size of the neonates and the complexity of calculations.
Episode of Care
Lucy is a 3‐month‐old baby who presented to a Children’s Emergency Assessment Department with a 36‐hour history of not taking her milk, being unsettled and crying more than usual. In the last 24 hours her temperature has increased to 38.5°C, she looks flushed, but her hands and feet are cool to touch.
On examination Lucy is crying and not being comforted by being held. As the doctor examines Lucy she is concerned at Lucy’s condition and temperature and is prescribing paracetamol to reduce the discomfort that Lucy appears to be in. The nurse allocated to Lucy weighs her with no clothes on, to gain an accurate weight to be able to calculate the accurate dose of paracetamol for her body weight. Lucy’s weight is 12lb 4oz (5.8kg) and ‘12.4’ is verbally passed on to the doctor writing the prescription.
As the measurement unit was passed on verbally (it was not communicated by writing it down), the doctor wrote the paracetamol dose based on a weight of 12.4kg and not 5.8kg. It was only when drawing up the amount of liquid paracetamol needed that an experienced nurse realised that this was too much for the age of the baby.
What would you do in this situation?
What dangers have you identified?
How could this potential error be prevented in the future?
Medicines Optimisation
NICE guidance has identified the term ‘medicines optimisation’, meaning ‘to make the best or most effective use of’ medicines, equipment or resources. To this end the Royal Pharmaceutical Society (2013) have developed four guiding principles:
Aim to understand the patient’s experience
Evidence‐based choice of medicines
Ensure medicines use is as safe as possible
Make medicines optimisation part of routine practice
Medicines optimisation is a wider encompassing approach than the system approach of medicine management. Medicines optimisation is an important concept in health and social care and is relevant for CYP with chronic or long‐term conditions or those who are taking more than one medication. The optimisation approach is person‐centred and develops an individual patient‐ or professional‐led self‐management plan for patients. Within paediatrics, depending on the age of the CYP, the family‐centred care approach maybe more appropriate, with the family being involved in the development of the self‐care plan for the child. It is also important to identify any over the counter medications or complementary therapies that may interfere with the effectiveness of any prescribed medication.
Where a child is on multiple medicines or the medicines need to be administered in a different way such as via a feeding tube, additional support and follow‐up might be needed. This should be identified whilst in hospital and support arranged before discharge. Within elderly care environments a screening tool is available to identify potential medicine‐related patient safety incidents. Within CYP care environments there does not appear to be such a screening tool available.
Medicines
Medicines can be grouped into four types in terms of access.
General sales list
Pharmacy medicines
Prescription‐only medicines
Controlled drugs.
Medicines within the general sales list are readily available in shops and there is no legal age restriction for the purchase of these medicines, although some shops have their own age limits for sales. GPs and nurses will not prescribe over the counter medications, such as paracetamol, for minor illnesses for a child or adult when they can be bought readily and at a cheaper cost to the individual and NHS, although there is a list of exemptions. The cost of prescribing over the counter medications to the NHS is approximately £136 million per year (NHS, 2018).
Pharmacy medications are also known as restricted medicines and are a small group of medicines that a pharmacist can prescribe without the patient seeing a doctor or a nurse.
Prescription‐only medicines are prescribed by a GP, nurse, dentist, midwife or a doctor working in environments other than general practice. The medications on this list are considered to be needed to be used under the supervision of a licensed healthcare practitioner due to the potential to cause harm. There are also many medicines that are used but are not licensed for CYP and these can only be prescribed by a paediatrician or hospital‐based doctor. In comparison to general sales and pharmacy medications, prescription‐only medicines are prescribed for an individual after assessment and the dose is calculated on the child or young person’s height and weight or surface area rather than a standard dose that is more often found with adults.
Controlled drugs are a group of medicines that can be abused and cause dependence and therefore they are controlled and regulated by the government. The term ‘control’ covers how and where the medicine is made, how it is used, the way that it is handled and stored as well as how it is distributed. In a hospital environment, GP surgery or community care environment such as a hospice or children’s unit, controlled drugs are stored in a metal locked cupboard inside another locked cupboard on a wall, usually in a specific room where medicines are checked and prepared. Access to the keys to the cupboards is limited and controlled. The stock levels of controlled drugs are checked daily by two people and new supplies are also often checked by two people and everything is recorded in a specific logbook (sometimes known as the controlled drugs register) according to local policy and procedure. When preparing a controlled medication to administer to a patient the stock level is checked against the logbook and the details of the patient including the dose, date and time are recorded and signed by two members of staff. The types of controlled substances most often used include opioids (morphine, diamorphine), sedatives (diazepam, temazepam), stimulants (amphetamines used in attention deficit hyperactive disorder), central nervous system depressants (diazepam), hallucinogens and anabolic steroids (testosterone).
Medicine Management
Medicine management involves the safe storage, management and administration of medications, which includes following local and national policies and guidelines for the safe administration of medication. Monitoring the effectiveness of any medication given, as well as understanding the side effects and contraindications, and being able to explain these to CYP and their family is part of the advancing role in healthcare. The ‘Professional Guidance on the Administration of Medicines in Healthcare Settings’ (RPS and RCN, 2019) outlines professional accountability and covers these aspects in more detail. This document is essential reading for all healthcare staff involved in medicine management and administration. Healthcare students and healthcare professionals are involved in medicine management in a variety of settings and should refer to the Standards of Proficiency for Pre‐registration Nursing Education for Guidance (NMC, 2018b) as well ensuring they are familiar with and abiding to local policy and procedure.
The Standards of Proficiency for Nursing Associates along with the Standards for Pre‐registration Nursing Associate Programmes (NMC, 2018c, 2018d) provide details regarding the preparation of nursing associates and the proficiencies that have to be met prior to the nursing associate’s
