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In 2003 An Bord Altranais introduced a Scope of Practice column in the An Bord Altranais Newsletter to respond to queries from nurses and midwives with regard to their scope of practice. Many of these queries are related to medication management topics, some of which are reproduced below.

If you would like an issue to be addressed in future columns, please e-mail education@nursingboard.ie or telephone and speak to one of the Education Officers.

Previous editions of the An Bord Altranais newsletter published quarterly is another source for queries relating to other Scope of Practice questions (click here). An Bord Altranais will continue to offer assistance to nurses and midwives who wish to discuss their queries privately.

 
Use of Medication Administration Compliance Aids

I work as a registered general nurse in the community. One of my roles involves supporting patients at home with self-administration of medication. Sometimes I encourage particular clients to use a dosette box to help them organise their medications for the week. On some occasions I have had to take this task on for clients who may not be capable of filling the box themselves. Although I want to be able to help the client with their medication needs I am concerned about taking on this responsibility. What should I be aware of for safe and appropriate practice?

Many individuals in the community or homecare setting may use a medication administration aid to assist them in organizing and taking their medications. There are various terms to describe this type of system (e.g. compliance aids, dosette boxes, monitored dosage systems). In addition there are a number of products marketed for this purpose. Compliance aids are designed to aid self-administration by patients/service-users.

The client’s individual requirements should be assessed to ensure there are no contraindications related to using the compliance aid. Consultation with the client’s pharmacist and general practitioner should be considered for guidance if supplying medicines in this manner and in assessing the need for using such a system. Systems for evaluation of the appropriateness of the compliance aid should be documented in local policy, based upon the client’s Condition and the client's Prescribed medications.

You must be aware of the decision-making associated with using such a system, having regard to the medication prescribed and the ability of the client to use the system. Optimally, the compliance aid should be filled by the pharmacist. Refer to Unit 3 Medication Management Cycle for additional information about compliance aids.

Am I "Covered"?

I work as nurse practice development coordinator in a regional hospital. Part of my role involves supporting nurses in their practice settings as nursing procedures and responsibilities are being expanded and introduced as part of health service reform initiatives. I am frequently asked by the nursing staff if they are “covered” to undertake these responsibilities. I respond to them by referencing the An Bord Altranais Scope of Nursing and Midwifery Practice Framework and discuss the decision-making framework. However I want to be sure I am comprehensive in giving guidance. Are there any other aspects/issues I should consider in addressing their questions of being “covered” in expanding their practice?

The frequently heard phrase “am I covered?” may have various connotations from one individual to another. It may be helpful to explore what the nurse actually means in using this term. The framework is a good reference model for speaking with nursing staff about role expansion and their concerns about “coverage”. It provides principles, which should be used to review, outline and expand the parameters of practice for nurses and midwives. Decisions about scope of practice are complex and involve consideration of a number of important determining factors. These include the core definitions and values that underpin nursing and midwifery practice, the levels of competence, the channels of accountability and the supports and resources available. Use the framework as an accompanying reference with this response. You may also want to refer nursing/midwifery staff to the An Bord Altranais interactive e-learning programme on the Scope of Practice which is available on the Board’s website www.nursingboard.ie.

One of the key factors in determining the individual’s scope of practice is whether there is any legislation in prohibiting the proposed role/function. All acts and statutory instruments of Irish legislation from 1922 to 2005 can be read and downloaded from the following websites www.irishstatutebook.ie and www.oireachtas.ie.

A second factor to consider is if there are established national and local guidelines relating to the issue for a nurse’s scope of practice and his/her accountability and responsibility to the patient/client and employer.

Health Service Executive and organisational policies should be sought/examined to determine if precedence has been set regarding the proposed activity/responsibility. Consider whether it should be reviewed with nursing/midwifery management and organisational management? It may be beneficial to contact risk management in the organisation for additional advice. If there is no local risk manager in place, contact the regional HSE area risk management department.

The topic of indemnity can also form part of the discussion about concerns of “coverage”.The Clinical Indemnity Scheme (CIS) covers all claims alleging medical malpractice or clinical negligence against an agency and/or its staff arising from the delivery of professional medical services by those employed by the agency. This includes services provided at hospitals, clinics, other facilities owned or operated by the agency as well as in patients’ homes and other community based facilities.

It covers doctors, dentists, nurses, midwives and other clinical staff employed by each agency, whether permanent, locum or temporary. The CIS provides coverage for the clinical activities of public health doctors, health board dentists, nurses and other community-based clinical staff within the HSE (and some private and voluntary organisations.) Further information on the CIS is available at http://www.stateclaims.ie/ClinicalIndemnityScheme/QA_brochure.pdf

Is the proposed activity or procedure determined/directed by evidence based practice through the use of clinical practice guidelines, care pathways or other such references? Various national and international organisations produce guidelines so it is important to consider the source of this information with regard to addressing the specific clinical situations or practice concerns. It might be helpful to provide staff with a general listing of references which they can review themselves to inform their clinical decisions thus ensuring evidence of best practice is examined.

An individual nurse/midwife may question his/her own competence to undertake a new or expanded role and responsibility in providing professional care and may perhaps voice this concern indirectly by enquiring about coverage. The nurse/midwife must take measures to develop and maintain the competence for professional practice. Health care organisations have a responsibility to have systems of support and resources available to facilitate the nurse/midwife.

Knowledge of Medication

I am registered general nurse working in a care of the elderly setting. It is my responsibility to administer medications to 40 residents. Should I be expected to know about all of the medications before administering them to each individual?

Nurses and midwives are accountable for maintaining their competence for Medication Management, which includes knowledge of medication(s) that they are supplying and/or administering to a resident. This elearning programme and An Bord Altranais’s Guidance to Nurses and Midwives on Medication Management, (2007) provide professional guidance regarding the general principles and responsibilities for Medication Management. These responsibilities incorporate assessment, planning, implementation and evaluation by the nurse or midwife in collaboration with other health care professionals in providing care.

It is expected that you possesses the knowledge to administer the resident’s medications safely and appropriately. The risk of error and adverse reactions related to lack of knowledge is significant in the area of Medication Management. A nurse is compromising his/her delivery of care to the resident if they do not possess adequate knowledge about the medication as he/she is unable to monitor the medication’s appropriateness or effectiveness.

You have a professional obligation to ensure your continued professional development for Medication Management. If you are concerned that you lack the knowledge about medications being prescribed in your clinical practice setting you should seek additional information. Familiarising yourself with frequently prescribed medications is advised. Gaining this knowledge may increase your confidence and competence in administering medications and for general Medication Management. Start by identifying the resources available to you (e.g. health library, websites specific to medication information such as www.medicines.ie and professional journals). Also seek support and assistance from your manager/health service provider/employer regarding access to pharmacology reference material, opportunities for continuing professional development for Medication Management concerns (particularly in relation to new medications).The resources of your community pharmacist should also be considered for medication managment queries you may have.

Double-Checking

Are registered nurses/midwives required to double-check medications as part of their role in administering medications?

Firstly, it is appropriate to clarify what is meant by double-checking. Double-checking is the process/activity of having a second individual/colleague independently check the preparation of a medication for administration. This may involve verification of the medication against the medical prescription order, performing calculations for dosing of the correct volume or quantity of medication and/or other aspects of medication administration as appropriate. The use of double-checking medications should be implemented purposefully in situations/indications that most require their use – particularly with high-alert medications.

Registered nurses/midwives are accountable for their professional decisions and do not need another professional colleague to routinely check their work. There is no legal or professional requirement that a registered nurse/midwife must double-check the preparation of a medication with a colleague prior to administration. However, a nurse/midwife may consider asking another nurse/midwife to double-check a medication preparation if she/he determines that assistance is needed.

For patient/service-user safety and risk management purposes health service providers may have a policy for double-checking preparations, particularly for those that are considered high-alert medications (such as insulin, heparin and chemotherapy) or that require complex calculations in preparation for administration.

IV Administration Policies

I work as a registered general nurse in a nursing home for elderly patients. The nursing home is now introducing the practice of intravenous medication administration for patients who require it. The majority of these IV medications are antibiotics. I am concerned about the safety aspect of this practice particularly in relation to adverse reaction and anaphylactic shock. Our nursing staff is limited to one nurse on each shift both during the day and at night. Medical cover is provided by the patients’ local GP on an as needed basis.

I am interested to know of any research in this area and would like to know if there are any other care of the elderly nursing homes/community hospitals that may have an established IV administration policy for staff or if they are considering such practices in providing care.

There are a number of resources we can direct you to regarding developments in practice and best practice guidelines in relation to intravenous medication administration and therapy. This e-learning programme and Guidance to Nurses and Midwives on Medication Management (An Bord Altranais, 2007) provide general principles and professional guidance on Medication Management for all nurses and midwives practising in any care setting. They outline the knowledge and competence required to safely administer medications.

Each nurse or midwife should take appropriate steps to develop and maintain competence with regard to all aspects of Medication Management ensuring that her/his knowledge skills and clinical practice are up to date. The nurse/midwife has a responsibility to ensure her/his continued professional development, which is necessary for the maintenance of competence with regard to medicinal products. This point is significant for you and other nurses in view of your health service provider initiating intravenous medication administration as an expanded service for elderly patients. The Scope of Nursing and Midwifery Practice Framework (2000) is also a useful tool for you in considering your professional responsibilities. You should seek assistance and support from your employer regarding any clinical skill and theoretical knowledge updates required to perform and monitor IV therapy safely and competently. This could include emergency management of anaphylaxis and adverse events associated with IV therapy. An enquiry to the your HSE area’s Centre for Nurse Education and the Nursing and Midwifery Planning and Development Unit about available education and local organisational policies on intravenous therapy may be helpful.

Detailed information about intravenous therapy can be found in the Royal College of Nursing November 2005 publication Standards for infusion therapy. This document can be accessed via the College’s website at www.rcn.org.uk/publications/pdf/standardinfusiontherapy.pdf.

There is a US speciality organisation for nurses interested in intravenous therapy: Infusion Nurses Society web address: http://www.ins1.org/ and contact information INFUSION NURSES SOCIETY, 220 Norwood Park South, Norwood, MA 02062. Phone.781.440.9408 fax.781.440.9409. The Society has published Standards of Practice (2006) and Policies and Procedures for Infusion Nursing (3rd edition).

A comprehensive health service provider policy on Medication Management and intravenous therapy and IV medication administration could include Infection control and safety observance; Site selection and placement for IV access; Site care and maintenance; Staff education; Patient education; Infusion equipment; Documentation/communication standards and IV related complications – treatment and reporting.

This list is not exhaustive and consultation with other members of the multidisciplinary health care team especially the doctor and pharmacist is important in devising and implementing a policy for safe IV therapy practices.

First Dose Administration of IV Medication

I am working as a staff nurse in a general hospital. We have a long standing policy that all first doses of IV medications are to be administered by the doctor. Currently, our nursing practice development department is involved with other members of the health care team in considering a change in policy to allow nurses to administer first doses of specific medications. Does An Bord Altranais have any policies or guidance for this practice?

There are general principles and responsibilities for nurses and midwives for Medication Management are detailed throughout the elearning programme and are in Guidance to Nurses and Midwives on Medication Management (An Bord Altranais, 2007), which can be applied broadly in considering this expansion of practice. The Nursing Board does not have a policy or practice standards for "first dose administration of intravenous medications".

As part of its overall Medication Management policy health service providers may have a specific statement and/or procedure relating to the nurse’s responsibilities for this activity. It is important that when this practice is introduced all members of the health care team understand the policy to support first dose IV administration by nurses. Many hospitals determine a specific list of medications that can be administered for the first time by a nurse. The list may also detail which units/wards are authorised (e.g. critical care and general areas) and if there is a need for special monitoring of the patient.

The nurse should be competent and be aware of the individual indications, appropriate dosage and diluents, storage and stability of the drug(s), administration, observation of the patient, side effects, and potential incompatibilities. He or she should be knowledgeable of emergent resuscitative actions necessary for treatment of allergic responses and/or IV related complications to the prescribed first dose. The decision to administer the first dose of IV medications should be based on organisational policy, competency of the staff involved, and accessibility to medical supervision if necessary. You should seek assistance and support from the organisation regarding any clinical skill and theoretical knowledge needed to perform first dose administration of IV medications and to monitor the patient safely and competently during and post administration. It may be helpful to contact other hospitals to see if any of them have introduced their own policies and learn from their experiences.

MDA Schedule 2 Drugs Administration

As public health nurses, we are usually working on our own and have to rely on clients or family members to check medication with us. I have particular concerns with regard to the care of patients who are receiving drugs through a syringe driver, especially MDA Schedule 2 controlled drugs. What is our position? Are we supposed to have two nurses with us when dealing with these drugs and what can we do to safeguard the client and ourselves?

General guidelines for the management of MDA Schedule 2 drugs including their use in community care are presented in Unit 4 of this programme. There are a number of key points to consider in addressing your concern about the safety of checking medications especially controlled drugs in community or home care settings. Does your health service provider have a Medication Management policy that includes the management of controlled drugs? If your organisation does have a policy on Medication Management it should be used in association with current medicines legislation and An Bord Altranais Guidance to Nurses and Midwives on Medication Management (2007) to guide your practice.

An Bord Altranais acknowledges that local need may dictate specific policies and protocols authorising the practices of individuals involved with medicines. The local health service provider policy may require two persons to conduct the administration of MDA drugs. The checking, preparation, administration or destruction of these drugs by two individuals may also be mandated for in the policy. However there is no legal requirement for controlled drugs to be checked and/or administered by two individuals. Best practice would indicate that where possible high risk medications (such as MDA drugs) should be checked with another individual. In your situation it may be appropriate for you to ask the client (if appropriate) or a family member to witness the checking of the prescribed medication. As a registered health care professional you are accountability for your actions in your delivery of nursing care. Clear and direct communication with the client and his/her family about your role and responsibilities for Medication Management should be undertaken at the initial stage of caring for the individual. This would include speaking to them about their expectations of nursing care particularly in relation to the administration of medication and monitoring the patient. This is part of establishing a therapeutic relationship with the patient and family. If you identify concerns about these practices either from your point of view or the client and/or family it may be helpful to organise a team meeting to openly talk about these issues. Maintaining good clinical records are also essential in providing care safely and effectively. The guidelines for good practice in recording clinical practice found within Recording Clinical Practice Guidance to Nurses and Midwives (An Bord Altranais, 2002) should be used for your documenting your nursing care thereby ensuring safe practice.

What is Medication Reconciliation

As part of our hospital’s clinical audit reviews our nursing and pharmacy staff identified that there were problems with the medication records received from one department to another, such as when patients are admitted from the emergency department and transfer to the ICU then onto another area of the hospital. We recently had a medication error where a patient with chest pain received a bolus of heparin and started on a heparin infusion in the emergency department and when sent to the ICU the bolus of dose of heparin was wrongly repeated. Our risk management suggested introducing “medication reconciliation” as part of the transfer procedures for our patients. I don’t know much about this – is it something that nurses should get involved with? I don’t see it mentioned in the Board’s Guidance to Nurses and Midwives on Medication Management (2007).

Your query about the nurse’s role in medication reconciliation is timely.The topic was presented at the Clinical Indemnity Scheme’s Seminar on Medication Safety within the last year. More recently Building a Culture of Patient Safety the Report of the Commission on Patient Safety and Quality Assurance (Department of Health and Children, 2008) makes reference to medication reconciliation for improving medication safety and reducing medication error. The report defines medication reconciliation as “the process of obtaining a complete and accurate list of each patient’s current medications from all available sources at all points of contact and verifying and reconciling medications to reduce medication errors.”

Medication reconciliation is a process central to the overall care for the patient. If you consider how many times a person may be moved or transferred from one care setting to another as part of patient journey the importance of comparing the previous medication orders with new orders alongside the person’s care plan and reconciling or resolving any differences is critical. Introducing medication reconciliation in any care setting requires a formal structured process and it needs to be communicated across the organisation.

Who should be involved?

In developing the structure for the reconciliation of medications there should be consideration as to which health care professional member is the most appropriate staff member in the clinical setting or organisation to undertake this activity. In some settings it may be the pharmacist, in others it may be a member of the nursing staff or a doctor assigned to undertake the process. Discussion should take place with nursing, pharmacy, medicine and risk management (and others as appropriate) for the development of structures to support medication reconciliation in order for it to work effectively and efficiently. The competence, knowledge and experience of the nurse are key determinants as to whether it is within the individual’s scope of practice to carry out medication reconciliation.

Further information about medication reconciliation include:

The Institute of Safe Medication Practices (US) gives a checklist of the basic steps which can be accessed at http://www.ismp.org/Newsletters/acutecare/articles/20050421.asp. Their website also provides detailed information about developing a system for medication reconciliation.

Institute for Healthcare Improvement (US) has extensive information on medication reconciliation including tools and sample documentation forms on its website at http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems.

1. The abstract presentation by T Grimes can be read at http://www.stateclaims.ie/ClinicalIndemnityScheme/publications/2008/TheEvidenceBase.pdf

(An Bord Altranais News, Winter 2008- Volume 20, No. 4 (pg. 2))

Reporting Adverse Reactions to Medication

Recently when I was working in the outpatient cardiology clinic a patient came in for a follow-up visit for his hypertension. At his last visit 2 weeks ago the cardiology consultant changed the man’s medication. At this visit when I saw the patient he was complaining that he didn’t think the medication suited him and showed me a generalised rash on his arms. He said he noticed the rash about 2-3 days after beginning the new medication. I took his blood pressure and questioned him about the appearance of the rash in relation to taking the medication and we considered other possible causes of the reaction, including any other medications the patient was taking. When the consultant came in to see the patient she discussed the possibility of an adverse drug reaction to this new antihypertensive. It was decided to discontinue the medication and the patient was to return in two days to assess the rash and determine alternative treatment for his chronic hypertension.

When the patient left the doctor asked me to complete a drug adverse reaction form as she said she wanted it submitted to the Irish Medicines Board. I was not familiar with this form which she also called a “yellow card” and was unsure about filling it out. Am I responsible for submitting an adverse drug reaction report to the IMB? Is it a nursing responsibility and is it within my scope of practice? I would think it would be the doctor’s role as they are the prescriber.

I did not find any reference to the nurse’s role in completing an adverse drug reaction form within my hospital’s medication management policy. The Guidance to Nurses and Midwives on Medication Management (2003)does not give any information about the responsibility of the nurse for this activity.

Adverse drug reactions have been identified as a leading cause of morbidity and mortality. As part of their every day care of patients/service-users, nurses and midwives are in prime positions to observe and report on suspected adverse drug reactions (ADRs). ADR reporting is critical for safe medication management and patient care and is within a nurse or midwife’s responsibility of care and scope of practice. Nursing/midwifery staff should liaise with the prescriber about the submission of the report as appropriate. It is not necessary for you to determine a causal relationship between a medication and subsequent event before reporting a suspected adverse drug reaction.

The Irish Medicines Board is responsible for the national reporting system of monitoring adverse drug reactions and requests that health care professionals (nurses, midwives, doctors, dentists, and pharmacists) report the following:

All suspected reactions to new products;

Serious suspected reactions to established products;

Any suspected increase in the frequency of minor reactions;

All suspected reactions to vaccines;

All suspected teratogenic (effecting development of foetus) effects.

The reporting and monitoring of adverse drug reactions has significant implications for patient/service-user safety. It is not solely the responsibility of the prescriber and should be considered a shared health care team responsibility for monitoring patients and reporting these cases. The revised edition of Guidance to Nurses and Midwives on Medication Management (soon to be published) does provide detail guidance regarding the role of nursing and midwifery professionals in communicating and reporting adverse drug reactions to other members of the health care team and the IMB. Additionally An Bord Altranais states that health service providers should include information and direction for health care professionals in reporting ADRs within its medication management policies. If your policy does not address this critical safety issue perhaps you can become involved in facilitating the development of one.

Additional information about adverse drug reaction reporting include:

The Irish Medicines Board has a dedicated section accessible at http://www.imb.ie/inner.asp?nav=4,46&pos=1&num=1 and its ADR report form can be downloaded for your review and completion.

The House of the Oireachtas - Joint Committee on Health and Children launched a report The Adverse Side Effects of Pharmaceuticals (April 2007) which advocates for increased reporting of ADRs as part of its review of medications and their adverse effects. This document can be accessed by clicking here

As part of the World Health Organisation work for World Alliance for Patient Safety it published Draft Guidelines for Adverse Event Reporting and Learning Systems (2005). The guidelines introduce reporting of adverse events and centre on reporting and learning to improve patient care safety. The WHO website to order this publication is http://www.who.int/publications/en/.

(An Bord Altranais News, Summer 2007- Volume 19, No. 2 (pg 14)) 

Assessment of Medication Needs

I work as a clinical nurse specialist in palliative care with responsibilities for providing services in the hospital and also to several nursing homes in the area. My question involves recording my nursing assessment and treatment plan in a nursing home resident’s chart. When the palliative care nursing services were introduced to this nursing home we were instructed by its Director of Nursing to write our palliative care notes in the nursing care plan. This is kept separate from the resident’s medical chart.

Over the course of the past six months the palliative care nursing team have experienced difficulties with communication and follow up with other health care professionals (such as the resident’s general practitioner and medical consultants) as a result of documenting our notes separately from the resident’s medical chart. I am concerned that this separation is adversely affecting the resident’s palliative care needs and plan especially in relation to communicating medication management issues amongst all the staff - nursing and medical. I want to be able to address this issue with the Director of Nursing, recommending that record keeping of multidisciplinary notes in a central location in the resident’s chart be implemented. I think it is within my scope of nursing practice to advocate for this change yet some of the nursing home staff think it is solely at the discretion of the Director of Nursing. What is your advice on this?

It is important that there are clear lines of communication and documentation to facilitate palliative care planning as part of addressing the overall needs of the individual. Sharing information about the assessment, care and treatment plan of a patient/resident is a critical point for each member of the health care team. In Recording Clinical Practice Guidance to Nurses and Midwives (An Bord Altranais, 2002) it is stated that the nursing record provides substantiation of practice for continuity of care between health care professionals amongst other record keeping factors. (pgs. 2 & 3). In Section 7 of the document – Guidelines for Good Practice in Recording Clinical Practice it is stated that all healthcare staff should be encouraged to read each other’s entries in the record (chart) as this facilitates good communication between healthcare staff. Consideration of the use of multidisciplinary notes in a central location within the resident’s chart supports this point. The recently published Professional Guidance and Standards for Nurses Working with Older People (An Bord Altranais, 2009) clearly illustrates the importance of collaboration with others in providing best practice and this includes documentation of care.

Advocating for change for documentation and record-keeping policies that would promote collective sharing of professional notes and records within the resident’s chart is indeed within your scope of practice as nurse. To influence change for documentation systems within the nursing home with the Director of Nursing and other key stakeholders you may wish to review Guidance to Nurses and Midwives on the Development of Policies, Guidelines and Protocols (An Bord Altranais, 2000). Referencing the above guidance documents in conjunction with relevant national standards (e.g. National Quality Standards for Residential Care Settings for Older People in Ireland, HIQA 2008) may be a starting point for you in highlighting to the nursing home management and staff the importance of reviewing current policy with a view to improving documentation practices and most importantly communication for the resident’s care and health care services provided. Each nurse is individually accountable for communicating his/her assessment and care plan to the appropriate members of the health care team involved with the resident’s care.

(An Bord Altranais News, Summer 2010- Volume 22, No 2 (pp 4-5))

Dealing with Medication Errors

Our hospital recently established a Medication Safety Committee. As the nursing representative I have been asked to assist with reviewing and updating the section on medication error identification and prevention as part of our medication management policy. I know the issue of identifying and reporting medication errors are matters of concern for the nursing staff and I would like to include systems to reduce the risk of medication errors. What are the key elements I need to communicate in the policy for a nurse to consider for their scope of practice in addressing medication errors?

Safety in medication management which includes medication error awareness and risk reduction is a critical aspect of professional practice for the registered nurse. Nursing staff should be supported by management with an open culture (non-punitive approach) for dealing with medication errors. Points to consider at an individual (and organisational) level include:

How is a medication error defined?

A common definition helps to create awareness of what constitutes an error. It can assist with reporting and analysing errors across the organisation.

The Guidance to Nurses and Midwives on Medication Management (An Bord Altranais, 2007) has included the National Coordinating Council for Medication Error Reporting and Prevention (1998) definition of medication error:

“Preventable events that may cause or lead to inappropriate medication use or patient/service-user harm while the medication is in control of the health care professional or patient/service user. These events may be associated with professional practice, health care products, procedures and systems. They include prescribing, order communication, product labelling, packaging, nomenclature, compounding, dispensing, distributing, supplying, administration, education, monitoring and use.”

When a medication error has occurred, patient safety is paramount.

Nursing and medical interventions need to be implemented immediately to reduce potential adverse effects/reactions. Assessment and monitoring of the patient are principal actions at this point.

Does the nurse know who to contact in this situation? What information should be communicated and how? It is important that the nurse is aware of the hospital’s written guidance and direction for managing medication errors. Recording Clinical Practice Guidelines (An Bord Altranais, 2002) is a good resource for nurses regarding documentation and communication of nursing care.

An Open Culture

An open culture for reporting medication errors and near miss events is key to supporting staff. This can encourage the nurse (and other staff) involved in medication management to view these situations as opportunities to assess practice(s); identify what went wrong; learn from mistakes and introduce changes to the medication system.

Collaboration amongst the health care team for the prevention, detection and reduction of medication errors and near misses should be fostered throughout the hospital because errors may reflect a problem (or problems) with the system, not just a single individual. Other professions and departments may be involved. 

Scope of Practice

Understanding and utilising the Scope of Nursing and Midwifery Practice Framework and its determinants: competence, accountability and autonomy, continuing professional development, support for nursing and midwifery practice, delegation and emergency situations in conjunction with An Bord Altranais’ professional guidance on medication management (referenced above and its e-learning programme Guide to Medication Management) can facilitate the nurse’s actions and response to medication errors as an individual and team member.

Other resources about medication errors that may be helpful to you in your work include:

Department of Health and Children. (2008) Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance. Dublin: The Stationery Office.

International Council of Nurses, Medication Errors, [Online] Available: http://www.icn.ch/matters_errors.htm (Accessed August 5 2008).

Institute of Medicine. (2007) Preventing Medication Errors. Washington DC: National Academy of Sciences.

Institute of Safe Medication Practices – www.ismp.org

Kirke, C, Tighe, P., Colohan G., Harnett B., Creaton, G. Delaney, T. (2007) A Collaborative Study of Medication Safety in Four Irish Hospitals, Irish Pharmacy Journal February pp 68-73.

National Medicines Information Centre. (2001) Medication Errors, [Online] Available: http://www.stjames.ie/ClinicalInformation/NationalMedicinesInformationCentre/NMICBulletins/2001/MedicationErrorsVolume7No32001/ (Accessed 5th August 2008)

(An Bord Altranais News, Autumn 2008- Volume 20, No. 3 (pp 10-11))

Repeat Prescriptions

I’m working as a practice nurse. The doctor in the practice wants me to see all patients who come in for repeat prescriptions for the oral contraceptive pill. He does not want to see them unless they have a problem. Is it o.k. to do this? Are there issues that I need to consider before I agree?

Using the Scope of Practice Framework to answer the questions you raise in your query, the first issue to consider is the legislation that governs the issuing of prescriptions for medicinal products. Only a doctor, dentist, registered nurse prescriber or veterinary surgeon can legally write a prescription. The issuing of a repeat prescription is the responsibility of the doctor or registered nurse prescriber and he/she is accountable for that decision.

It may be appropriate for you, as the practice nurse, to be involved in the assessment of the woman that informs the decision making process. You must communicate the findings of your assessment to the doctor so that the decision to issue the repeat prescription is based on informed consultation between yourself and the doctor. All the findings of your assessment and the consultation with the doctor must be documented.

For reasons of patient safety and because it would be in breach of An Bord Altranais guidelines you should not write out the repeat prescription and present it to the doctor for signing.

In relation to the issue of your involvement in assessing the patient, you should use the Scope of Practice Framework and ask yourself the following questions: Is what you are planning to do in the best interests of the patient? Will it maintain best quality health services for the patient? Does it fit with the definitions and values that underpin nursing? If the answer to these questions is yes, you should then look at the issues of policies/guidelines related to this issue.

You must also assess your own level of competence in relation to the assessment of women requiring repeat prescriptions for the oral contraceptive pill. Do you have the necessary knowledge and clinical skills to carry out the appropriate assessment? If not, you should not carry out the assessment. You need to take steps to acquire the necessary knowledge and skills. This is usually done by undertaking an appropriate education programme, which includes supervised clinical practice and competence assessment.

Ultimately, you have to make a judgement about your own level of competence and what you will undertake. You, and not the doctor, are accountable for your actions.

Can I Administer Botox?

I have recently started working in a clinic where, amongst other services provided, clients come to have Botox injections. As a registered nurse, am I allowed to administer Botox injections?

Botox is the trade name for Clostridium botulinum type A neurotoxin complex. It is a medicinal product authorised by the Irish Medicines Board.The Irish Medicines Board is the statutory authority responsible for the approval of medicinal products for use in Ireland. The discovery that botulinum toxin blocks neuromuscular transmission, and thereby causes weakness, laid the foundation for its development as a therapeutic agent. It is used in the treatment of a wide variety of medical conditions. In recent years, the use of Botox to temporarily reduce facial ‘frown lines’ has been on the increase. Botox is administered by injection. Dosage has to be tailored according to the indication for use and the individual patient. Usually a medicinal product may be administered by a registered nurse provided it has been appropriately prescribed by a registered medical practitioner and provided the nurse is competent to administer the product. However, in certain situations, the Irish Medicines Board, the manufacturer of the medicinal product and/or an employing authority may impose restrictions or conditions in relation to the administration of a medicinal product. In the case of Botox, the product authorisation issued by the Irish Medicines Board and the product information leaflet issued by the manufacturers state that "Botox should only be given by physicians with appropriate qualifications, and documented expertise in the treatment and use of the required equipment" (IMB Product Authorisation, Section 4.2).

In utilising the Scope of Nursing and Midwifery Practice Framework, the first question to be addressed is whether or not there is any legislation, national or local guidelines prohibiting a specific role/function. In the case of the administration of Botox by nurses, the answer is clearly YES – there is a legal prohibition on the administration of Botox by nurses. A nurse who administers the medicinal product Botox is not acting within his/her scope of practice and could be called to account both professionally and legally for his/her actions.

Cosmetic Procedures

I have been offered a position working as a nurse in a private clinic which provides cosmetic procedures – ‘medical aesthetics’ as the clinic describes it. I am told that I will have an extensive orientation which will cover various treatments such as laser therapy, collagen injections, botox injections, microdermabrasions and chemical peels. Although I have some basic knowledge about these treatments before starting this position I am aware that I may be asked to provide many of these services on my own. What do I need to consider in determining whether this new role is within my scope of practice as a nurse?

There are some critical elements to consider when determining whether or not certain activities/procedures are within a nurse’s scope of practice in this speciality area. The first involves client consent for procedures and documentation of care. If you are the sole individual responsible for treating the client you are also responsible for discussing with and obtaining consent from the client for any procedures undertaken. This also extends to providing client education. If other health professionals are involved with the client’s care you should discuss who is responsible for obtaining consent before initiation of treatment. These staff responsibilities should be set out in the organisation’s policies. It is critical to document consent to treatment. Be familiar with Recording Clinical Practice Guidance to Nurses and Midwives (An Bord Altranais, 2002) as it provides concise guidelines for maintaining good clinical records.

There may be different skills and knowledge for competencies that you are expected to obtain and maintain for medical aesthetics. It may involve learning different techniques related to the care of clients having different forms of treatment. This may require you to participate in a formal recognised education/training course, followed by a period of supervised practice. It is important that you are able to demonstrate safe, effective and competent techniques underpinned by a sound knowledge in providing patient care. A process of assessment and evaluation of your practice should be determined between yourself and your employer. Access to supervision as required should also be part of that process along with continuing professional development needs. There should be an established clinic policy outlining what procedures can be carried out with and without a doctor on the premises. Policies and procedures for dealing with emergencies, including possible situations of anaphylactic shock, should also be known. Having the competency and resources to manage these events is critical.

As a registered nurse you are accountable for your actions to the client, the public, your employer, An Bord Altranais and any relevant supervisory authority. You should be aware of your professional clinical indemnity and liability coverage as a nurse practising in a private clinic. Discuss this with your employer. If you are a member of a professional union you may want to contact the appropriate person to review your policy for coverage.

You also need to consider issues in relation to the administration of medications. A written prescription for medication must be provided by a doctor. You should be aware of the summary product characteristics (SPC) of medications which you administer. The SPC must be provided by the pharmaceutical manufacturer in order for the drug to be licensed by the Irish Medicines Board for specific use in Ireland. SPCs can be accessed via the website www.medicines.ie or from the manufacturer.

There may be medications that are used in unlicensed ways (e.g. Botox) and it is important that you have access to information about the medications and the care that clients require for safe administration. It is strongly advised that you become familiar with medications’ SPCs and their licensed (and unlicensed) uses.

The Scope of Nursing and Midwifery Practice Framework addresses the important considerations in determining the scope of nursing practice. These are competence, accountability and autonomy, continuing professional development, support for professional nursing and midwifery practice, delegation and emergency situations. By reviewing these considerations for your own practice for medical aesthetics you may discover more areas that you need to research and/or review with your future employer.

Some sources of information specific to this growing specialty are the Royal College of Nursing (UK) publication Competencies: an integrated career and competency framework for nurses in aesthetic medicine and the American Society of Plastic Surgical Nursing document on Plastic Surgery Nursing: Scope and Standards of Practice. Be aware that other countries’ nursing practice legislation, medicines legislation and other relevant legislation and regulations are diverse and should not be considered to be the same as Irish legislation when determining scope of practice.