In Aged Care Management Of Medicines Nursing Guidelines
Management of Medicinesin Aged CareNursing Guidelines
Nursing Guidelines: Management of Medicines in Aged CareAuthor: Australian Nursing and Midwifery Federation (ANMF).Prepared by Julianne Bryce and Elizabeth Foley, ANMF Federal Professional OfficersISBN 978-0-909599-06-5 (Print)ISBN 978-0-909599-07-2 (Electronic) Copyright Australian Nursing and Midwifery Federation, July 2013For referencing: Australian Nursing and Midwifery Federation. Nursing Guidelines:Management of Medicines in Aged Care. Melbourne: ANMF, 2013.
IndexForeword3Background4Introduction6Rights of older people7Service provider’s responsibilities9Medicine advisory committee11Prescribing12Dispensing and supply12Management of medicine regimens13Administration13Consent13Self administration13The role of the registered and enrolled nurse14The role of the nurse practitioner17‘When required’ (PRN) medicines17Nurse initiated medicines17Standing orders18Emergency medicine instructions18Monitoring19Evaluation19Non prescription and unscheduled substances19Documentation20Dose administration aids21Compartmentalised medicine box22Storage23Disposal23Information24Quality improvement24References25Additional Resources26Glossary27
ForewordThe review of the Nursing Guidelines: Management of Medicines in AgedCare has been a collaborative project between the Australian Nursing andMidwifery Federation (ANMF) and Royal College of Nursing Australia(RCNA). Now published by the ANMF, this document aims to ensure thesafe and competent delivery of medicines to older people.The Nursing Guidelines provide support and direction for registered andenrolled nurses1 in the administration of medicines in aged care2. Theseguidelines inform providers, consumers and families, medical practitioners,pharmacists, and allied health professionals of the expectations ofregistered nurses, enrolled nurses and assistants in nursing (howevertitled), in quality use of medicines.The guidelines also establish the quality of care to which consumers ofaged care services and the community are entitled, in relation to thecompetent use of medicines by nursing professionals.A review of this document has been undertaken to ensure currency andrelevance to both aged care and to nursing practice.While this edition is primarily focused on care provided in residential agedcare settings, it is also applicable to aged care services provided in thecommunity.Lee ThomasFederal SecretaryAustralian Nursing and Midwifery Federation1Enrolled nurses have completed the education to allow them toadminister medicines. Those who are not educated to this level willhave a condition on their registration which prohibits them fromadministering medicines.2Aged care settings include residential facilities and the communitysetting.3Nursing Guidelines: Management of Medicines in Aged Care
BackgroundSafe, quality care, reinforced by accreditation and funding requirementsfor aged care facilities, demands a safe medicines delivery system. Asstated in previous editions of these Nursing Guidelines (APAC, 2002),registered or enrolled nurses, in consultation with medical practitionersand pharmacists, are the appropriate professionals to administermedicines to older people who are unable to self-administer theirmedicines. Management of medicines by appropriately qualified healthprofessionals gives greater assurance of quality use of medicines.Registered nurses are educated to be aware of the benefits and potentialhazards in the use of medicines and to administer medicines safely andlegally, as well as to monitor their efficacy and identify any adverse effects.Additionally, registered nurses have the necessary skills to assess thechanging needs of the older person and their care; evaluate the person'sresponse to medicines; and accurately communicate that information. Inthis way, registered nurses provide a vital link between the older personand other health professionals such as medical practitioners, pharmacists,enrolled nurses and allied health professionals.Enrolled nurses work under the direction and supervision of registerednurses and practice within legislative and regulatory requirements. Underthe Health Practitioner Regulation National Law Act 2009 (the NationalLaw), all enrolled nurses may administer medicines except for those whohave a notation on the register against their name which reads ‘Does nothold Board-approved qualification in administration of medicines’ (NMBA,2010). Employers and facility staff need to be aware of national legislationand state and territory drugs and poisons legislation relating to enrollednurses and medicines administration, as well as professional scopes ofpractice.The role of assistants in nursing (however titled) in medicines use is thatof assisting older people with self-administering their medicines from prepackaged dose administration aids. They should not be directed byemployers or facility staff to practice outside of this role.Nursing Guidelines: Management of Medicines in Aged Care4
The following practices pose risks to quality use of medicines: polypharmacy and the excessive use of tranquillisers andpsychotropic agents; lack of processes for medicines review; and the administration of medicines by unqualified or inappropriatelyqualified staff.Registered and enrolled nurses are increasingly concerned that in somecircumstances assistants in nursing (however titled) and other unqualifiedor inappropriately qualified care workers are being directed to administermedicines to residents in aged care facilities.While unqualified or inappropriately qualified care workers can be madeaware of correct procedure for medicines delivery, they do not have thenecessary education and knowledge required for making clinicaljudgements on why they are administering a medicine or when not toadminister. It is for this reason that medicines administration by unqualifiedor inappropriately qualified staff has the potential for error and possibledire consequences. Without the necessary education, staff will be unableto identify side effects or adverse reactions requiring intervention.Adequate resources should be made available by both governments andservice providers of aged care to ensure medicines are able to beadministered safely and within legislative requirements.5Nursing Guidelines: Management of Medicines in Aged Care
1.IntroductionWhile medicines make a significant contribution to the treatment of illhealth, the prevention of disease, increasing life expectancy andimproving health outcomes, they also have the potential to cause harm.The quality use of medicines requires that the appropriate medicine isprescribed; that it is available at a price the individual can afford; and thatit is prescribed, dispensed and administered correctly. The goal of anymedicines service for older people is to promote quality of life.Age-related changes in physiology affect the manner in which the bodyresponds to and metabolises medicines. In addition to pharmacokineticchanges that occur as a result of normal healthy ageing, the effects ofpathology must also be considered. A significant number of older peoplesuffer from more than one chronic illness. The concurrent use of multiplemedicines (or polypharmacy) occurs due to co-morbid chronic diseaseprocesses and is characterised by complex medicine regimens which canhave equally complex interactive patterns. This makes evaluation ofadverse drug reactions difficult, particularly as the incidence of thesereactions increases with age.Polypharmacy also increases the risk of adverse medicines events suchas falls, confusion and functional decline. Older people are more likely toexperience poor vision, hearing and memory loss and have alteredmetabolic rates, such as declining renal function. Changes in physiology,as well as to social and physical circumstances, can also contribute to therisk of adverse medicines events in older people. However, adversereactions may go undetected because symptoms may be similar toproblems associated with older age such as forgetfulness, weakness ortremor. Adverse reactions may also be misinterpreted as a medicalcondition and lead to the prescription of additional medicines.These altered pharmacokinetic and pharmacodynamic changesassociated with age and polypharmacy in older people require the specificpharmacological knowledge and skills of medical practitioners,pharmacists, registered nurses and enrolled nurses. The following arebest practice guidelines for registered nurses and enrolled nurses inmedicines management in aged care and are regarded as minimumstandards for safe care and competent practice.Nursing Guidelines: Management of Medicines in Aged Care6
The overriding principles on which these best practice guidelines arebased are as follows:a) all persons receiving aged care services have the right to quality useof medicines;b) medicines have the potential for harm if not prescribed, dispensedand administered correctly;c) the right medicine in the right dose must be administered to the rightperson at the right time by the right route;d) all medicines administration should be documented;e) the person administering the medicine/s must know when and howto administer the medicine/s, why to administer, and when not toadminister; andf) the person administering the medicine/s must be able to recogniseadverse effects and respond appropriately, including reporting anyadverse effects to the registered nurse or prescribing practitioner.2.Rights of older people2.1Every person receiving aged care services is entitled to quality useof medicines through:a)ongoing assessment by a health professional who is qualified toassess the physical, mental and socio-emotional status of theperson and the ways in which medicines may affect them;b)care from a health professional who is able to exercise clinicaljudgement with regard to medicines, integrating physical, mentaland behavioural assessment with relevant contextual variables;c)care by a health professional who is competent to act alone withregard to medicines in a situation where medical advice is notavailable;d)care by a health professional who is able to collaborate with theperson prescribing medicines (the prescribing practitioner)regarding the appropriateness of medicines in response to theolder person's changing physical, mental and behavioural needs;e)care by a health professional who is skilled and experienced incommunicating with the older person, their families and otherhealth personnel with regard to medicines;7Nursing Guidelines: Management of Medicines in Aged Care
f)care by a health professional who is skilled and experienced inteaching and assisting the older person and their families to usemedicines in a way which enhances quality of life, and promotesthe safe use of medicines; andg)care by a health professional who recognises the dynamic natureof the older person's health status and is constantly evaluating theneed for a response to any health status change.2.2Recipients of aged care services have a right to:a)consent, or refuse consent, to a medicine;b)management of medicines by appropriately qualified healthprofessionals;c)manage their own medicines regimen where possible;d)regular review of their medicines regimen by appropriately qualifiedhealth professionals;e)confidentiality in relation to their medicines regimen;f)a medicines storage system which maintains their privacy as wellas the efficacy and security of their medicines;g)education, counselling and advocacy in relation to their medicine/suse;h)the administration of medicines by appropriately qualified registerednurses and enrolled nurses in a manner which maintains personaldignity and safety;i)know which pharmacist is dispensing their medicines; andj)nominate their preferred pharmacist.2.3All older people have a right to a medicines regimen that ischaracterised by regular reviews and re-issuing of their medicinesinstructions by their treating and prescribing practitioner. Regularreviews should address issues of polypharmacy. It is the prescribingpractitioner's responsibility to ensure that such reviews andinstructions are attended at regular intervals or in accordance withstate or territory legislative or regulatory requirements.Nursing Guidelines: Management of Medicines in Aged Care8
3.Service provider’s responsibilities3.1Aged care service providers have a responsibility to ensure qualityuse of medicines by:a)employing registered nurses and appropriately qualified enrollednurses to safely undertake the management, administration and(where appropriate) review of medicines;b)providing resources to enable the medicines and the medicineschart to be available at the time and place of administration of themedicines. This may include use of the National ResidentialMedication Chart (NRMC)1 and the National Interim ResidentialMedication Administration Chart (NIRMAC)2 where these arelegally permissible in the state or territory;c)providing current medicines information (for example, on-linemedicines information), which includes the name of each medicine,the schedule, the reason for its use in particular circumstances, theexpected outcomes, contraindications for use, and possible sideeffects;d)providing staff with current information and education on relevantdrugs and poisons legislation and regulation;e)providing registered nurses and appropriately qualified enrollednurses with regular education regarding current trends in the use ofmedicines for older people and in specific age related healthconditions;f)providing a system for documentation of all medicinesadministration and medicines incidents where errors are accuratelyreported, assessed, and remedial action taken in a timely manner;andg)providing a system of safe storage for all medicines, includingthose being self-administered by older people in residential agedcare settings, which complies with relevant legislation er/pbs/fifth-agreement/supplyand pbs ing Guidelines: Management of Medicines in Aged Care
3.2Aged care service providers have a responsibility to ensure thereare written policies and protocols, which reflect relevant legislativeand regulatory requirements and which include:a)the specific responsibilities of each health professional involved inmedicines management, including the provision of information,prescribing, dispensing, administration, storage, disposal, andevaluation;b)an acknowledgment of the arrangement of medicines intoschedules, by clearly stating the organisation's policy, consistentwith relevant legislation for each applicable division of theschedule, with particular and separate requirements for drugs ofaddiction and other restricted substances;c)the specific requirements for the different routes of medicinesadministration;d)the mechanism by which each older person can be correctlyidentified (for example, names or photographs); ande)the mechanism by which medicines and medicines charts canaccompany older people throughout the continuum of their careacross a range of settings: if they are discharged from acute care;if they are receiving care in a community setting; if they aretransferred to another facility, including a hospital; or if they areusually in residential care but are absent from the facility for anyreason. This could be achieved by use of the National InterimResidential Care Medication Administration Chart (NIRMAC) wherethis is legally permissible in the state or territory.3.3Aged care service providers have a responsibility to providemedicines charts which contain:a)the older person's identifying information;b)a record of allergies or medicines sensitivities;c)the consent of the older person or their representatives to theirmedicines regimen (where possible);d)the name, strength, dose, route and frequency of the medicine/s;e)the date of commencement of a medicine/s and duration whereapplicable;Nursing Guidelines: Management of Medicines in Aged Care10
f)an identified space for the signature of the prescribing practitioner(unless using the NIRMAC where this is permissible in the state orterritory; andg)the date of the medicines review.4.Medicine advisory committee4.1Each aged care service should have a medicines advisorycommittee, whose objectives are to develop, promote, monitor andevaluate activities which support quality use of medicines.Such a committee should include: a nurse practitioner (where available); registered nurses - more than one position whenever possible (forexample, Director of Nursing, Clinical Nurse Consultant, registerednurse) due to the extensive role they play in medicinesadministration; a medical practitioner; a pharmacist; a representative of the aged care provider; and, 4.2a consumer representative/s.The responsibilities of the medicines advisory committee shouldinclude:a)promotion and support of intra and interdisciplinary communication,collaboration and co-operation;b)development and review of medicines policies and protocols;c)development and review of a list of medicines, includingunscheduled substances, able to be initiated by registerednurses;d)maintenance of a register of incidents or errors related tomedicines to enable analysis on trends and action taken;e)monitoring of compliance to medicines policies and protocols;f)monitoring of compliance to the review of older person's medicinesregimens;g)the review of medicines usage generally within the facility;11Nursing Guidelines: Management of Medicines in Aged Care
h)provision of advice on the implementation of national policies andrelevant legislation and regulation;i)implementing and overseeing education programs related to qualityuse of medicines; andj)implementing and overseeing medicines quality improvementactivities.4.35.All activities of the committee must comply with requirements of thePrivacy Act 2001 and the privacy principles outlined in the Act.Prescribing5.1Medicines should not be administered without a legible, signed anddated instruction from the prescribing practitioner, including: anurse practitioner; medical practitioner; or dental practitioner, in theaged care service's designated medicines chart (this includesprescribing by electronic means).Such instructions include:a)full name of the older person;b)name and strength of the medicine/s;c)dose, route and frequency of the medicine/s; andd)date of commencement and duration where applicable.5.26.The National Interim Residential Care Medication AdministrationChart may be used where this is permissible in the state orterritory.Dispensing and supply6.1Each aged care service should have access to a communitypharmacist who can provide a medicines service, which includes:a)the dispensing and supply of medicines;b)the provision of information and advice;c)involvement in medicines education for the older person, healthprofessionals and staff;d)involvement in the medicines advisory committee; ande)involvement in relevant quality improvement activities.Nursing Guidelines: Management of Medicines in Aged Care12
7.7.1Management of medicine regimensAdministrationThe registered nurse is the appropriate person to manage themedicines regimen for the older person receiving aged careservices and is key to quality use of medicines in aged care.Registered nurses are educated and competent to understand thetherapeutic action of medicines, including the reason for their use,the effects of their use and to recognise adverse reactions andrespond appropriately. Registered nurses use clinical judgement toassess whether medicines should be administered or withheld withregard to the consumer’s health and family history, diagnosis,co-morbidities and health status. Under the supervision ofregistered nurses, enrolled nurses also administer medicinesunless there is a notation on their reg
Nursing Guidelines: Management of Medicines in Aged Care 6 1. Introduction While medicines make a significant contribution to the treatment of ill health, the prevention of disease, increasing life expectancy and improving health outcomes, they also have the potential to cause harm. The quality
Indirect employment in aged care 3 Contents 1. About this study 4 Defining key concepts and the study's scope 8 2. Current employment arrangements in aged care 12 The aged care workforce: an overview 12 Indirect employment in aged care 15 Regulation of indirect employment in aged care 19 3. Impacts of indirect employment in aged care 22
3.1 Population ageing 14 3.2 The need for care 15 3.3 Aged care provision 16 3.4 Aged care workforce needs 17 3.5 Care quality 19 3.6 Government funding 20 4 A package of reform for high quality care 22 4.1 Reforms considered 22 4.2 Projected care recipients 26 4.3 Aged care workforce requirements 27 4.4 Education and training 30
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