The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [536]
Prescribing
A supplementary prescriber, when acting in accordance with a clinical management plan, can prescribe a controlled drug provided the controlled drug is included in the clinical management plan. An independent nurse prescriber can prescribe from the list of controlled drugs included in the nurse prescribers’ formulary solely for the medical conditions indicated (DH 2007). The controlled drugs most commonly prescribed by nurses between 2007 and 2008 were methadone, buprenophine, diazepam and co-codamol (Care Quality Commission 2009).
In response to seven case reports, published between 2000 and 2005, regarding deaths due to the administration of high-dose (30 mg or greater) morphine or diamorphine to patients who had not previously received doses of opiates, the NPSA released a safer practice notice in 2006, Ensuring Safer Practice with High Dose Ampoules of Morphine and Diamorphine (NPSA 2006). In line with this safer practice notice, the following guidance should be adhered to (Box 13.8).
Box 13.8 High-dose opiate guidance
High-strength preparations of morphine or diamorphine (30 mg or above) should be stored in a location separate from lower-strength preparations (10 mg) within the controlled drugs cupboard.
Awareness should be raised of the similarities of drug packaging, and consider use of alert stickers being attached to high-strength preparations by pharmacy.
A review of stock levels should be undertaken in all clinical areas where morphine and diamorphine are stored to assess whether high-strength preparations need to be kept on a permanent basis or whether they could be ordered according to specific patient requirements.
Clear guidance should be provided to ensure that the correct doses of diamorphine and morphine are prepared in the appropriate clinical situation. For example, diamorphine 5 mg and 10 mg ampoules could be used for both bolus administration and patients newly commenced on diamorphine infusions; diamorphine 30 mg ampoules could be reserved for patients already receiving diamorphine infusions and who require higher daily doses.
Patients should be observed for the first hour after receiving their first dose of diamorphine or morphine injection.
Naloxone injections should be available in all clinical areas where morphine and diamorphine are stored.
(NPSA 2006)
Between 2005 and 2008, 4223 incidents were reported to the NRLS involving opioid medicines and the ‘wrong/unclear dose or strength’ or ‘wrong frequency’ of medication. As a result, the NPSA released a Rapid Response Report in July 2008. The guidance shown in Box 13.9 has been given.
Box 13.9 Opioid dose/strength guidance
Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done, for example, through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records.
Where a dose increase is intended, ensure that the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than 50% higher than the previous dose).
Ensure they are familiar with the following characteristics of that medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side-effects.
(NPSA 2008a)
The NPSA was notified of 498 midazolam patient safety incidents between November 2004 and November 2008 where the dose prescribed or administered to the patient was inappropriate. Three midazolam-related incidents have resulted in death. As a result, the NPSA released a Rapid Response Report in December 2008. The guidance in Box 13.10 has been given.
Box 13.10 Midazolam guidance
Ensure that the storage and use of high-strength midazolam (5 mg/mL in 2 mL and 10 mL ampoules, or 2 mg/mL in