The Medicines Act 1968

This act protects manufacturers, prescribers and recipients of medicines. It controls licensing, manufacturing and distribution of medicines, the registration of retail pharmacists, and identifies three classes of medicinal products:

The Act stipulated that only doctors, dentists and veterinary surgeons could prescribe medicines; however, later legislation has since extended prescribing to appropriately qualified registered nurses (RNs) (see below) and other healthcare professionals such as some pharmacists. The Act outlines:

Many medicinal products not governed by legislation are widely available, e.g. homeopathic and herbal preparations. In addition, GSL medicines – often referred to as ‘over-the-counter drugs’, such as aspirin and medicines for indigestion – are widely believed to be safe. However, they can have serious side effects and may interact with each other and with prescribed medicines. Additionally, the use of alcohol and recreational drugs can have harmful effects and they too can interact with prescribed medication.

The Misuse of Drugs Act 1971

This Act identified controlled drugs that are likely to cause dependence and other harmful effects if misused. It aims to prevent the misuse of these drugs and protects public safety by controlling their importation, exportation, supply and possession. Controlled drugs are widely known as CDs and were previously known as ‘dangerous drugs of addiction’. The Act classifies CDs according to the harm they may cause if misused.

The Misuse of Drugs Regulations 1985

This divides controlled drugs into five schedules, which have specific requirements regarding their supply, possession, prescribing and record keeping. There is a legal requirement to keep a controlled drug register for drugs in Schedule 2, which includes the most addictive drugs used in practice such as morphine and pethidine. Further information can be found in the British National Formulary (BNF; see Useful websites, p. 651). Storage, ordering, prescribing and administration of CDs are described later.

Nurse prescribing

The Medicinal Products: Prescription by Nurses Act 1992 and The Health and Social Care Act 2001 contain the primary legislation that allows nurse prescribing and its subsequent extension to ‘non-medical prescribing’. Increasingly, RNs who have undertaken further specific training are prescribing many drugs in a range of settings.

Professional advice that affects nurses

In relation to the administration and prescribing of medicines, nurses are not only constrained by the legislation above but also by Guidelines for the Administration of Medicines (NMC 2004a). These outline nurses’ professional accountability (see Ch. 7) in relation to knowledge of drugs and their actions, and the safe administration of medicines. Nurses must also be familiar with the Code of Professional Conduct: Standards for Conduct, Performance and Ethics (NMC 2004b) and Guidelines for Records and Record Keeping (NMC 2005).

The NMC (2004a) recommend that only RNs, midwives and specialist community public health nurses should be involved in the administration of medicines. Practitioners must always be aware of local policy as it may vary regarding the number of practitioners involved. For example, in some placements the second checker will also require to be a registered practitioner whereas in others this may be a student nurse.

The Standards of Proficiency for Pre-registration Nursing Education (NMC 2004c) state that student nurses must be able to demonstrate competence in essential skills including administration of medicines. Student nurses undertaking administration of medicines must do so only under the direct supervision of a RN. The RN must countersign the signature of a student who administers any prescription (NMC 2004a).

Storage of medicines

In clinical settings all drugs, not just CDs and including GSL medicines, are ‘controlled’ by the legislation outlined above. Storage depends on the type of drug and the setting involved.

Storage of non-controlled medicines in hospitals and nursing homes

The Duthie report (Department of Health [DH] 1988) set out precautions concerning the storage of medicines in hospitals to safeguard staff and patients/clients. The nurse in charge of a clinical area is responsible for the safe storage of all medicines (Box 22.1). Safe storage requires that:

1. Medicines are always stored in:

• A locked cupboard

• A locked medicine trolley (Fig. 22.1A)

• A locked section of the patient’s/client’s bedside locker (Fig. 22.1B), or

• A locked refrigerator that is only used for drugs

  Page 629 

2. Some medicines are stored at room temperature (between 15 and 258C), others require to be kept in a cool dark cupboard and some are stored in a refrigerator (between 1 and 48C), e.g. vaccines and reconstituted antibiotics

3. Disinfectants/antiseptics such as chlorhexidine, intravenous (i.v.) fluids such as 0.9% sodium chloride, clinical reagents such as urine testing materials and topical substances, including creams and ointments, should be stored in locked cupboards and separately from other medicines

4. Medicines should always be kept in their original packaging, e.g. blister packaging is designed to reduce decomposition of the drugs by moisture.

Box 22.1 REFLECTIVE PRACTICE

Storage of medicinal products

Medicinal products are stored in different parts of placements and under different conditions.

Student activities

1. In your placement, identify at least one medicine that is stored:

• At room temperature

• In the drugs refrigerator.

2. Find out where the following are stored:

• Disinfectants

• Urine testing materials

• Creams and ointments

• i.v. fluids.

Fig. 22.1 Storage of medicines: A. Medicine trolley. B. Locked section of bedside locker

Storage of controlled drugs in hospitals and nursing homes

Because of their potential to cause harm if misused, there are specific legal requirements concerning the ordering, storage and dispensing of controlled drugs. Controlled drugs are the responsibility of the charge nurse. They are kept locked in an inner cupboard within a cupboard (Fig. 22.2). The keys for both cupboards are held in the sole custody of the charge nurse or a designated RN or other healthcare professional. The contents of the cupboard and the controlled drug register are checked regularly according to local policy. This may be at each change of shift, daily or weekly. The controlled drug register is kept as an accurate record of the contents of the controlled drugs cupboard. Once completed, the registers are kept in the clinical area for 2 years.

Fig. 22.2 Drug cupboard with an inner controlled drugs cupboard

Ordering drugs in hospitals

This depends on the type of drug to be ordered.

Principles of prescribing

It is essential to ensure that the prescription meets the principles laid down in the Guidelines for the Administration of Medicines (NMC 2004a). In order to safeguard both the public and practitioners, specific guidelines govern the prescribing of medicines (Box 22.3). Drugs may be prescribed:

If the prescription does not meet the required standards for safe practice, the nurse should contact the prescriber to amend their prescription before proceeding further. An example of a prescription sheet is provided in Figure 22.3

Fig. 22.3 Prescription chart

(reproduced with permission from NHS Lothian 2005)

Pharmacodynamics

Receptors on cell membranes often act as recognition sites for substances produced by the body to regulate or mediate specific functions. Substances that act on cell membrane receptors include hormones and neurotransmitters – chemicals that transmit nerve impulses across the tiny gaps (synapses) between nerve cells. Many drugs produce their effects because they are structurally similar to the naturally occurring substances that act on receptors (Fig. 22.4A). Drugs that act on receptor sites in a similar way to natural body substances are known as agonists, whereas those that prevent (block) their normal action are known as antagonists. Therefore, by attaching to specific receptor sites on target cells, some drugs act by stimulating or blocking the storage, manufacture or release of naturally produced substances.

Fig. 22.4 Sites of drug action: A. Receptors. B. Ion channels. C. Enzymes

(adapted with permission from Rang et al 2003)

However, not all drugs act on receptor sites, e.g. antacids reduce indigestion by neutralizing gastric acid. Many other drugs act by inhibiting the actions of enzymes (Fig. 22.4B), e.g. non-steroidal anti-inflammatory drugs (NSAIDs), or by blocking ion channels in cell membranes (Fig. 22.4C), e.g. local anaesthetics.

Pharmacokinetics

Important processes influence plasma levels of a drug within the body, in particular absorption, distribution, metabolism and excretion (Fig. 22.5). Knowledge of pharmacokinetic principles is useful when considering factors that determine how much of a drug is needed to maintain appropriate (therapeutic) blood levels.

Fig. 22.5 Effects of absorption, distribution, metabolism and excretion on the plasma concentrations of an administered drug

(reproduced with permission from Downie et al 2003)

Therapeutic range

To achieve optimal concentrations at the target tissue the correct dose must be given. If this is too low drug action will be ineffective; if too much is administered it may produce side effects that might be toxic. The therapeutic range refers to the plasma levels of a drug that must be maintained so that it can exert its optimal response without producing side effects (Fig. 22.6). Some drugs have a narrow therapeutic range while for others this is wider. Nurses need to recognize the implications of this in relation to drug administration, i.e. if drugs are omitted or given at times other than those prescribed, plasma drug levels will not be maintained in the therapeutic range.

Fig. 22.6 Therapeutic range

(reproduced with permission from Hopkins & Kelly 1999)

Fig. 22.7 Non-touch technique for dispensing oral medication

(reproduced with permission from Nicol et al 2004)

Fig. 22.8 Drawing up an injection

(reproduced with permission from Nicol et al 2004)

Measurement of plasma drug levels is carried out when drugs with a narrow therapeutic range are used, e.g. gentamicin (an antibiotic) causes irreversible kidney damage and hearing impairment when therapeutic levels are exceeded. Children, until their liver and kidneys are fully mature, older adults whose kidney and liver function may be declining and people with a liver or kidney disorder are at greatest risk of drug toxicity.

Naming of drugs

The recommended International Non-proprietary Name (rINN) of a drug is also referred to as the generic, non-proprietary or British Approved Name (BAN). This name may start with a lower case letter, e.g. ‘p’ in paracetamol.

The manufacturer gives the trade or proprietary name to a particular preparation. This is recognized by the symbol ® denoting its registered trademark, which follows its name on the packaging. Proprietary names start with a capital letter, e.g. ‘P’ in Panadol®, which is a trade name for paracetamol. The manufacturer who has registered a drug has exclusive rights to market it for up to 10 years, during which time they can recover the development costs. Different drug companies often manufacture similar or identical generic preparations and may give them similar names.

To avoid errors, and because manufacturers price drugs differently, the Department of Health (1999) recommended that drugs be prescribed by their generic name (e.g. paracetamol) and that trade names (e.g. Panadol®) should only be specified if a particular manufacturer’s drug has different effects. Lists of drugs can be found in the BNF.

Common groups of drugs and their actions

Common drug groups are listed in Table 22.1 together with their effects and examples. Nurses must understand how commonly used drugs in their practice area act and be familiar with their side effects and contraindications in order to maintain patient/client safety (Box 22.4). This information can be found in the BNF/Children’s BNF.

Oral medication

Once swallowed, drugs are usually absorbed from the small intestine. Oral preparations include tablets, capsules and liquids (see Table 22.2). Some tablets are manufactured to exert their effect over long periods and are described as ‘slow release’ (SR) or ‘extended release’ (XR). Other tablets are covered in an enteric coating (e/c). For example, NSAIDs are potential gastric irritants and are enteric coated so that they travel through the stomach unchanged before entering the small intestine where they are absorbed, thus avoiding gastric irritation. People should therefore swallow these tablets whole and not crush or chew them, so that the enteric coating and/or extended release action is maintained. Crushing tablets increases the risk of adverse drug reactions and toxicity (Miller & Miller 2000). Bending (2001) cautions that when controlled release tablets are crushed the whole dose may be released within 5–15 minutes instead of over the 24-hour period intended. Manufacturers’ instructions warn against the crushing of tablets or opening of capsules as this is outwith the marketing licence (Wright 2003). When available, it is safer to use liquid preparations when swallowing tablets is difficult or impossible.

Parenteral medication

Parenteral medication includes those given by any route other than the alimentary tract. This includes preparations that are:

Consent

It is important that healthcare professionals are aware of the individual’s right to refuse treatment, including medication, and must always respect their decisions (NMC 2004b). Adults must always be presumed to have the mental capacity (see Ch. 6) to consent to, or refuse, treatment, including taking medication, and no medication should be given without their agreement.

However, there are many situations when people may not be capable of providing valid consent. People with mental health problems, including dementia, or a learning disability may lack the capacity to make the decision whether or not to take medication (Box 22.5). When patients/clients are incapable of providing consent, or their wishes are contrary to their best interests (see Ch. 6), a registered practitioner should consult relevant people such as the family, carers or members of the multidisciplinary team (MDT). Assessment of capacity is primarily a matter for the treating clinicians but nurses as members of the MDT should be involved in such discussions.

For people detained under mental health legislation the principles of consent still apply to medications prescribed for other conditions. In other words, only medicines prescribed for mental health problems can be administered without the client’s consent.

The Children Act 1989 ensures that children’s wishes and feelings are taken into account, that they should always be consulted (subject to age and understanding) and kept informed about what is planned (see Ch. 6). The age of consent to medical treatment varies across the UK:

Covert administration of medicines

The United Kingdom Central Council (2001) states that the practice of covert, or ‘hidden’, administration of medicines may be only carried out in some specific instances. This should only be necessary or appropriate in the case of individuals who actively refuse medication and who are judged not to have the capacity to understand the consequences of their refusal. Treloar et al (2001) state that, in these cases, there is a duty to care and practitioners should be protected by transparent procedures which are framed in local policy. The following principles must always apply:

Calculation of drug doses

The units used for drug doses and accepted abbreviations are shown in Box 22.3. Most drugs are manufactured in a form that enables straightforward administration, and some are found in a variety of strengths. This helps to ensure that the prescribed dose can be provided accurately and easily calculated.

Accurate calculation of drug doses requires practice. Student nurses must always have their drug calculations checked by a RN.

Preparation for the administration of medications

Nurses must be familiar with both the procedure and the drugs(s) to be given in order to answer any questions the patient/client may ask about their medication and to administer it safely. It is important to explain to the patient/client how the drug works and how it is to be administered. Explanation may be either verbal, using language appropriate to the individual, and/or in writing, and must include the reason why the drug has been prescribed. Before receiving a new medicine, people may feel anxious about its administration and/or their reaction to it.

It is essential to ensure that any allergies are written in the medical/nursing notes and on the prescription sheet to ensure that people are not given drugs to which they are allergic.

There are several additional and specific precautions that must be adhered to when prescribing and administering drugs to children and also points of good practice (see Box 22.6).

Checks are carried out to ensure that the correct patient/client is given the right medication (correct dose via the right route and the correct preparation) at the right time and that the correct documentation is accurately completed afterwards. It is essential to adopt a systematic approach to ensure that medicines are administered safely (Box 22.7).

Administration of oral medications

When possible the patient/client is assisted to sit upright as this makes swallowing easier. The person should be offered a glass of water, which moistens the mouth, prevents tablets or capsules sticking to the oral or oesophageal mucosa and aids their transport to the stomach. Principles for administering oral preparations are shown in Box 22.8. Some medications should be given at specific times. For example, nystatin pastilles given to treat an oral fungal infection should be taken after food as the drug would be removed by food and drink. Nurses administering medicines should be aware of specific instructions.

Injections

Injections are considered the appropriate route of administration when:

Fig. 22.12 Administering a Z-track injection

(reproduced with permission from Downie et al 2003)

Injections can be given via the intradermal, subcutaneous, intramuscular, intravenous, intraosseous and intrathecal routes (see Table 22.3). Student nurses are normally only involved in administering injections by the subcutaneous and intramuscular routes.

The intramuscular route

Intramuscular injections are delivered into the muscles below the skin. Figure 22.9B shows the needle angle used to access the muscle layer. There are several sites that can be used for i.m. injections. The person’s general health and age are considered before deciding upon the most appropriate site. Older and emaciated people are likely to have less muscle than those who are young and active. The proposed site should be inspected for signs of swelling, inflammation, infection and skin lesions; affected areas should be avoided.

Fig. 22.9 Skin layers and needle insertion for injections: A. Subcutaneous. B. Intramuscular

(reproduced with permission from Downie et al 2003)

Deltoid muscle

The deltoid muscle is commonly used for vaccinations and for older children (Royal College of Paediatrics and Child Health 2002) (Fig. 22.10C).

Fig. 22.10 Intramuscular injection sites

(A, B, C reproduced with permission of Nicol et al 2004; D reproduced with permission from Wong et al 2001)

Fig. 22.11 Intramuscular injection technique

(reproduced with permission from Nicol et al 2004)

Dorsogluteal site

The dorsogluteal site, also known as ‘the upper outer quadrant’ of the buttock, uses the gluteus maximus muscle (Fig. 22.10A). Studies have shown that there is relatively slow uptake of medication from this site (Rodger & King 2000). This is due to the large amount of adipose tissue located there, even in mildly obese patients, and means that the medication often ends up in the adipose tissue rather than the muscle (Workman 1999, Greenway & Hainsworth 2004). The nurse must therefore choose an appropriate length of needle depending on the size of the adult. There is also a risk of damaging the sciatic nerve if the site is not carefully located.

The Royal College of Paediatrics and Child Health (2002) do not advocate this site for children, except when a large volume of fluid is to be injected.

Ventrogluteal site

The ventrogluteal site accesses the gluteus medius muscle (Fig. 22.10D). Following an extensive literature review, Beyea and Nicoll (1995) promote the use of this site as it avoids potential sciatic nerve damage and the adipose tissue in the area is of relatively consistent thickness, thus ensuring the medication is administered into the muscle tissue (Greenway 2004). Workman (1999) suggests that a standard 21G (green) needle could be used in most adults of any size due to the consistent thickness of adipose tissue over this site.

Vastus lateralis muscle

This muscle is on the outer aspect of the thigh (Fig. 22.10B) and can be used for children, including infants (Royal College of Paediatrics and Child Health 2002). However Beyea and Nicoll (1996) suggest that, after 7 months of age, the ventrogluteal site should be the site of choice.

Rectus femoris

The rectus femoris is the anterior quadriceps muscle of the thigh. This is rarely used in adults, but can be easily accessed for self-administration or for infants (Workman 1999).

Administering intramuscular injections

The principles of administering i.m. injections are shown in Box 22.10.

Box 22.10 NURSING SKILLS

Administration of intramuscular injections

Principles

• The technique is explained to the person and their agreement is sought

• Handwashing is carried out according to local policy (see Ch. 15) and gloves worn

• The injection is drawn up as outlined in Box 22.9

• Privacy is ensured and the injection site exposed

• The skin is cleaned according to local policy

• The normal needle size for adults is 21G (green) (Nicol et al 2004). Local policy may recommend the use of smaller needles (23G blue) in, for example, very thin individuals or children

• The skin is stretched or pulled apart (Fig. 22.11) using the non-dominant hand. Alternatively, the Z-track technique (Fig. 22.12) should be used

• The syringe barrel is held like a dart or pencil in the dominant hand

• The patient/client is informed and the needle inserted swiftly and firmly into the skin at an angle of 908 (see Fig. 22.11). The plunger is inserted until about only 1 cm of the needle is showing (Nicol et al 2004)

• The plunger is withdrawn slightly to check that the needle is not in a blood vessel. Nicol et al (2004) recommend that if blood is present at this stage, the needle should be withdrawn, the needle and syringe discarded and the injection drawn up again using fresh equipment

• The plunger is then firmly and steadily depressed until all the fluid has been expelled

• The syringe is quickly removed and the alcohol-impregnated wipe held firmly over the puncture site until any bleeding stops

• The syringe and unsheathed needle are disposed of immediately into the designated sharps bin (NICE 2003, NES 2004)

• The remaining equipment is discarded

• Handwashing is carried out according to local policy

• The recording sheet is signed.

The Z-track technique, formerly used exclusively for medications that stain the skin, is now widely recommended for all i.m. injections, as it is believed to reduce pain and leakage of medicine from the injection site. This technique involves gently pulling the skin and subcutaneous tissue so that it is no longer directly over the underlying muscle before carrying out the injection (Fig. 22.12) (Workman 1999). This is widely used for depot injections, commonly given to people with mental health problems.

Subcutaneous injections

These are given into the subcutaneous fat or connective tissue that lies between the muscles and the skin (see Fig. 22.9A). A short fine needle is used, e.g. 25G orange (Workman 1999). This route is suitable for drugs such as insulin that require slow and steady release. If a needle longer than 9 mm (25G orange) is used, an angle of 458 is recommended. When a shorter needle is required, e.g. for the administration of insulin, an angle of 908 is recommended (Workman 1999).

Some s.c. injections are pre-filled with the drug (such as heparin, given to prevent deep venous thrombosis), which means that there is no need to draw up the injection and therefore reduces the risk of needlestick injury. When using a shorter needle, it is not necessary to aspirate before injecting (Peragallo-Dittko 1997).

Figure 22.13 shows the sites that can be used for s.c. injections. People who require frequent s.c. injections, e.g. those with diabetes, should rotate injection sites and avoid using alcohol-impregnated wipes, which harden the skin. The principles of giving s.c. injections are shown in Box 22.11.

Fig. 22.13 Sites for subcutaneous injection

(reproduced with permission from Nicol et al 2004)

Fig. 22.14 Administration of eye medication: A. Drops. B. Ointment

(reproduced with permission from Nicol et al 2004)

Fig. 22.15 Insertion of a vaginal pessary

(reproduced with permission from Nicol et al 2004)

Box 22.11 NURSING SKILLS

Administering subcutaneous injections

Principles

• The technique is explained to the person and their agreement is sought

• Privacy is ensured by, for example, closing the cubicle door or pulling the screens

• Handwashing is carried out according to local policy (see Ch. 15) and gloves worn

• The injection is drawn up as outlined in Box 22.9

• Select a suitable site

• Skin cleansing is not usually required if the skin is clean

• The site is exposed and the skin fold pinched

• The drug is injected using the desired angle (see Fig. 22.9). For a 908 angle, the syringe is held in a ‘pencil’ grip and the needle is stabbed through the skin. For a 458 angle, the syringe is cradled across all four fingers, steadied with the thumb and, with the needle bevel uppermost, is pushed gently through the skin

• The syringe and unsheathed needle are disposed of immediately into the designated sharps bin (NICE 2003, NES 2004)

• The remaining equipment is discarded

• Handwashing is carried out according to local policy

• The recording sheet is signed.

Administration of medication into the eye

People who regularly receive eye drops or ointment may prefer to have the medication instilled either while lying down or sitting upright and their wishes should be taken into account. This may be for an eye condition (e.g. glaucoma), after eye surgery or in preparation for examination of the eye. Postoperatively it may be essential that the patient is lying down while eye drops are instilled. The patient/client is prepared to receive medication following the principles outlined on page 639. Box 22.12 lists the principles of administering eye medication.

Administration of medicines into the ear

The patient is prepared to receive medication following the principles outlined on page 639. Ear drops may be instilled (Box 22.13, p. 646) to soften earwax prior to irrigation or syringing, or to relieve inflammatory or infective conditions of the outer ear.

Administration of medication into the nose

The patient is prepared to receive medication following the principles outlined on page 639. Box 22.14 lists the principles of administering nose drops.

Rectal administration

This route is selected when:

Medication can be inserted into the rectum as suppositories and enemas (see Ch. 21). When this route is used for therapeutic drug administration (rather than for evacuation of the rectum), it must be explained that the medication should be retained, as many people associate suppositories and enemas with evacuation of the bowel. Ready access to lavatory facilities is necessary following administration of evacuant medication.

Administration of pessaries

The patient should be prepared to receive medication following the principles outlined on page 639. Box 22.15 (p. 647) provides the principles of administering a pessary into the vagina. Nurses must remember that mostwomen find insertion of anything into the vagina very embarrassing and when possible the patient/client shouldbe encouraged to do this themselves. Nystatin pessaries may be prescribed for vaginal thrush (Candida albicans).

Inhaled medication

Medications can be introduced directly into the airways for local action (e.g. bronchodilators to relieve bronchospasm, corticosteroids to reduce inflammation) in respiratory conditions such as asthma and chronic bronchitis. Action via this route is fast and high concentrations can be delivered. There are various types of inhaler devices and their use is explained in Chapter 17. These include:

Administration of topical medication

The patient should be prepared to receive medication following the principles outlined on page 639. Box 22.16 provides the principles involved in administering topical creams, ointments or lotions that are usually prescribed for skin conditions.

Transdermal patches

Transdermal patches are used to deliver medication such as hormones, opioids and nicotine replacement therapy (Fig. 22.16). In these situations topical application is used to provide systemic effects, usually for a prolonged period. The old patch is removed, the skin cleaned and a new patch is applied, usually to a different area. The skin is observed for redness, soreness and other signs of a reaction to either the drug or the adhesive. Patches are placed on non-hairy areas according to the prescription and the manufacturer’s instructions.

Fig. 22.16 Transdermal patch

(adapted with permission from Downie et al 2003)

Post-drug administration measures

After administration of any medication, the nurse must always ensure that:

The nurse must ensure that the patient/client knows:

The RN must check that:

It should be noted that if the patient has been unable to swallow medicines, this should be reported immediately to the pharmacist and prescriber. A suitable alternative may be prescribed and dispensed.

Concordance, compliance and polypharmacy

The success of any medication regimen is most likely when it is completed according to the prescription. In this section, compliance, concordance and polypharmacy are considered.

Improving compliance and concordance

Many people will require considerable support if compliance and concordance are to be achieved. Nurses must take the individual’s physical and psychological state into account when explaining, demonstrating and teaching people about medication. Relatives and carers may also become involved in education about drug treatment in, for example, children and people with a learning disability. Individuals who lack manual dexterity, e.g. due to arthritis, may require medications to be organized in a Dosette box or supplied in easy-to-open containers. For people with visual impairment large-print labels help with compliance. In Scotland, written instruction leaflets must be supplied with all medicines (Scottish Executive Health Department 2002). Overcoming the factors that may predispose to poor compliance/concordance forms the basis of enabling people to follow their drug treatment.

Dosette boxes

These contain sections for each day of the week, which are further divided to correspond with the times of day when the patient/client takes their medication, e.g. 8 am, 12 midday, 6 pm, 10 pm. Each daily column has a sliding lid that can be opened to expose only the drugs to be taken at a particular time (Fig. 22.17). Individuals, carers, pharmacists or other healthcare professionals can fill these boxes with the appropriate prescribed medications. There may, however, be a loss of efficacy if tablets are removed from blister packs and put into these boxes.

Fig. 22.17 Dosette box

Self-medication

Deeks and Byatt (2000) reported that compliance may improve if patients/clients are encouraged to self-medicate. Self-medication has long been performed in the individual’s own home and now, increasingly, patients administer their own drugs in hospital. Since the introduction of lockable medicine cabinets (see Fig. 22.1B, p. 629) at each hospital bedside, self-administration hasbeen discussed widely (Scottish Executive Health Department 2002). However, successful self-administration and ultimately compliance relies not only on nurses providing adequate education and support but also patient cooperation (Nicol et al 2004).

Box 22.17 HEALTH PROMOTION

Medication in older adults

Mary is 79 years old and was admitted to hospital in a confused state. Investigations revealed she had a chest infection. She takes regular medication for high blood pressure and arthritis and has been prescribed antibiotics for her chest infection.

Student activities

Looking at the factors that may influence a person’s concordance/compliance with their drug regimen, think about those that may apply to Mary:

1. Identify the nursing interventions that will help maximize compliance and concordance after Mary is discharged.

2. Find out from the pharmacist what aids to compliance are available in your placement.

3. Speak to some patients/clients in your placement and find out:

• How much they know about drugs they take regularly.

• The likely extent to which they comply with prescribed treatment.

• What medications they often buy for themselves in a shop or pharmacy.

Patient-centred drug administration

Many patients/clients successfully adhere to complex medication regimens at home, but in the past people almost universally gave up control of this aspect of their care when admitted to hospital. Today many clinical areas have introduced an individual-centred drug administration system where all a person’s drugs are stored locked in their bedside locker. These include their own drugs brought in on admission and/or new ones prescribed following admission.

In many clinical areas the nurse caring for a patient/client will administer their own drugs from the bedside locker according to the prescription sheet. This is a step towards complete individual-centred medicine administration where the patient/client administers their own medication from their bedside locker. One of the reasons behind this government-backed system is an effort to reduce the cost of medicines in both primary and secondary healthcare settings. Additionally, this system provides opportunities for patient education about drug treatment and assessment of people’s understanding and likely compliance after discharge.

Drug errors

Much has been done to make drug administration safe and yet errors do still sometimes occur. The extent of drug errors has been the subject of much attention from the government, hospital management, pharmacists and healthcare professionals, all of whom consider the safe administration of medicines to be an essential nursing skill.

Following studies into how errors occur, changes to drug administration policies have been made in an effort to make this as safe as possible. Student nurses are taught how to administer drugs safely in university, then supervised carrying this out in practice and later assessed as competent before gaining registration. Thereafter nurses are expected to continually update their knowledge of the drugs they administer. In spite of this, errors sometimes still occur and the consequences for a patient/client can be fatal. The consequences for nurses can result in disciplinary action, an investigation of professional misconduct, criminal charges or a civil case for negligence (see Ch. 6). Most importantly, however, being involved in drug errors significantly reduces their confidence as practitioners.