Measurement and Administration of Liquid Medicines

NPA

STANDARD OPERATING PROCEDURE

Promoting safer measurement and administration of liquid medicines

GUIDANCE NOTES

PROMOTING SAFER MEASUREMENT AND ADMINISTRATION OF LIQUID MEDICINES

In March 2007 the National Patient Safety Agency (NPSA) issued a patient safety alert: NPSA Alert 19 -Promoting the Safer Measurement and Administration of Liquid Medicines via Oral and Other Enteral Routes. The alert was in response to reports of three deaths and 33 patient safety incidents which arose due to the intravenous administration of oral liquid medicines between 1 January 2005 and 31 May 2006. The NPSA guidance is designed to help NHS organisations, including community pharmacies, in England and Wales to take steps to minimise the risks of incorrect administration of oral medicines. The NPSA report recommendations should have been implemented by 31st March 2008.

The NPSA patient safety alert includes guidance and recommendations that are relevant to community pharmacy. This resource aims to help you review your dispensing procedures and prepare a written standard operating procedure (SOP) to ensure that you are following the guidance when supplying devices for measuring oral liquid medicines in your pharmacy. You can use the template NPA SOP (Appendix 1) to write a separate SOP for the supply of devices for measuring oral liquid medicines or you can incorporate the guidance into your existing dispensing SOPs.

The NPSA patient safety alert includes the following recommendations of relevance to community pharmacy:

Patients supplied with oral liquid medicines should be supplied with a 5ml medicine spoon or graduated medicine measure. Whenever possible a medicine spoon should be provided and an oral syringe or graduated measure should only be supplied if a spoon is unsuitable.
An oral (or enteral) syringe should only be supplied if a medicine spoon or graduated measure cannot be used.
Intravenous syringes should not be used to measure or administer oral liquid medicines.
Pharmacies should ensure that they are able to supply a range of oral syringes as appropriate.
As a minimum a 1ml, 5ml or 10ml syringe should supplied depending on the dose prescribed. Please see the Drug Tariff note below.
All syringes must be clearly labelled “Oral” and/or “Enteral” in a large font size. If the manufacturer has not labelled the syringe it is the pharmacy’s responsibility to ensure the syringe is labelled.

Drug Tariff Note: Pharmacy contractors are paid a container allowance (see the Drug Tariff for further information) which includes provision for either a 5ml plastic measuring spoon (which complies with BS 3221:Part 6: 1987)or a 1ml, 5ml or 10ml plastic oral syringe measure to be supplied with every oral liquid medicine (unless the manufacturer’s pack includes one). The syringe must be clearly labelled “oral” and/or “enteral” in a large font size and should be wrapped with a bottle adaptor and instruction leaflet. Oral syringes should comply with BS 3221: Part 7:1995 or an equivalent EU standard.

Enteral feeding sets

The NPSA guidance also covers the supply of enteral feeding sets. Most community pharmacies will not be involved in the supply of these devices but some pharmacies may occasionally supply these to care homes or clinics and will need to be aware of the NPSA guidance.

The NPSA alert includes detailed guidance. However the main points are:

enteral feeding sets should not have ports or connectors that can be connected to intravenous syringes or other parenteral lines.
enteral feeding sets should be labelled to indicate the route of administration.
three-way taps and syringe tip adaptors should not be used as this enables connection design safeguards to be bypassed.

RESOURCES AND FURTHER INFORMATION

NPSA

The full NPSA rapid response report and further supporting materials are available at

NPA resources

The following items can be obtained from NPA Sales on 01727 800401 -

Prescription alert stickers – can be placed onto dispensed medicines, including oral liquid medicines, to alert the pharmacist that counselling is required.
Disability Discrimination Assessment record book – to record DDA assessments and action taken.

Contact NPA Information for details of suppliers of oral syringes, measuring devices and compliance aids.

Appendix 1

TEMPLATE STANDARD OPERATING PROCEDURE

Supplying measuring devices for liquid medicines

The template standard operating procedure (SOP) below should be read in conjunction with the accompanying guidance notes and should be tailored to meet your individual circumstances.

PURPOSE

To ensure the supply of measuring devices for liquid medicines complies with the NPSA recommendations on promoting the safe measurement and administration of liquid medicines via oral or enteral routes.

SCOPE

This procedure covers the supply of suitable measuring devices when patients are supplied with oral liquid medicines to be administered via the oral or enteral route. The term oral liquid medicine includes soluble tablets (once dissolved) and flushes to be administered by oral or enteral routes. This procedure does not include the supply of syringes for administering medicines via other routes or the supply of enteral feeding sets.

PROCESS/PROCEDURE

Typical steps may include some of the following (the order and the way in which you do these in your pharmacy may vary from the list below so choose those most suited to your own practice).

Prescription receipt

If the patient presents a prescription for a liquid medicine for the first time check whether the patient has had the liquid medicine before (e.g. from the hospital or from another pharmacy)
Ask the patient whether they have previously received a measuring device e.g. a medicine spoon, graduated measuring device or an oral syringe.
Ask if they have ever experienced any problems with measuring liquid medicines.
If the prescription is for a solid formulation to be crushed and/or dissolved and administered via the enteral route, alert the dispensary team.
If the prescription is for syringes find out how these are going to be used.
If syringes are prescribed on an NHS prescription, check whether they are allowed as only a limited number are included in the Drug Tariff
Pass any relevant information obtained to the dispensary team.

Pharmaceutical assessment

Check the prescription docket for information about whether the patient has previously received a measuring device and whether they have had any problems in using this device.
Record this information on the patient’s PMR.
If the prescription is for a solid formulation to be dissolved and/or crushed and administered via the enteral route find out if the patient or carer is using a suitable device e.g. an appropriate enteral syringe or giving set to administer the medicine.

Interventions and problem solving

If the patient is unable to measure and/or administer their liquid medicines correctly consider carrying out a Disability Discrimination Act (DDA) assessment. You may decide to do this as part of a Medicines Use Review (MUR).
If a suitable measuring device is not available contact the prescriber to discuss whether an alternative product or formulation could be prescribed.
Check whether syringes are being supplied for measuring or administering oral liquid medicines.
If the prescription includes intravenous or hypodermic syringes which are to be used for measuring oral liquid or enteral medicines contact the prescriber to suggest an alternative

Assembly and labelling

Ensure clear instructions on how to take the liquid medicine are included on the dispensing label.
Patients supplied with oral liquid medicines should be supplied with a separate medicine spoon (which complies with British Standard BS 3221: Part 6: 1987) or graduated measure unless one is included in the manufacturer’s pack.
If a medicine spoon or graduated measure cannot be used an oral or enteral syringe should be supplied. Remember oral syringes should only be used where other administration devices such as spoons and measuring cups are considered unsuitable.
If a syringe is required then a 1ml, 5ml or 10ml syringe should be supplied depending on the dose prescribed and the requirements of the Drug Tariff.
Ensure all syringes are clearly labelled “Oral” and/or “Enteral” in a large font size.

Transfer to patient

Find out what the patient already understands and remembers about measuring their oral liquid medicine.

Explain in clear and simple terms how to use the measuring device provided.
Assess the patient’s manual dexterity to see if they require an alternative measuring device.
Assess the patient’s visual status to find out whether they can use the measuring device accurately.
Offer compliance aids, such as large font measuring devices, if appropriate.

RESPONSIBILITY OF STAFF

Your SOP needs to specify who is responsible for dealing with all aspects of the supply of measuring devices for oral liquid medicines from prescription receipt through to transfer to patient. All staff involved in the supply of measuring devices should have received adequate training to ensure they have the necessary work competences.

KNOWN RISKS

This section should contain a description of anything you are aware of that can make the procedure more risky than usual. These are circumstances that you know can increase the likelihood of things going wrong and where you believe extra care and attention should be paid. For example, known risks might include:

Prescriptions presented by representatives.
Prescriptions for tablets or capsules to be crushed or dissolved and administered via the enteral route.
Prescriptions for patients in care homes where alternative measuring devices may be used.

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