Medicines - Administering & Handling

• Only a Doctor, Midwife or some Nurses may prescribe an individual a Medicine.

• Pharmacists may sell an individual certain restricted medicines - read more about Medicine Regulations.

• Anyone can legally administer a Prescription Only Medication to another person, so long as it is in accordance with the directions of the prescriber.

In some situations a reasonable adult may be in a position where they take responsibility to handling or administering a medication, usually under the direct or indirect guidance of a Medical Director - a named Doctor who is employed to oversee medical aspects of the company or organisation.  If you are in this position it is important that you have seen and signed the protocols and know the names of the Medical Directors as they will ultimately take responsibility for your actions.  For example:

• Working in remote environment, far from definitive care a 'medic' may operate within written protocols to administer medicines in certain circumstances.

• On expedition a medic or team leader may also have responsibility for handling or administering medicines.

• In the care setting, teachers and carers routinely handle or administer medicines.

  NICE Guidance - Managing Medications in Care Homes.

Written protocols are called "Off-Line" protocols.  These only change under periodic review by the medical director.   Within these protocols a named person (or persons) may be able to administer a specific medication for a specific condition in specified situations.

On expedition or in remote environment tele-medicine may be available; the ability to communicate directly with a Doctor who may instruct the individual to administer a particular medicine.  These ad-hoc instructions are called "On-Line" Protocols

The 5 Rights of Administration:

The "5 Rights" of administering Medication ensure that the right person receives the right drug in the right dose by the right route at the right time .

The Right Person.

In urban care or school setting an individual may be responsible for the handling of medications for several patients; ordering repeat prescriptions, picking up or taking delivery of prescriptions.  In this first stage of handling the medicine it is imperative that the right medicines get to the right people.

The prescription should hold all of the important information needed to facilitate this, therefore it should be checked accordingly.

Prescriptions should contain:

• The patients name

• The patients date of birth or age if under 12

• The generic drug name (i.e. ibuprofen rather than Nurofen), its form, strength, dose and quantity to supply.

• The Doctors signature & stamp

• Special Instructions

The Right Drug

On receipt of the medicine the pharmacy label should tally exactly with the prescription exactly.   Pharmacy labels should carry the following information:

• Name of prescribee

• Drug; name, form, strength, dose and quantity

• Special instructions

• The name and address of the pharmacy.

Medicines are known by both their generic names (e.g. ibruprofen) and their trade name (e.g. Nurofen).  It is important to know them both.   Prescriptions will refer to the generic name but the medicine may come packaged and branded as the trade name.  If in any doubt - ASK. 

In a remote environment where permission to administer controlled medicines occur without a written prescription, the drug, form and strength should be confirmed from the original packaging of the drug.   It is illegal to repackage drugs - for transport or reducing quantities for example - to ensure that the drugs remain with their original information.

In these environments the medic or team leader will have access to a very limited selection of medicines and the casualty should be obvious.  There should, theoretically, be less margin for errors!

The Right Dose

How much medicine will you be administering?   Fluids are usually measured in ml but tablets may be in mcg or mg.

If you have been asked to administer 1000mg or paracetamol you must know whether the tablets you have available are 1000mg each or 500mg each.

The Right Route

Let's say you have been asked to help a casualty take one sublingual nitroglycerin tablet.  They do not have any left but they do have another bottle of nitroglycerin capsules; these are to be swallowed four times a day.  The drug is the same and the dosage may be the same but the route is different so you cannot just swap one for another.

Drugs can be administered in several forms; each form having a particular benefit or potential issue.   The form of administration is usually dictated by either the speed of administration, the convenience, the skill level of the person who is available to administer or a combination.

Tablets, capsules and caplets - Per Oral

In many ways the easiest to manage as they come in a predetermined strengths.  The issue here is know which strength you are administering.   A lay person will commonly come across 200mg tablets or capsules of ibuprofen which are freely available and will routinely take two for mild to moderate pain relief.   If the ibuprofen available to you in the medical kit is 400mg strength only one should be given.

As a rule, tablets should not be crushed nor capsules split open.  There are two reasons for this; if it is being done to secrete the medicine in the casualties food this in itself could be illegal if the casualty is not aware or would not consent if they had the capacity to do so.  Another reason is that drugs are deigned to release the active ingredient over a particular period of time or in a particular part of the digestive system, not always the stomach.  If the tables are broken (especially enteric coated tablets) or the capsules opened, they active ingredient may be released too fast or in the wrong phase of the digestive system.  Either of these scenarios may render the drug completely ineffective or cause serious complications.

Tablets and capsules are one of the most convenient medicines to administer but only if the casualty is conscious and able.  Tablets are one of the slowest release methods.

Liquids - Per Oral

These medicines could be in the form of syrups, solutions, suspensions or emulsions.  The last two forms or not pure solutions so need to be shaken to ensure that the dose (and all subsequent doses remaining in the bottle) are delivered in the right quantity.  Suspensions include paracetemol suspensions where the particulate paracetemol is carried in a sugary base.  Emulsions are increasingly rare; a liquid medicine is diluted or carried in a oil base.  Calamine lotion is one of the few examples still in use.  If either of these are left to settle the top of the bottle will not contain enough of the drug and the bottom will contain too much.

When dispensing the required measurement, a small syringe is more accurate (especially if dispensing small volumes) than a measuring spoon or cup.  A syringe may be more convenient for the patient to take.

Topical Medicine - Transcutaneous

Topical medicines are applied to the skin or mucus membrane to deliver the drug to a local area rather than affecting the body systemically.  They can include:

• Creams, gels (water based) & ointments (oil based).

• Eye or ear drops

• Inhalers

• Suppositories

• Enemas

• Vaginal preparations

Topical medicines can be applied by he patient or (usually only in the first two instances) by someone else.  Inhalers cannot effectively be administered by someone else and rectal or vaginal medicines should not be administered without appropriate training.

Record the date when creams and ointments are opened.  As a rule of thumb the use by dates are:

• Jars: One month after opening

• Tubes: Three months after opening

• Drops: 4 weeks after opening.

If applying a cream it is important to where gloves as you will otherwise be administering some of the drug to yourself through your own skin.  This may seem trivial but aside from the wearing of gloves being good practice when treating casualties, but bear in mind repeated exposure over a period of time or exposure to a mixture of medications if this becomes a routine aspect of your role.

When administering eye drops, wait for 30 seconds between each drop for as much of the solution to absorb as possible otherwise most will 'flood' out of the eye.  If administering two different types of eye or ear drops, wait for 30 minutes between each administration.

Parenteral medicines

Commonly grouped as injections are a route of medicine that avoids the digestive system.   Injections require training and training in itself does not license someone to administer! 

• Subcutaneous - a bolus (a small concentrated dose delivered by syringe) just under the skin e.g. Insulin

• Intravenous - sometimes as a bolus but usually delivered as a dilution of fluids over a period of time.

• Intramuscular - usually delivered in the deltoid or vastus lateralis (upper outer aspect of the thigh) e.g. Adrenaline by auto-injector.

• Intraarticular - a means to administer anti-inflammatory drugs to treat injury or illness, such as rheumatoid arthritis.

• Depot Injections - deep muscle injection sites for sustained slow release e.g. a contraceptive injection may last 3 months.

The Right Time

When the medicine is administered may depend on the lifespan of the drug or the daily routine of the patient.   Common instructions include:

• 1 o.d. = One tablet daily

• 1 b.d. = One table twice daily (12 hours apart)

• 1 t.d.s = One three times daily (8 hours apart)

• 1 q.d.s = One 4 times daily (6 hours apart). There is usually no need to wake patients so medicines should be spread evenly throughout the waking day.

• 1 o.m. or 1 mane = one to be taken in the morning

• 1 o.n. or 1 nocte = one to be taken at night

• 1 p.r.n = one to be taken when required

• a.c. = before food

• c.c. = with food

• p.c. = after food

• m.d.u. = as directed

Some medicines will also come with specific instruction, for example;  "swallow whole do not chew" or "Apply sparingly"

Administering medicine

Having checked the medicine against the prescription or - in the case of On-Line medicine - having recorded the instructions and repeated them back to the authorising doctor:

1. Wash your hands

2. Take the medicine to the patient

3. Make sure the patient is in a comfortable position to take the medicine or have it applied.

4. Tell them you have their medicine and what it is.

5. Offer a drink (if in line with directions).

6. Record what you have done using the 5 Rights as a prompt- If it is not recorded it didn't happen.

7. Record the casualty's condition before and after. Did they improve? Were there any side effects?

How do I manage On-Line instructions?

Verbal instructions should be recorded immediately.  Write down all of the details (remember the 5 Rights as a prompt) and repeat back to the doctor for confirmation.

What do you do if the medicine is spoilt / spat out / lost / vomited?

In the case of tablets, use the next tablet in the blister pack and record.  For long-term medication ask for a repeat prescription plus one extra dose.

What do I do if I give the wrong medicine?

Record the medicine that was given and contact Team Leader / Manager / Medical Director.   Contact the pharmacy to arrange correct prescription.  Seek medical advice from Medical Director, GP or Pharmacy. 

Do not pretend it did not happen.  Reflect on what happened, possible reasons and what you could do to prevent it happening again.

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