The draft NMC code details nurses’ responsibilities when prescribing, dispensing and administering medicines. Katie Osborne reports
Making drugs safe
SUMMARY
The focus on patient safety in the health service has, arguably, never been as intense as it is now. In the wake of major care scandals, health secretary Jeremy Hunt has embarked on an improvement programme that aims to make the NHS ‘the safest healthcare system in the world’. The Nursing and Midwifery Council (NMC) has also taken action by overhauling its code of conduct so that nurses and midwives know, in unprecedented detail, the standards of conduct, performance and ethics that are expected of them. A notable addition to the draft code, which is out to consultation until August 11, is a section on prescribing and medicines management (see box). It says registrants should only prescribe, dispense or administer medicines within the limits of their training or competence, and only when they have adequate knowledge of a patient’s health. The current Code has no specific section on prescribing or medicines management, although the NMC does publish guidance in this area. More than 60,000 medication incidents were reported to the National Reporting and Learning System by acute
hospitals in England between April and September last year. The need to reduce errors is not in doubt, but RCN head of policy Howard Catton is concerned that the changes to the code could increase the tendency to target individuals and miss the bigger picture. ‘The NMC knows that medicines management, which is a core part of a nurse’s role, is a high-risk area in terms of errors occurring,’ he says. ‘But 95 per cent of healthcare errors are the result of system failures such as a lack of resources, staffing problems and funding issues.
MOST HEALTHCARE ERRORS ARE THE RESULT OF SYSTEM FAILURES – Howard Catton ‘It is absolutely legitimate to remind people of their responsibilities. However, it must not become a punitive measure that causes nurses to become fearful of being blamed individually and therefore less likely to be open and acknowledge when an error has occurred.’
Mathematical competency
The draft NMC code warns nurses and midwives not to exceed the limits of their competence when prescribing, dispensing and administering medicines. The code reinforces individuals’ responsibilities in this area, but reducing the toll of medication errors also requires progress in error reporting and system failures.
The NMC does not hold figures on the number of nurses and midwives who have been reported to it as a result of medication issues, but a spokesperson says: ‘Anecdotally, we frequently see fitness to practise cases with an element of medicines management or prescribing issues.’ The National Patient Safety Association (NPSA) reports
that errors involving incorrect dosage, strength or frequency of medication account for 28.2 per cent of all reported errors. Poor mathematical competency is an important cause of medication administration errors by nurses. Tenfold overdoses in neonatal departments, with fatal consequences, have been documented. Poor adherence to protocol has also been highlighted. The NMC’s current guidance states that nurses must follow the ‘five rights’ of safe medication administration – right patient, right time, right dose, right route, right documentation. According to NPSA reports, a basic part of protocol – checking patients’ identities on their hospital wristbands – is often neglected. But can the code improve practice on the front line? As Mr Catton indicates, research suggests that system failings, creating time pressures on overworked nurses and competing demands on their attention, are important factors in medication errors. There is also anecdotal evidence. One nurse, commenting on the draft code on Nursing Standard’s Facebook page, says: ‘You get roared at by bed managers if you tell them you cannot take a handover because you are on a drug round; yet if you stop and make a mistake the first thing they say is you should have refused to be interrupted.’ Birmingham City University visiting professor of prescribing and medicines management Matt Griffiths advocates a move
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CHARLES MILLIGAN
tests for all nurses who prescribe or administer drugs. The trust’s course includes three hour-long taught sessions followed by three 15-minute written competency tests on prescribing, administration and controlled drugs. Nurses who fail have to resit the tests until they pass. Director of pharmacy Karen Thomas, who runs the courses, says it is vital that nurses receive this type of training – freeing up nurses’ time to go on the courses can potentially saves lives. ‘It has resulted in nurses being more open in reporting incidents and near misses,’ she says. ‘We are then able to adapt the courses to take account of emerging trends.’
Existing skills
The draft NMC code: prescribing and medicines management You must only prescribe, dispense and administer medicines within the limits of your training and competence, the law, our guidance and that of your employer and other regulations. In delivering care you must prescribe medicines and treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and you are satisfied that the medicines or treatment serve the patient’s needs. In delivering care you must check that the care or treatment you prescribe for each patient is compatible with any other care the patient is receiving, including (where possible) self-prescribed, over-the-counter medicines. You must comply with appropriate guidance when recording the prescribing, dispensing or administration of controlled drugs. away from a blame culture that focuses on individuals to an approach whereby whole organisations take responsibility. Although he welcomes the draft code’s additions, he insists there is no substitute for watertight reporting. ‘One of the most important ways to reduce the number of errors is to ensure that every single one is reported. It is well known that organisations which ensure they have efficient reporting systems are better organisations overall because they introduce education and training in response to findings.’ Professor Griffiths adds that the number of officially reported medication errors is ‘just the
tip of the iceberg’ and probably accounts for less than 10 per cent of the actual number. NHS England, which has overall responsibility for patient safety, has confirmed that by September 19 every trust and large healthcare organisation should have a medication safety officer in place. This will enable data to be collected and disseminated from a central point so national lessons can be learned from local mistakes. There are some impressive examples of local initiatives. At Mid Cheshire Hospitals NHS Foundation Trust, for example, medicines errors fell by more than 10 per cent following the introduction of training and
There are currently 67,000 nurse prescribers in the UK, making up about 10 per cent of the nursing workforce. Investing in more nurse prescribers would be a cost-effective way to ease the effects of the current shortage of doctors and potentially reduce medication errors, argues University of Surrey professor of clinical practice Molly Courtenay. Professor Courtenay points out that there is no evidence that increasing nurse prescribing powers is unsafe. ‘If you take the example of a nurse prescriber in a GP practice, they see the patient, provide the care, assess, diagnose and write the prescriptions all in one go. In the past they would have to wait for a doctor, who had not even seen the patient, to sign off the prescription.’ She adds: ‘Nurse prescribers are highly trained so we should be using those skills far more, rather than talking about training more doctors’ NS Join the consultation on the draft code, open until August 11, at www.nmc-uk.org/code-survey For more on the proposed revalidation process, which is underpinned by the new code, go to www.revalidation.zone Last in this series on the NMC Code, August 6: social media
NURSING STANDARD july 30 vol 28 48 :: permission. 2014 25 Downloaded from RCNi.com by ${individualUser.displayName} on Nov 23, 2015. For personal use only. No ::other usesno without Copyright © 2015 RCNi Ltd. All rights reserved.
Making drugs safe
SUMMARY
The focus on patient safety in the health service has, arguably, never been as intense as it is now. In the wake of major care scandals, health secretary Jeremy Hunt has embarked on an improvement programme that aims to make the NHS ‘the safest healthcare system in the world’. The Nursing and Midwifery Council (NMC) has also taken action by overhauling its code of conduct so that nurses and midwives know, in unprecedented detail, the standards of conduct, performance and ethics that are expected of them. A notable addition to the draft code, which is out to consultation until August 11, is a section on prescribing and medicines management (see box). It says registrants should only prescribe, dispense or administer medicines within the limits of their training or competence, and only when they have adequate knowledge of a patient’s health. The current Code has no specific section on prescribing or medicines management, although the NMC does publish guidance in this area. More than 60,000 medication incidents were reported to the National Reporting and Learning System by acute
hospitals in England between April and September last year. The need to reduce errors is not in doubt, but RCN head of policy Howard Catton is concerned that the changes to the code could increase the tendency to target individuals and miss the bigger picture. ‘The NMC knows that medicines management, which is a core part of a nurse’s role, is a high-risk area in terms of errors occurring,’ he says. ‘But 95 per cent of healthcare errors are the result of system failures such as a lack of resources, staffing problems and funding issues.
MOST HEALTHCARE ERRORS ARE THE RESULT OF SYSTEM FAILURES – Howard Catton ‘It is absolutely legitimate to remind people of their responsibilities. However, it must not become a punitive measure that causes nurses to become fearful of being blamed individually and therefore less likely to be open and acknowledge when an error has occurred.’
Mathematical competency
The draft NMC code warns nurses and midwives not to exceed the limits of their competence when prescribing, dispensing and administering medicines. The code reinforces individuals’ responsibilities in this area, but reducing the toll of medication errors also requires progress in error reporting and system failures.
The NMC does not hold figures on the number of nurses and midwives who have been reported to it as a result of medication issues, but a spokesperson says: ‘Anecdotally, we frequently see fitness to practise cases with an element of medicines management or prescribing issues.’ The National Patient Safety Association (NPSA) reports
that errors involving incorrect dosage, strength or frequency of medication account for 28.2 per cent of all reported errors. Poor mathematical competency is an important cause of medication administration errors by nurses. Tenfold overdoses in neonatal departments, with fatal consequences, have been documented. Poor adherence to protocol has also been highlighted. The NMC’s current guidance states that nurses must follow the ‘five rights’ of safe medication administration – right patient, right time, right dose, right route, right documentation. According to NPSA reports, a basic part of protocol – checking patients’ identities on their hospital wristbands – is often neglected. But can the code improve practice on the front line? As Mr Catton indicates, research suggests that system failings, creating time pressures on overworked nurses and competing demands on their attention, are important factors in medication errors. There is also anecdotal evidence. One nurse, commenting on the draft code on Nursing Standard’s Facebook page, says: ‘You get roared at by bed managers if you tell them you cannot take a handover because you are on a drug round; yet if you stop and make a mistake the first thing they say is you should have refused to be interrupted.’ Birmingham City University visiting professor of prescribing and medicines management Matt Griffiths advocates a move
24 july 30 :: vol from 28 no 48 :: 2014 STANDARD Downloaded RCNi.com by ${individualUser.displayName} on Nov 23, 2015. For personal use only. NoNURSING other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CHARLES MILLIGAN
tests for all nurses who prescribe or administer drugs. The trust’s course includes three hour-long taught sessions followed by three 15-minute written competency tests on prescribing, administration and controlled drugs. Nurses who fail have to resit the tests until they pass. Director of pharmacy Karen Thomas, who runs the courses, says it is vital that nurses receive this type of training – freeing up nurses’ time to go on the courses can potentially saves lives. ‘It has resulted in nurses being more open in reporting incidents and near misses,’ she says. ‘We are then able to adapt the courses to take account of emerging trends.’
Existing skills
The draft NMC code: prescribing and medicines management You must only prescribe, dispense and administer medicines within the limits of your training and competence, the law, our guidance and that of your employer and other regulations. In delivering care you must prescribe medicines and treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and you are satisfied that the medicines or treatment serve the patient’s needs. In delivering care you must check that the care or treatment you prescribe for each patient is compatible with any other care the patient is receiving, including (where possible) self-prescribed, over-the-counter medicines. You must comply with appropriate guidance when recording the prescribing, dispensing or administration of controlled drugs. away from a blame culture that focuses on individuals to an approach whereby whole organisations take responsibility. Although he welcomes the draft code’s additions, he insists there is no substitute for watertight reporting. ‘One of the most important ways to reduce the number of errors is to ensure that every single one is reported. It is well known that organisations which ensure they have efficient reporting systems are better organisations overall because they introduce education and training in response to findings.’ Professor Griffiths adds that the number of officially reported medication errors is ‘just the
tip of the iceberg’ and probably accounts for less than 10 per cent of the actual number. NHS England, which has overall responsibility for patient safety, has confirmed that by September 19 every trust and large healthcare organisation should have a medication safety officer in place. This will enable data to be collected and disseminated from a central point so national lessons can be learned from local mistakes. There are some impressive examples of local initiatives. At Mid Cheshire Hospitals NHS Foundation Trust, for example, medicines errors fell by more than 10 per cent following the introduction of training and
There are currently 67,000 nurse prescribers in the UK, making up about 10 per cent of the nursing workforce. Investing in more nurse prescribers would be a cost-effective way to ease the effects of the current shortage of doctors and potentially reduce medication errors, argues University of Surrey professor of clinical practice Molly Courtenay. Professor Courtenay points out that there is no evidence that increasing nurse prescribing powers is unsafe. ‘If you take the example of a nurse prescriber in a GP practice, they see the patient, provide the care, assess, diagnose and write the prescriptions all in one go. In the past they would have to wait for a doctor, who had not even seen the patient, to sign off the prescription.’ She adds: ‘Nurse prescribers are highly trained so we should be using those skills far more, rather than talking about training more doctors’ NS Join the consultation on the draft code, open until August 11, at www.nmc-uk.org/code-survey For more on the proposed revalidation process, which is underpinned by the new code, go to www.revalidation.zone Last in this series on the NMC Code, August 6: social media
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