, to adhere to the following:

i. Observe the written order ii. Observe the preparation of the drug iii. Identify the patient at the bedside with the person administering drug iv. Check known allergies prior to administration of medication v. Check and confirm the rate / dose vi. Observe the initiation of the drug administration, and vii. Write signature, initial and document on the WACHS Series 170

medication chart and/or Fluid Therapy Order Chart.

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19.1.4 Where a medication is administered via an IV infusion, the RN or midwife is to ensure an additive label is completed and attached to the infusion bag, syringe or pump. The label must be completed and signed by two nurses, one of whom is an RN or midwife. (refer to section 19.5 labelling of intravenous medications)

19.1.5 Intravenous S8 infusions may be administered by an RN, midwife or NP. This must be via a lockable infusion pump or syringe driver (refer also to PCA OD). The RN or midwife must monitor and document on the observation and response chart throughout the administration of the infusion and escalate as per the early recognition and response to clinical deterioration site escalation process.

19.1.6 The use of a burette is to prevent accidental rapid infusion of large fluid/ drug volumes. All IV infusions must be connected to a burette with the exception of the following:

i. Those going through an infusion pump ii. Non additive intravenous fluids with a volume less than 500mL

(adult only). iii. Blood products. iv. Resuscitation fluids.

19.1.6.1 Paediatric IV fluid administration 19.1.6.1.1 Every patient under the age of 16 years receiving

(ongoing) IV therapy must have an infusion pump, if a pump is not available i.e. in operating room/ recovery area a burette must be used. Refer also to IV pump section 19.4

19.1.6.1.2 For safety reasons, all children 12 years and under must have a burette, where the duration of IV therapy is greater than two hours irrespective of whether antibiotics are pushed or infused via the B line.

19.1.6.1.3 Babies under 18 months of age must NOT have antibiotics infused via the burette (due to excessive fluid volume). Alternative options are either: i. use the ‘B’ line. ii. ‘push’ the drug manually if this is permissible. or iii. use a syringe pump

19.1.7 All IV therapy, including those with additives (if prepared immediately before use) must be used within 24 hours of commencement, or changed.

19.1.8 Specialised medication guidelines* for intravenous infusion, guidelines and checklists include (but are not limited to):

i. Infliximab Guideline and Pre-Infusion Checklist MR 173a ii. Natalizumab Guideline and Pre-Infusion Checklist MR 173b iii. Iron Polymaltose Guideline and Pre-Infusion Checklist MR173c iv. Phosphate Guideline v. Rituximab Guideline and Pre-Infusion Checklist MR173d vi. Nurse Compounding of Antibiotics in Elastomeric Devices

Guideline

* (use search option in HealthPoint using the term ‘specialised medication’ for new guidelines)

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19.2 IV Flushes

19.2.1 Sodium Chloride 0.9% Injection for IV flush maybe given without prescription to maintain venous access patency (minimum once in 24 hours) and flushing, prior to and post prescribed medication. Consider compatible diluents refer to Australian Injectable Drug Handbook. Refer to RPH PIVC CPS

19.2.2 Volume of Sodium Chloride 0.9% Injection for adult patients 5 - 30mL. 19.2.3 Volume for paediatric patients, Sodium Chloride 0.9% Injection refer to

weight related volumes in the Guide for flush solutions and volumes in the PMH Nursing Practice Manual section 2.3.8 (see link above).

19.2.4 The RN is to ensure all IV cannulae are not flushed using any residual medication in order to avoid an adverse reaction.

19.3 Intravenous Additives and Bolus Dose

19.3.1 Only a RN or midwife may administer the first dose of IV medication

provided they operate within their individual scope of practice and ensure: i. that there is a clear process for the Early Recognition and

Response to Clinical Deterioration site clinical escalation process should an emergency occur

ii. they confirm that the patient is not allergic to the medication iii. they access information regarding the effects, side effects,

precautions, contraindications and the required patient monitoring/care specific to the medication is readily available refer to section 1

iv. is aware of the anaphylaxis flowchart Appendix 7 v. The medical practitioner prescribing the medication is aware the

medication is about to be given and is available at the hospital to respond should an emergency situation arise, or the Early Recognition and Response to Clinical Deterioration site clinical escalation process is initiated to contact of the medical practitioner in the event of an emergency

vi. Refer also to sections 17.2 Midazolam for sedation and 17.8 re bolus high risk drugs.

19.3.2 Allergic and anaphylactic reactions may occur at the second or third

dose of antibiotic administration and the nurse must always remain vigilant when monitoring the patient.

19.3.3 Bolus medication doses are only to be introduced into an IV line or

burette containing other medications when the line is flushed with compatible IV fluid before and after the administration of the bolus dose, unless specific compatibility information on the combination is available or provided by the pharmacy department. Refer also to section 19.1.6.1 for paediatric considerations.

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19.3.4 Provided a valid prescription exists, a RN or midwife may add any

prescribed therapeutic substance to a mini bag including the first dose with the exceptions of medications that may be considered to pose an occupational risk these include but are not limited to: Asparaginase; Azathioprine; Ganciclovir; cytotoxic drugs; targeted therapies including but not limited to monoclonal antibodies, kinase inhibitors and anti-angiogenesis agents - unless a risk assessment has been undertaken on the specified medication and there is a WACHS Specialised Medication guideline published.

19.3.5 The therapeutic substance must be prepared immediately prior to use.

19.4 Infusion Pump Safety Information

The Hospira Plum A+ infusion pump is a volumetric delivery device that is designed to ensure accurate and controlled administration of intravenous fluids, additives and medications. This pump is used across all of WA Health and must be operated as per system operating manual for Hospira Plum A+ 19.4.1 It is the nurse's responsibility to check the rate of infusion and to ensure

that the pump is working efficiently at all times. Refer also to the WACHS clinically endorsed policy SMHS Plum A + Volumetric Pump Nursing Practice Standard in addition follow the specific paediatric information regarding the B line in section 19.4.4 below.

19.4.2 Confirmation of drug / fluid compatibility, concentration, delivery rates

and volumes are suitable for piggyback or concurrent administration must be undertaken before administration.

19.4.3 All infusions of drugs are to be administered directly after reconstitution

and connection. The delay function of the pump must not be used. 19.4.4 Paediatric IV infusions use of the B line The Plum Manual states a 3ml syringe is the smallest that can be used

on the Plum A+ pump. However the small syringe will increase resistance when drawing fluid into the cassette generating an occlusion alarm. Therefore the manufacturer suggests using a 10mL syringe to deliver small doses such as 3mL - no accuracy will be lost and occlusion alarms may be prevented.

The clave port should always be flushed following delivery of drug through the B line, particularly if a small volume has been programmed. This will clear the Clave and ensure that no sediment builds up. You could leave the delivery syringe on when VTBI complete, back prime with 1mL then deliver it to clear line.

Refer also to section 19.1.6.1 for paediatric considerations.

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19.4.5 Pressure Settings Check the distal pressure setting each time an infusion is commenced, if required the limit can be changed manually. Note: The pump defaults to medium (258 mmHg) when it is switched on. If required, the distal pressure limit can be changed manually. The formula to determine distal pressure limit is M.A.P x 3. e.g. MAP = 80 x 3 = 240 mmHg.

i. paediatrics, limit is to be reduced to 90 mmHg (except some PICC lines which require higher pressures.

ii. neonates, the limit is usually 60mm/Hg 19.5 Labelling, Changing Infusions and Intravenous Lines

19.5.1 In the case of infusions - an Intravenous Additive Label must be

completed and attached to the mini bag/ burette/syringe 19.5.2 When changing infusions and IV lines the following applies:

i. IV infusion bags and syringes are to be changed every 24 hours. ii. IV fluid bags must not be taken down and reused once insertion

port has been punctured. iii. IV fluid bags must be discarded if the bag integrity is breached, i.e.

the bag is punctured or leaking. iv. Continuous IV lines are to have a completed IV change sticker

attached to the line and are to be changed every 72 hours. v. Intermittent IV lines are to have a completed IV change sticker

attached to the line and are to be changed every 24 hours, and vi. Time and date of the change is to be recorded on the label and

signed when completed on the nursing care plan. vii. IV fluids in warming cabinets to remain in outer packaging to be

labelled with a date timeframe of two (2) weeks, and discarded if not used after the two week timeframe.

19.5.3 Minimum labelling requirements are outlined in OD 385/12 Updated:

national recommendations for user-applied labelling of injectable medicines, fluids and lines

20. STORAGE OF MEDICATIONS

20.1 Bedside Storage When medications are stored and administered at the bedside, the storage unit must be locked at all times and key/code or swipe card held by a RN, midwife, EN or NP.

20.1.1 Two nurses (exception section 4.1.8), one of whom must be a RN, midwife or EN, must check the medications to be placed in the medication drawer. The practice of double checking placement in the drawer against the WACHS series 170 medication chart on admission or stock replacement is a requirement to avoid human error in medication incidents.

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20.1.2 Blister strips may be taken out of the packet and placed in the patient’s medication drawer, but the strip is not to be cut. Identification of the drug name, strength, batch number and expiry date are to be retained.

20.1.3 Medication drawers are to be emptied on discharge or transfer of the

patient. 20.1.4 Bedside medication drawers are for medications only. Other items e.g.

watch and other valuables are not to be stored in bedside patient medication drawers.

20.2 Storage of Patient’s Own Medication

20.2.1 These medications must not be used by the patient while in hospital, unless the medication is unavailable from the pharmacy.

20.2.2 Staff are to encourage family/ carer to take medications home after

medication reconciliation has occurred. (refer to section 5) 20.2.3 The EN, RN or midwife must document in the patient medical record or

medication chart the location of a patient’s medication - on admission and discharge, including any medications taken home by carer.

20.2.4 Patient’s own S4R or S8 medication storage: Dispensed controlled drugs must be separated from the remainder of the

discharge drugs and stored in the controlled drugs locked cupboard or safe. A note is to identify the presence of dispensed controlled drugs.

20.2.4.1 Any S4R or S8 medications are to be stored in the locked S4R

or S8 controlled drug cupboard/safe in a tamper proof bag and documented in the Register of Drugs of Addiction. i. The tamper proof bag contents should be recorded and then

stored in the safe. Only the seal and bag number need to be checked each safe check after this.

ii. If tamper proof bags are not available then each drug needs to be recorded on a separate page in the register of Drugs of Addiction and checked during the ward checking regime. (refer to section 18.2.7.3)

20.2.5 On discharge, two (2) persons check dispensed S4R or S8 medications

(one of which must be an RN) returned to the patient, and documented in the Register of Drugs of Addiction. Except in the case of a single RN site (refer to section 4.1.7)

20.3 Storage of controlled drugs

20.3.1 Storage of S4R and S8 medicines are to be stored in separate cupboards,

securely attached to a wall or floor in a secure storage area not accessible to the public. (OD0528/14)

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20.4 Keys and Access to Controlled Drug Keys

20.4.1 Keys/codes are required to ensure locks to the S4R and S8 medication

cupboards are keyed separately and key/code is to be kept on the person of the nurse in charge, or their delegate who may be an RN or midwife. (OD0528/14)

20.4.2 The S4R and S8 keys/codes are to be kept on separate key rings

(OD0528/14)

20.4.4 In outpatient areas with after hour storage, controlled drugs keys are to remain in the control of an RN or pharmacist e.g. a key safe.

20.4.5 The receipt of a S4R or S8 medication (including any patient's own

medicines) is to be signed by two people (except section 4.1.8) in accordance with local policy.

20.5 Transfer of controlled drug keys

20.5.1 In sites where there is not a RN on duty 24 hours per day, 7 days per

week, the key to the drug safe must at all times remain under the control of an authorised person (see definitions). The RN may retain possession of the keys while off duty.

20.5.2 If a spare key is available this is to be held by the Regional Pharmacist. 20.5.3 Under no circumstances may the key be left with unauthorised persons

such as police or staff of another agency. If the RN is leaving the area and it is necessary to transfer the key to another person, arrangements must be made to transfer the key to the regional pharmacist. If this is not possible, the key is to be transferred to a senior nurse at another WACHS facility, provided that the regional pharmacist is aware and approves of the arrangement.

20.5.4 The Poisons Regulations require that a stocktake is taken when control of

the key is transferred. Ideally, the stocktake is to be conducted jointly by the two parties involved. Where this is not possible because transfer of the key occurs at a location removed from the drug safe: i. the nurse relinquishing control is to conduct a stocktake, record the

results in the drug register, and the balances on hand at the time of checking, and,

ii. the nurse accepting control must conduct a stock control using the drug register on arrival on site.

iii. any discrepancies discovered must be reported. Refer to section 20.8

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20.6 Transfer of recordable medication including Controlled Drugs

20.6.1 Movement of recordable stock between hospital wards or between the pharmacy and wards on the same site is to be documented in the Register as well as in a transaction record, such as the Requisition for Drugs of Addiction Form, with the supplier and receiver both signing the requisition form and the receiving register.

20.6.2 Transfer of recordable medications from one site to another

i. Only in urgent situations may recordable medications be sought from another site outside of working hours. Recordable medications may only be supplied with the approval of both the requesting and receiving site nurse managers.

ii. Must be requested on an appropriate requisition form which has been appropriately authorized, and the details of the transaction must be recorded in the drug register of both the requesting and receiving site.

iii. The regional pharmacy must be faxed a copy of this requisition to alert the pharmacists to the transaction.

iv. It is the responsibility of the lending site to replace any stock transferred via a faxed requisition to the Regional Pharmacy during working hours.

20.6.3 If a recordable medication is to be obtained from another ward, a

requisition must be completed. i. The requisition, the medication chart and Register must be taken to

the ward where the medication is being transferred from. ii. The acquired recordable medication is recorded as "transferred" on

both registers. The requisition number is recorded under “req. no” and amount issued is recorded in the “amount issued from stock” column in the ward the stock is removed from. The date, amount and requisition number are recorded in the “received” columns in the receiving wards book.

iii. The RN or midwife removing the stock must accompany the nurse receiving the stock to the receiving ward and confirm the balance is correct.

iv. The recordable medication can then be checked and administered in the usual way.

20.7 Disposal of Drugs of Addiction and Poisons Included in Schedule 4

Restricted and Schedule 8

20.7.1 A S4R or S8 medicine is to be administered immediately after preparation or drawing up into a syringe and any unused portion discarded and recorded. If incremental dose is required the RN must stay with the patient.

20.7.2 If the full amount of a S8 medication is drawn up and not administered, the

same two (2) persons (one of which must be an RN) are required to witness the disposal of this drug. This should be recorded in the discarded column of the register.

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20.7.3 Where a partial amount of a solid dose form (e.g. tablet or lozenge) of a S4R or S8 is used the balance of the solid dose form should be destroyed and discarded in a manner preventing diversion. This should be recorded in the discard column in the register.

20.7.4 If a S4R or S8 medication has been unused (i.e. seal intact) it can be returned to stock. The medication must be re-entered into the Register of Drugs of Addiction with date, time, patient name and the statement "returned to stock". Two persons involved in the initial preparation must sign the entry.

20.7.5 Exemption of second checker. Refer to section 4.1.7 20.7.6 Expired stock is to be returned to the pharmacy or, in hospitals without

a pharmacist on site, the regional pharmacist is to be notified to arrange transfer or disposal. Medications dispensed to aged care facility residents by a retail pharmacy may be returned to the retail pharmacy for disposal in this circumstance the retail pharmacy must be contacted to arrange for the secure collection disposal of the medications.

20.8 Reporting Of Schedule 4 Restricted and 8 Medication Stock Discrepancies

20.8.1 All discrepancies (lost, stolen or theft) in the stock of S4R and S8 medications are required to be investigated and reported. OD0377/12 Reporting of medicine discrepancies in public hospitals and licensed private facilities which provide services to public patients in Western Australia.

20.8.2 If the discrepancy involves a clinical incident, an incident form must be completed. Poisons Reg 45(2) requires that the authorised person (Regional Pharmacist or as per individual regional processes) immediately notify clinical governance who would then report to the CCC and CEO in writing. Refer to: i. Flowchart: Investigating and reporting loss in public hospitals and

private facilities treating public patients and complete ii. Form: S8 & R4 medicine discrepancy /loss report.

20.9 Medication Fridge

20.9.1 Medications deemed suitable to be stored in a ward medication fridge must be securely stored and managed in accordance with legislation, licensing permit requirements, manufacturers’ recommendations and local WACHS pharmacy procedures.

20.9.2 All medications, including vaccines, stored in the ward medication fridges must meet cold chain storage requirements, where applicable.

20.9.3 All staff handling these pharmaceutical items are responsible for maintaining cold chain integrity and utilising the record sheets for temperature monitoring.

20.10 Transport

Refer to regional pharmacist for information on transporting medication. The use of plain packaging and a reputable post/courier is the responsibility of each WACHS facility when transporting medication. Refer to WACHS Requisitioning and Receipt of Schedule S4R and 8 Medications and Ordering of Pharmacy Imprest Supplies Procedure for district sites.

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Where stock discrepancy is identified e.g. drugs dispatched but not delivered/ received, the Post/Courier and WACHS persons involved must investigate and report the discrepancy and involve senior staff in accordance with local procedure. (refer to section 20.8) A S8 and S4R medications are not to be transported between facilities by a staff member other than a medical practitioner or pharmacist, and should generally be consigned by post or courier. Medications to be secured appropriately in tamperproof/tamper evident packaging prior to plain-packaging (refer to section 7.2.4). Refer also to WACHS Requisitioning and Receipt of Schedule S4R and 8 Medications and Ordering of Pharmacy Imprest Supplies Procedure.

21. EVALUATION

Medication incidents are the second most commonly reported incidents in Australian hospital incident monitoring systems. Organisations can learn about the safety of medication management processes by reviewing incidents and undertaking in depth analyses of incidents causing, or with the potential to cause, patient harm (NSQHSS 4). 21.1 Compliance

Compliance with this medication policy is to be measured by the number of medication incidents, adverse events and near misses relating to inappropriate medication administration by a RN, midwife, EN or NP and reported through the Clinical Incident Monitoring system. Specific national audit tools are available for medication safety e.g. aged care audit tool, high risk areas i.e. oncology and antithrombotic therapy.

WACHS sites are encouraged to participate in the Medication Safety Self-Assessment® for Australian Hospitals. This audit reviews a sample of medication charts to:

i. evaluate the effect of NIMC safety features ii. identify areas for improvement iii. provide a baseline for NIMC use and quality improvement initiatives. iv. improve the safety of medication charting.

21.2 Mitigation strategies

21.2.1 Site and regional review of incident reports, adverse events and near misses using Failure Modes and Effects Analysis (FMEA) identify: i. trends in the type and causes of errors, ii. particular areas in the medication management pathway where

incidents are occurring, or iii. specific medicines involved. (ref NSQHSS 4)

21.2.2 Regions include specific issues in the WACHS Riskbase risk register 21.2.3 Site nurse managers and pharmacists communicate to the workforce

and students about medication incidents and actions and proposed practice changes to reduce occurrence. (NSQHHS 4 - 4.4.2).

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REFERENCES Aged Care Act 1997 and Quality of Care Principles Quality of Care Amendment

Principles 2011 (No. 1). (Australian Government). Australian Commission on Safety and Quality in Healthcare (ACSQHC) 2011 National

Safety and Quality Health Service Standards, ACSQHC, Sydney. Australian Health Practitioner Regulation Agency (AHPRA) 2008, Code of Ethics and

Professional Code of Conduct for Nurses. Australian Health Practitioner Regulation Agency, Australia.

Australian Nursing and Midwifery Council, 2007, National Framework for the Development of Decision-making Tools for Nursing and Midwifery Practice.

Australian Pharmaceutical Advisory Council, 2005, Guiding principles to achieve continuity in medication management, Department of Health and Ageing, Canberra.

Burridge N & Deigun D (eds.) 2011, Australian Injectable Drugs Handbook Society of Hospital Pharmacists of Australia.

Cancer Institute NSW n.d. - Standard Cancer Treatments - eviQ for use in clinical practice Carers Recognition Act (WA) 2004 Office of Health Protection. 2013 Australian Immunisation Handbook10th ed.,

Department of Health and Ageing: Canberra WA Health, Administrative Circular A 7652 Supply of Drugs and Medications. WA Health, Operational Instruction 0280/93 Drug Supplies To Outpatients of Health

Department Of Western Australia Government Non-Teaching Hospitals And Nursing Posts WA Health Operational Circular OP 1988/05 Scope of Enrolled Nursing Practice and

Enrolled Nurse Competencies. WA Health Information Circular IC 0179/14 Guidelines for the Transmission of Client

Identifiable Health Information by Facsimile Machine. WA Health, Operational Directive OD 0141/08 - Code of practice for the handling of

Schedule 8 medicines (drugs of addiction) in hospitals and nursing posts WA Health, Operational Directive OD 0142/08 Administration of Schedule 8 medicines

to patients attending for emergencies. WA Health, Operational Directive OD 0528/14 Storage and recording of Restricted

Schedule 4 (S4R) medicines Australian Commission on Safety and Quality in Health Care Recommendations for

Terminology, Abbreviations and Symbols used in Medicines Documentation. WA Health, Operational Directive OD 0312/10 Western Australian Patient Identification

Policy WA Health, Operational Directive OD 0377/12 Reporting of medicine discrepancies in

public hospitals and licensed private facilities which provide services to public patients in Western Australia and Flowchart: Investigating and reporting loss in public hospitals and private facilities treating public patients

3 WA Health, Operational Directive OD 0385/12 Updated: national recommendations for

user-applied labelling of injectable medicines, fluids and lines WA Health, Operational Directive OD 0397/12 Use of Acute Oxygen Therapy in

Western Australian Hospitals WA Health, Operational Directive 0414/13 Smoke Free WA Health System Policy. WA Health, Operational Directive 0415/13 Guidelines for Department of Health

Vaccination Programs – School and Community Health Immunisation.

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WA Health, Operational Directive OD 0416/13 Prescription and management of intravenous patient controlled analgesia

Department of Health WA 2011, Clinical Guidelines and Procedures for the Management of Nicotine Dependent Inpatients. Perth, Department of Health.

Department of Health WA n.d., Smoke Free WA Health System Policy, Guidelines for the management of nicotine withdrawal and cessation support in nicotine dependent patients. Perth, Department of Health.

Department of Veterans’ Affairs. 2010, Guidelines for the provision of community nursing services. Australian Government.

Health Practitioner Regulation National Law (WA) Act 2010. National Health and Medical Research Council. 2009. Clinical practice guideline for the

prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to Australian hospitals. Melbourne: National Health and Medical Research Council: Canberra

National Institute of Clinical Studies 2011 Emergency Care Acute Pain Management Manual national emergency care Pain management initiative. National Health and Medical Research Council: Canberra.

Nursing and Midwifery Board of Australia n.d. Prescribing Formulary for eligible Midwives with a scheduled medicines endorsement.

Occupational Safety and Health Act 1984. (Western Australia). Office of Safety and Quality in Healthcare, 2008, National Inpatient Medication Chart

(NIMC) Standardised Charts and Guidelines (for adults, paediatric, neonatal and adult anticoagulant). Perth, Department of Health.

Office of the Chief Nursing Officer. 2003, Guiding Framework for the Implementation of Nurse Practitioners in Western Australia, Perth, Department of Health WA.

Poisons Act 1964. (Perth, Western Australia Government) Poisons Amendment Regulations 2010, Perth, Western Australia Government Poisons Regulations 1965. (Perth, Western Australia Government) Princess Margaret Hospital, 2011, Nursing Practice Manual drug and intravenous

therapy section 2. Royal Perth Hospital, 2012, Clinical Practice Standard for insertion and management of

a Peripheral Intravenous Cannula (PIVC). Royal Perth Hospital, 2010(revised version), RPH Policy Manual (V3 2007) Safe use of

medication refrigerators.

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The Office of Safety and Quality in Healthcare 2012, Safer Guidelines for the WA

National Inpatient Medication Chart: Guidelines for use of the WA NIMC including the long stay NIMC. Department of Health WA

Therapeutic Goods Administration, 2010, Advisory Committee on the Safe Use of Medicines. Department of Health and Ageing, Canberra.

WA Country Health Service, 2007, Smoke Free WA Health System Policy Implementation Procedure.

WA Health High Risk Medication Policy WACHS High Risk Medications Procedure WACHS Chemotherapy Administration - WACHS Clinical Practice Standard

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APPENDIX 1 STARTER PACK APPROVAL SITE LIST Albany Hospital Warden Avenue ALBANY WA 6330 Augusta Multi-Purpose Health Service Donovan Street AUGUSTA WA 6290 Bayulu Remote Area Health Service via FITZROY CROSSING WA 6765 Beacon Nursing Post Lindsay Street BEACON WA 6472 Bencubbin Nursing Post 79 Monger Street BENCUBBIN WA 6477 Beverly Health Service Sewell Street BEVERLEY WA 6304 Boddington Hospital Hotham Avenue BODDINGTON WA 6390 Boyup Brook Hospital Hospital Drive BOYUP BROOK WA 6244 Bremer Bay Health Centre 29 John Street BREMER BAY WA 6338 Bridgetown Hospital Peninsula Road BRIDGETOWN WA 6255 Brookton Nursing Home Lennard Street BROOKTON WA 6306 Broome Hospital Robinson Street BROOME WA 6725 Bruce Rock Hospital 35 Dunstall Street BRUCE ROCK WA 6418

Burringurrah Nsg Post Burringurrah Community Aboriginal Corporation UPPER GASCOYNE WA 6705 Collie Health Service Deakin Street COLLIE WA 6225 Coonana Nursing Post Coonana Community COONANA WA 6431 Coolgardie Health Centre Wilkie St COOLGARDIE WA 6429 Coral Bay Nursing Post Coral Bay Shopping Centre CORAL BAY WA 6701 Corrigin Hospital 49 Kirkwood Street CORRIGIN WA 6375 Cue Nursing Post Victoria Street CUE WA 6640 Cunderdin Hospital Cubbine Road CUNDERDIN WA 6407 Dalwallinu Hospital PO BOX 115 DALWALLINU WA 6609 Denmark Health Service Scotsdale Road DENMARK WA 6333 Derby Hospital Clarendon Street DERBY WA 6728 Dongara MPS 48 Blenheim Road DONGARA WA 6525 Donnybrook Hospital Bentley Street DONNYBROOK WA 6239

Dumbleyung Hospital McIntyre Street DUMBLEYUNG WA 6350 Dundas Health Service Talbot Street NORSEMAN WA 6443 Eneabba Nursing Post Grover Street ENEABBA WA 6518 Esperance Community Health Forrest St ESPERANCE WA 6450 Esperance Hospital Hicks St ESPERANCE WA 6450 Exmouth Hospital Lyons Street EXMOUTH WA 6707 Fitzroy Crossing Hospital Fallon Road FITZROY CROSSING WA 6765 Gnowangerup Hospital Yougenup Road GNOWANGERUP WA 6335 Goldfields Population Health 36-42 Ware St KALGOORLIE WA 6430 Goomalling Hospital PO BOX 107 GOOMALLING WA 6460 Halls Creek Hospital 70 Roberta Avenue HALLS CREEK WA 6770 Harvey Hospital 45 Hayward Street HARVEY WA 6220

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Hedland Health Campus Colebach Way South Hedland WA 6722 Jerramungup Health Centre - Kokoda Road JERRAMUNGUP WA 6337 Junjuwa Remote Area Health Service Junjuwa via FITZROY CROSSING WA 6765 Jurien Bay Health Centre Whitfield Street JURIEN BAY WA 6516 Kalbarri Health Centre Kaiber Street, KALBARRI WA 6536 Kalgoorlie-Boulder Community Health 36-42 Ware St KALGOORLIE WA 6430 Kalumburu Remote Area Health Service Kalumburu WA 6740 Kambalda Health Centre Gumnut Place KAMBALDA WA 6444 Katanning Health Service Clive Street KATANNING WA 6317 Kellerberrin Health Services 51-53 Gregory Street KELLERBERRIN WA 6410 Kojonup Hospital Spring Street KOJONUP WA 6395 Kondinin Hospital Graham Street KONDININ WA 6367

Koorda Community Health Centre 21 Allenby Street KOORDA WA 6475 Kukerin Health Centre Manser Street KUKERIN WA 6352 Kununoppin and Districts Health Service Leake Street KUNUNOPPIN WA 6489 Kununurra Hospital 96 Coolibah Drive KUNUNURRA WA 6743 Lake Grace Hospital Stubbs Street LAKE GRACE WA 6353 Laverton Community Health Laver Place LAVERTON WA 6440 Laverton Hospital Beria Road LAVERTON WA 6440 Leeman Nursing Post Lot 692 Morcombe Road LEEMAN WA 6514 Leinster Nursing Post Link Road LEINSTER WA 6437 Leonora Community Health 96 Tower St LEONORA WA 6438 Leonora Hospital Sadie Canning Drive LEONORA WA 6438 Lombadina Remote Area Health Service LOMBADINA WA 6725 Looma Remote Area Health Service LOOMA via DERBY WA 6728

Marble Bar Nursing Post 2 Francis Street MARBLE BAR WA 6760 Margaret River Hospital Farrelly Street MARGARET RIVER WA 6285 Meekatharra Hospital Savage Street MEEKATHARRA WA 6642 Menzies Nursing Post Sandstone Road MENZIES WA 6436 Merredin Health Services Kitchener Road MERREDIN WA 6415 Mingenew Nursing Post 80 Philip Street MINGENEW WA 6522 Moora Hospital PO BOX 154 MOORA WA 6510 Morawa and Districts Health Service Caulfield Road MORAWA WA 6623 Mount Magnet Nursing Post Cnr Welcome & Criddle Sts MOUNT MAGNET WA 6638 Mukinbudin Health Service Ferguson Street MUKINBUDIN WA 6479 Mullewa Health Service Elder Street MULEWA WA 6535 Nannup Hospital Carey Street NANNUP WA 6275

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Narembeen Health Svcs Ada Street NAREMBEEN WA 6369 Narrogin Hospital Williams Road NARROGIN WA 6312 Nickol Bay Hospital Millstream Road KARRATHA WA 6714 Newman Hospital Mindarra Street NEWMAN WA 6753 Noonkanbah Remote Area Health Service via FITZROY CROSSING WA 6765 North Midlands Health Service Thomas Street THREE SPRINGS WA 6519 Northampton Hospital Stevens Street Northampton WA 6535 Northam Hospital PO BOX 312 Northam WA 6401 Northcliffe Nursing Post Wheatley Coast Road NORTHCLIFFE WA 6262 Norseman Comm.Health 72-74 Princep St NORESMAN WA 6443 Norseman Hospital Talbot St NORSEMAN WA 6443 Nullagine Nursing Post 2 Cooke Street NULLIGINE WA 6758 One Arm Point Comm. Remote Area Health ONE ARM POINT WA 6725 Onslow Hospital Second Avenue ONSLOW WA 6710

Paraburdoo Hospital Rocklea Road PARABURDOO WA 6754 Pemberton Northcliffe Health Service Railway Crescent PEMBERTON WA 6260 Pingelly Hospital Stratford Street PINGELLY WA 6308 Plantagenet Hospital Langton Road MOUNT BARKER WA 6324 Quairading Hospital Harris Street QUAIRADING WA 6383 Ravensthorpe Health Service Morgan Street RAVENSTHORPE WA 6346 Roebourne Hospital 42-44 Hampton Street ROEBOURNE WA 6718 Sandstone Nursing Post 120 Payne Street SANDSTONE WA 6639 Shark Bay Nursing Post 35 Hughes Street DENHAM WA 6537 Southern Cross Health Service Coolgardie Road SOUTHERN CROSS WA 6426 Tambellup Nursing Post Norrish Street TAMBELLUP WA 6320 Tom Price Hospital Mine Road TOM PRICE WA 6751 Wagin Hospital Warwick Street WAGIN WA 6315

Walpole Nursing Post South Coast Highway WALPOLE WA 6398 Wangkatjungka Remote Area Health Service via FITZROY CROSSING WA 6765 Warmun Remote Area Health Service - Ord Street WARMUN WA 6743 Warren Hospital Hospital Avenue MANJIMUP WA 6258 Wheatbelt Health Region Furnival Street NARROGIN WA 6312 Wickepin Community Health Centre Wogolin Road WICKEPIN WA 6370 Williams Health Centre Adams Street WILLIAMS WA 6391 Wongan Hills Hospital PO BOX 250 WONGAN HILLS WA 6603 Wyalkatchem-Koorda and Districts Hospital Honour Street WYALKATCHEM WA 6485 Wyndham Hospital Minderoo Road WYNDHAM WA 6740 Yalgoo Nursing Post Stanley Street YALGOO WA 6635 Yandeyarra Community Health Clinic Great Northern Highway De Grey WA 6722 York Hospital Trews Road YORK WA 6302

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Appendix 2 - "APPROVED STARTER PACKS" AS AT 18 SEPTEMBER 2013

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Appendix 2 continued

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APPENDIX 3a NURSE INITIATED MEDICATIONS NON-PRESCRIBED

SCHEDULE 2 and 3 MEDICATIONS FOR ADULT PATIENTS The following medications may be administered to an adult patient by a RN, or an EN (after consultation with an RN) who has undertaken an assessment of the patient without a medical officer's written or verbal order, as per section 8. Subsequent repeat dose require medical review. Therefore any S2-3 preparation that is only provided in a multi dose pack is not included in this list (e.g. anti-fungal preparations).

Supply of nurse initiated non-prescribed medication is subject to availability on regional formulary.

The RN is accountable for their practice including adhering to Section 5 principles of medication administration.

The administration of these medications must be documented on the ‘Once Only and Pre-Operative Medication’ section of the MR170 series medication chart.

Nicotine replacement therapy may only be administered as per DOH Clinical guidelines and procedures for the management of Nicotine dependent inpatients (see section 11). Analgesics / Anti-inflammatory • Paracetamol mixture or tablets (500mg) • Aspirin 300mg • Ibuprofen 200-400mg • Topical Lignocaine 2% gel for wound

management only Antihistamine • Loratidine 10mg • Fexofenadine 60mg • Promethazine 10-25mg

Bowel Stimulants • Docusate (Coloxyl oral or rectal formula) • Paraffin emulsion (Agarol mixture) • Docusate with Senna (Coloxyl with

senna) • Senna tablets • Bisacodyl tablets • Fruit Laxative (Nulax) Bulk Laxatives • Fibre supplements (Metamucil,

Benefibre) • Sterculia (Normacol, Granacol) • Movicol

Enemas and Suppositories • Microlax enema • Glycerin suppositories • Bisacodyl suppositories 10mg Antacids • Aluminium hydroxide (GavisconTM, MylantaTM) Ocular • Ocular lubricants – Polytears • Fluorescein Sodium 2% stain (emergency

department only)

Respiratory • Salbutamol MDI with spacer • Nebulised saline Incidentals • Glucose oral solution • Carbotest • Sodium citro-tartrate (Citravescent/Ural/

Uricalm) • Saliva Substitute • Antiseptic throat lozenges (Capitol) • Sodium citrate 8.8% 0.3M (single dose) • Pholcodine linctus • Senega and ammonia mixture • Glyceryl trinitrate sublingual • Simethicone capsules • Hyoscine butylbromide 20mg • Hirudoid/Lasonil • Head Lice Treatments

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APPENDIX 3b NURSE INITIATED NON-PRESCRIBED SCHEDULE 2 and 3 MEDICATIONS FOR PAEDIATRIC PATIENTS

The following medications may be administered to a paediatric patient by a RN, who has undertaken an assessment of the patient without a Medical Officers written or verbal order, as per section 8. Subsequent repeat dose require medical review. Therefore any S2-3 preparation that is only provided in a multi dose pack is not included in this list (e.g. anti-fungal preparations). Supply of nurse initiated non-prescribed medication is subject to availability on regional formulary. The RN is accountable for their practice including adhering to Section 5 Principles of medication administration. The RN must consult the appropriate endorsed for use in WACHS administration of medications handbook e.g. Royal Children’s Hospital Melbourne paediatric pharmacopeia (see section 1) for weight related dosing schedule. The administration of these medications must be included in the ‘Once Only and Pre-Operative Medication’ section of the WACHS MR170D medication chart including documenting the basis for dose calculation e.g. mg/kg. Analgesics/ Anti-inflammatory • Paracetamol oral or rectal • Ibuprofen • Topical Local Anaesthetics e.g. Eutectic Mixture of Local Anaesthetics (EMLA) • Sucrose 25% solution Antihistamine • Loratadine Respiratory • Salbutamol (inhalational) • Nebulised saline Incidentals • Wax removal ear drops (e.g. Cerumol®; Waxsol®) • NaCl 0.9% nose drops • Artificial tears (ointment and drops) • Glycerine suppository (infant/child/adult) • Head Lice Treatments

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APPENDIX 4 - DESIGNATED REMOTE AREA NURSING POSTS Please refer to Appendix 1 of Registered nurses – remote area nursing posts (Word 97KB) located at Department of Health Structured Administration and Supply Arrangement website under CEO of Health SASA

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APPENDIX 5 - SUPPLY BY REGISTERED NURSES AT REMOTE AREA NURSING POSTS Please refer to Registered nurses – remote area nursing posts (Word 97KB) located at Department of Health Structured Administration and Supply Arrangement website under CEO of Health SASA

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APPENDIX 6 - DRUG AND IV FLOW CALCULATIONS 6.1 Calculating Rate of Flow for Intravenous Infusions Check the delivery rate of the giving set used for infusion (i.e. drops per mL). Formula is as follows: Rate of flow = Volume x Drops/minute

Time in Hours x 60 Or Time [hours] = Volume x Drops/mL

Rate in Drops / mL x 60 mL/hr = Volume or Volume x 60

Time (hrs) Time (mins)

The rate for IV medications going through a pump is also to be checked by an RN and a second nurse in order to avoid any errors in the rate programmed into the pump.

6.2 Drug Calculation Formula

Dose required = Number of tablets to be administered Stock Strength

Dose Required x Volume of Stock Strength = Volume to administer Stock Strength

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APPENDIX 7 - ANAPHYLAXIS FLOWCHART (Modified to remove administration of Epipens within hospitals)

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APPENDIX 8 - POLICY REVIEW CONTRIBUTORS

With thanks to the contributions from individual submissions and the tireless work of Medication Review Group 2012/2013. 1. Shirilee Kerrison (Chair) Coordinator of Nursing and Midwifery - WACHS Central

Office 2. Pamela Coates Senior Project Officer Nursing and Midwifery - Central Office 3. Ruth Littler, WACHS Aged Care Project Officer - WACHS Central Office 4. Kerry Fitzsimmons Pharmacist Office of Safety and Quality DOH 5. Meeghan Clay Pharmacist - Great Southern 6. John Van der Post FACEM Albany - Great Southern) 7. Marianne Slattery Regional Nurse Director - South West 8. Naomi Lillywhite Chief Pharmacist Bunbury - South west. 9. Mair Jones Nurse Educator - South West 10. Diana Ellison DON/HSM Quairading - Wheatbelt 11. Chris Cream Regional Nurse Director, Midwest (proxy Sue Hogan) 12. Janine Glasson Clinical Nurse/CNI, Geraldton - Midwest 13. Ken Thomson Mental Health Manager, Geraldton 14. Peter Barrett Regional Medical Director - Goldfields 15. Karine Miller regional Coordinator of Population Health, Goldfields 16. Krysten Todd Registered Nurse Hedland Health Campus, Pilbara 17. Geraldine Rolfe Mental Health Manager, Broome 18. Scott Stokes Nurse Practitioner Paediatric – Kimberley; (Proxy Angela Fisher NP) 19. Ruth Bath DON/HSM Kununurra

Specific subject matter expert consultations: 20. Peggy Briggs Rural Cancer Nurse Coordinator, WACHS Perth 21. Kate Reynolds Senior Midwifery Project Manager, WACHS Perth 22. Garth Hetherington, FACEM lead WACHS 23. Siva Balu Psychiatric Kimberley 24. Linda Smith HACC project officer; Carol Fryer Community West auditor

Title: Medication Administration Policy Contact: WACHS Great Southern Regional Chief Pharmacist (M. Clay)

Directorate: Medical Services TRIM Record Number: ED-CO-13-124530 Version: 7.00 Date Published: 25 January 2018

Date of Last Review: January 2018 Date Next Review: June 2018

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© WA Country Health Service