WEEK 2
Pharmacology Principles - Week Two Overview
This week’s focus will be on pharmacology principles, specifically:
Health professionals and the law concerning acts and regulations.
Drug scheduling with emphasis on Schedule 2, 3, 4, and 8.
Australian Legal System and Medicine Regulation
Commonwealth Laws (Federal Laws)
Control the quality, safety, and efficacy of medicines.
Overarching legislation ensuring compliance regarding various aspects of therapeutic goods.
State and Territory Laws
Specific provisions for medicine regulation are established within individual states or territories.
Provide guidance for the prescriptions and administration of medicines.
Precedence of Laws: In case of conflicting regulations, Commonwealth laws take precedence due to their overarching nature.
Key Acts Governing Medicine in Australia
Therapeutic Goods Act 1989 (TGA)
Federal control related to:
Standards
Manufacturing
Supply
Presentation
Registration and availability of therapeutic goods.
Definition of therapeutic goods: Items used for:
Prevention
Diagnosis
Cure
Alleviation of disease, defect, or injury in humans or animals.
Therapeutic goods must conform to international standards and require approval by the TGA before entering the market.
Example: The approval process of COVID-19 vaccines highlights regulatory practices under the TGA.
Narcotic Drugs Act 1967
Implements safeguards against illegal manufacture, supply, and use of narcotics.
Individuals or companies manufacturing narcotic medications must be licensed and adhere to stringent regulations that include:
Security management
Record keeping
Handling
Labeling
Storage
Non-compliance can result in license revocation and criminal prosecution.
State and Territory Legislation
Acts and Regulations
Each state (e.g., Queensland) has its own act, often known as a Poison Act or Poisons Regulation (named differently in various states).
Regulations typically cover:
Agricultural poisons
Domestic pesticides
Prescription medications
Veterinarian needs.
Acts provide an overarching framework, while regulations detail the specific handling of medicines.
Drug Scheduling in Australia
Purpose of Drug Scheduling
Categorizes medicines based on their:
Potency
Therapeutic use
Toxicity
Addictive and abusive potential
Safety and modes of action.
Medicines with lower safety risks fall into lower schedule categories.
The scheduling committee aims to create uniform standards across states.
Major Schedules Covered
Schedule 2 (S2): Pharmacy Medicine
Available to the public typically only through pharmacies.
In remote areas, a licensed person may provide products if a pharmacy is unavailable.
Examples: Paracetamol, cold and flu medications (notably requiring pharmacist advice for large quantities).
Schedule 3 (S3): Pharmacist-Only Medicine
Available to the public only through pharmacies, requiring pharmacist involvement.
No prescription is required.
Pharmacist may inquire about health to provide suitable options.
Examples: Ventolin inhalers, EpiPens.
Schedule 4 (S4): Prescription Only Medicine
Requires a prescription from authorized providers (typically doctors or dentists).
Stored in dispensaries with access restricted to the public.
Some specially qualified nurses, optometrists, and podiatrists may prescribe a limited range of S4 drugs.
Examples: Blood pressure medications, cholesterol medications, antibiotics, antidepressants, oral contraceptives.
Schedule 8 (S8): Controlled Substances
Substances that may cause dependence and have strict regulations.
Their manufacture, supply, distribution, and possession are highly restricted.
Possession without authority is illegal.
Must be stored in locked cabinets (often bolted down).
Logging requirements may require records to be kept for up to five years.
Examples: Morphine, methadone, fentanyl, dexamphetamine, Endone (oxycodone hydrochloride).
Summary and Implications
Understanding these acts and drug scheduling is crucial for health professionals regarding compliance with legal standards when handling and prescribing medications.
Awareness of the varying laws and regulations across states and the implications of non-compliance is essential for practicing nursing and other health-related professions.
Health Professionals and the Law Overview
Discussion focuses on health professionals' responsibilities regarding restricted substances and common law related to duty of care in nursing.
Emphasis on Schedule 4 (S4) medications and Schedule 8 (S8) controlled drugs.
Restricted Substances
Definition of Schedule 4 Medications:
Schedule 4 medications are drugs that require a prescription for dispensing.
Different terms used include:
Restricted substances
Restricted drugs
Prescription drugs
Prescription only medicines
Poisons
Authority to Prescribe S4 Medications
Typically, those who can prescribe S4 medications include:
Doctors
Dentists
Veterinary surgeons (when necessary)
Increasing authorizations for certain health professionals:
Nurse practitioners
Optometrists
Podiatrists (in limited circumstances)
Emergency Prescribing
Verbal Orders:
In emergencies, a doctor can provide a verbal order for medication administration.
This order must be documented within 24 hours following the verbal communication.
Nursing Authority Regarding S4 Medications
Nurses (aside from nurse practitioners) do not have independent authority to administer S4 medications without a physician’s written order.
Medication charts must be signed by a physician for legal compliance.
Storage and Accountability in Hospitals
Pharmacists are responsible for the storage and documentation of S4 medications.
Community pharmacies maintain records for at least 3 years.
Medications stored in a locked facility to prevent unauthorized access.
In hospital wards:
The responsible nurse must hold the key to the locked storage.
Remote Area Care Guidelines
In remote areas (e.g., Northern Territory, parts of Queensland, Tasmania), limited access to doctors may require nurses to diagnose and dispense medications.
Nurses must apply for authority from relevant health authorities to carry out these duties.
This responsibility includes conducting triage and managing medications as necessary, based on established protocols.
Controlled Drugs (Schedule 8)
Definition and Risks:
Schedule 8 drugs are controlled drugs, including:
Prohibited substances
Drugs of dependence
Prescribing authority is restricted to:
Doctors
Dentists
Veterinary surgeons (limited)
Some nurse practitioners may have authorization within their scope of practice.
Emergency Administration of Controlled Drugs
Nurses may administer controlled drugs in emergencies with verbal instruction from a doctor, which also requires documentation within 24 hours.
Security Measures for S8 Medications
Controlled drugs must be stored in a locked cupboard or safe.
The pharmacist’s safe is often bolted to a secure structure for safety.
Only authorized nursing staff in charge of the ward or under supervision may access these medications.
Documentation Requirements for Controlled Drugs
Nurses must maintain a ward drug book for controlled substances, documenting:
Patient's name
Prescribed medication and dosage
Prescribing doctor’s name
Date and time of administration
A balance check of medication must be carried out to ensure proper accounting.
Regular audits and internal checks on medication balance are mandatory.
Disposal Practices for Controlled Drugs
Disposal must occur in compliance with state regulations and involve two nurses for oversight to prevent misuse.
Common Law and Duty of Care
Definition of Duty of Care
Health professionals must take reasonable care to prevent harm from negligent handling and administration of medications.
Each nurse's duty of care is informed by their professional training and standards expected post-qualification.
Rights of Medication Administration
Nurses must adhere to a minimum of five rights of medication administration:
Right patient
Right drug
Right dose
Right route
Right time
Failure to follow these rights may constitute a breach of duty of care, resulting in patient harm due to medication errors.
Compliance with Policies and Legislation
It is a legal requirement for workplace protocols to align with the law.
Nurses should not assume that all policies comply with current legislation and must seek clarity on ambiguous orders.
Handling Unclear Orders and Telephone Orders
Unclear Orders
If a medication order is unclear, nurses should:
Question the prescribing doctor about the intention behind the order (e.g., dose, timing).
Avoid making assumptions; seek clarity.
Telephone Orders
Follow workplace policy for handling telephone orders, which generally includes:
Obtaining the order in writing as given verbally, including medication names, doses, routes, and frequency.
Asking the doctor to repeat the order and confirming the details.
Documenting all order details immediately in the medicine order chart, noting it is a telephone order.
Ensuring compliance within 24 hours by having the physician sign and a second nurse counter-sign the order.
Standing Orders
Standing orders allow nurses with proper training to administer certain medications without direct physician orders in predefined circumstances.
These orders are applicable in emergencies or during procedures (e.g., post-operative pain management).
Nurses must adhere strictly to established protocols when executing standing orders, ensuring professional boundaries are maintained.
Introduction to Ethical Principles
Focus of Lecture: Understand the principles of ethics in relation to medication administration.
Learning Objective: Describe the six principles of ethics and their application to patient medication administration.
Overview of the Six Ethical Principles
Autonomy
Definition: The right of patients to make their own healthcare decisions.
Significance: Encourages respect for individuals' preferences and choices regarding their treatment options.
Application: Health professionals must inform patients about treatment options and respect their decisions, even if they choose not to follow recommendations.
Beneficence
Definition: The ethical principle of acting in the best interest of the patient by promoting good and preventing harm.
Significance: Ensures healthcare providers actively contribute to the well-being of their patients.
Application: In medication administration, this includes administering treatments that are effective and beneficial while ensuring patient safety.
Nonmaleficence
Definition: The obligation to abstain from causing harm to patients.
Significance: Emphasizes the duty of healthcare providers to prevent harm in both actions and omissions.
Application: When prescribing medication, careful consideration must be taken to avoid harmful side effects and adverse reactions.
Justice
Definition: The principle of fairness in medical treatment and allocation of resources.
Significance: Advocates for equitable treatment for all patients regardless of their background or circumstances.
Application: In medication administration, this principle mandates fair access to prescriptions and treatments for all patients without discrimination.
Veracity
Definition: The commitment to truthfulness and honesty in all interactions with patients.
Significance: Builds trust between patients and healthcare providers.
Application: Health professionals must provide clear and accurate information regarding medications, including potential risks and benefits.
Fidelity
Definition: The principle of being faithful to commitments and obligations, especially regarding promises made to patients.
Significance: Reinforces the importance of loyalty and responsibility in the patient-healthcare provider relationship.
Application: This includes keeping promises about medication regimens and following through with care plans.
Conclusion
Understanding these six ethical principles is crucial for healthcare professionals when engaging in medication administration.
Ethical considerations will guide the decision-making process and promote high standards of patient care.
Overview of Ethical Principle Three: Non-Malfeasance
Context of Voluntary Assisted Dying Laws in Australia
Recent changes to voluntary assisted dying laws across Australia have been enacted.
Each state and territory's status:
Victoria: Law operational.
Western Australia: Law operational.
Tasmania: Law operational.
Queensland: Laws active since January 1, 2023.
South Australia: Laws in effect since January 31, 2023.
New South Wales: Laws passed with implementation expected by November 28, 2023.
Australian Capital Territory (ACT): Previous ban lifted, legislative discussions anticipated for 2024.
Importance of Knowledge and Compliance
Necessity for healthcare providers to be knowledgeable about the specific laws in their state; legal guidelines may differ.
Healthcare facilities may not universally accept voluntary assisted dying, highlighting the importance of checking local policies and legal frameworks.
Encourage verification of individual facility practices regarding voluntary assisted dying.
Process of Requesting Voluntary Assisted Dying
Sequence of steps involved in accessing voluntary assisted dying:
Initial Request: Patient expresses interest to their healthcare practitioner.
Eligibility Assessment: Conducted by two independent practitioners (a two-step verification process).
Written Request: Patient submits a second, formal request in writing.
Administration Decision: Decision made regarding approval for voluntary assisted dying.
Prescription and Dispensation: If approved, medication prescribed and dispensed.
Administration of Medication: Patient can self-administer or receive assistance from a practitioner.
Data on Voluntary Assisted Dying in Victoria
Over three years, around 1,400 requests for voluntary assisted dying were documented:
Approximately 1,000 permits issued, indicating a screening process for eligibility.
604 individuals proceeded to end-stage, receiving the medication, either self-administered or administered by a healthcare professional.
Demographics of Individuals Requesting Voluntary Assisted Dying
Majority of applicants (about 75%) were aged 65 years or older.
Breakdown of age categories:
Age 18-54: A minority portion of applicants.
Age 55-64: Another proportion, less than the older demographic.
Palliative Care: 81% of these individuals were receiving palliative care at the request time.
Terminal Diagnoses: High incidence (over 80%) of malignant diagnoses, predominantly cancers, with about 17% presenting non-malignant diagnoses:
Most common conditions included neurodegenerative disorders such as ALS, with eligibility typically requiring patients to be within the last 6-12 months of diagnosis.
Barriers to Accessing Voluntary Assisted Dying
Not all healthcare providers can initiate conversations; it must come from the patient.
Documentation required to verify Australian citizenship or permanent residency; issues in locating paperwork may exclude individuals from the process.
Limited access due to a shortage of eligible and willing doctors who have undergone the mandatory training.
Complicated processes can lead to undercompensation for doctors involved due to lengthy administrative duties.
Some aged care facilities and healthcare providers do not support or facilitate access to voluntary assisted dying.
Increased barriers for access in rural or remote areas compared to metropolitan regions, emphasizing the need for consideration of regional healthcare disparities.
Medical Adherence Education Advocacy
Introduction
The lecture will focus on medical adherence education advocacy and the quality use of medicines.
Objective: Understanding the role in helping with medicine adherence education and client advocacy.
Reference readings listed for further study.
Medicine Adherence
Definition:
Medicine adherence refers to the compliance of a person to a prescribed medicine regimen, which includes:
Dose
Method of administration
Frequency
Specific recommendations and precautions for that medicine.
Non-Adherence
Definition:
Non-compliance occurs when patients diverge from their prescribed medication regimen.
Ideal scenario: 100% compliance and adherence is not realistic.
Reasons for Non-Adherence
Multiple factors can contribute to non-adherence:
Personal characteristics:
Cost of medications can prohibit adherence.
Patient-Health Professional Interaction:
Communication barriers may hinder understanding of medication.
Chronic Conditions:
Long-term conditions without a cure can diminish patients’ motivation to follow medication regimens.
Perceived Efficacy:
Patients may not perceive the benefits of treatment, leading to discontinuation.
Complicated Regimens:
Complex medication schedules can overwhelm patients, impacting adherence.\n
Strategies for Improvement
Use Consumer Medication Information forms (CMIs) for patient education:
Pharmacist provides information upon the start of a new medication to enhance understanding.
Nurse's Role:
Individualize instructions based on patient’s circumstances to improve adherence rates.
Emphasize understanding patients' beliefs and values, cultural backgrounds, and preferences (e.g., preference for herbal remedies).
Cultural Competency in Medication Adherence
Cultural Considerations:
Understanding different cultural perspectives on health and illness can enhance adherence:
Example: First Nations peoples in Australia may have differing health beliefs and practices affecting adherence.
Higher rates of chronic conditions (e.g. hypertension, diabetes, rheumatic fever).
Community and spiritual beliefs significantly influence treatment perceptions.
Practical Application:
Use natural indicators (e.g., sun and moon) as reminders for medication timing instead of structured times.
Simplification: Once-a-day dosing can enhance adherence in populations with different time perceptions.
Medicine Education and Learning
Facilitating Adherence Through Education
Assist in the transfer of information to the patient about their medications:
Key aspects to consider for effective learning:
Active Participation:
Involvement in their medication process increases success.
Motivation to Learn:
Assess underlying motivations; consider personal background and condition.
Prior Experience and Knowledge:
Utilize previous experiences to enhance engagement.
Immediate Application of Knowledge:
Patients retain more if they apply knowledge immediately.
Readiness for Learning:
Assess physical, mental, cultural, and spiritual readiness.
Expectations and Goals:
Understand personal goals to tailor education.
Reinforcement through Repetition:
Frequent practice leads to better retention and understanding.
Teaching Principles
Effective Teaching Methodologies:
Build rapport and communicate effectively with patients:
Importance of empathy and friendliness in interaction.
Controlling the Learning Environment:
Minimize distractions to enhance concentration.
Establishing a Mutually Negotiated Contract:
Collaboratively set learning goals with the patient.
Employing Various Teaching Methods:
Group activities, one-on-one discussions, visual aids, read-back scenarios.
Client Advocacy
Role as a Client Advocate:
Inform patients of their rights to enable informed decision-making.
Support patients in making their choices, protecting their interests.
Challenges:
Adversaries (e.g., other health professionals, family members, policies) may disempower patients.
Nurses can empower patients by providing information and support in decision-making.
Quality Use of Medicines
Overview of National Medicines Policy (Australia)
Established around 2000 with four key aims:
Timely access to affordable medicines.
Medicines meeting quality, safety, and efficacy standards.
Appropriate usage of medicines.
Maintenance of a viable medicines industry.
Quality Use of Medicines Components
Judiciousness:
Selecting management options wisely.
Non-medicinal alternatives should be considered before medication:
Example: Positioning patients to alleviate pain instead of medication.
Appropriateness:
Choosing the right medicine based on clinical condition, risks, benefits, dosage, and cost:
Example: Ensuring the correct antibiotic is used based on test results.
Safety and Effectiveness:
Minimize misuse and ensure therapeutic benefits are achieved:
Example: Transitioning a patient from IV antibiotics to oral medication when appropriate.
Conclude with a reminder to think about quality use of medicines in nursing roles.
Clinical Decision Making Processes Overview
Focus on clinical decision making processes, medicine administration, and documentation.
Emphasizes individualized care considering all aspects of a patient’s condition.
The nursing role involves gathering and organizing information to plan, administer, and evaluate nursing care.
Acronym: ADPIE
Represents the steps involved in nursing process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
Logical sequence indicating a comprehensive approach to patient care.
Assessment
Purpose: Collect comprehensive information to inform individualized medicine therapy.
Data Collection Strategies:
Direct Interaction: Engage with the patient to gather information.
Family Collaboration: Involve family members for historical data and support.
Interprofessional Collaboration: Work with other healthcare professionals involved in the patient’s care.
Physical Assessment: Conduct a physical exam of the patient.
Diagnostic Reviews: Examine existing medical records and laboratory results.
Types of Data Collected
Objective Data: Unbiased facts such as test results and physical assessments.
Subjective Data: Personal insights from patients about their feelings, values, expectations, and experiences with their medication.
Questions to Guide Assessment
Current medicine orders and history of previous medications.
Patient’s knowledge about medications, including adverse reactions.
Special diets or fluid restrictions possibly affecting medication.
Immunization status and attitudes toward medications.
Communication barriers and ability to swallow tablets.
Diagnosis
Definition of Diagnosis in Context: Identification of actual or potential issues regarding medication administration, not a medical condition diagnosis.
Identify Issues: Understand reasons for non-adherence or complications in taking medications.
Possible reasons for non-adherence:
Misunderstanding instructions.
Financial constraints preventing purchase.
Physical barriers to accessing prescriptions.
Lack of knowledge regarding drug therapy and administration.
Assess potential risks: Knowledge deficits in self-administration may lead to fear of medication use.
Considerations in Diagnosis
Patient education deficiencies impacting understanding of medication therapy.
Potential for injury due to adverse drug reactions, especially concerning central nervous system effects.
Planning
Formulate a plan including expected outcomes for medication therapy.
Goals:
Short-term Goals: Immediate improvements, relevant to hospital settings or home care visits.
Long-term Goals: Outlined for comprehensive health promotion, education, and rehabilitation.
Important Goals to Establish:
Ensure the patient receives appropriate education regarding the medication regime.
Guarantee safe administration of medications.
Implementation
Actioning the Care Plan:
Administer medication based on established prescriber orders, following protocols and policies.
Provide additional support/education to patients unfamiliar with medication administration, especially insulin injections.
Types of Planning
Independent Care Plans: No need for collaboration with other healthcare professionals.
Interdependent Care Plans: Involve teamwork with dietitians, diabetes educators, etc., to enhance medication management.
Evaluation
Review the effectiveness of the care plan:
Assess if planned goals were achieved and outcomes met, focusing on therapeutic benefits.
Evaluate:
Any adverse or unwanted reactions to medications.
Issues arising with patient compliance and adjustments needed.
Drug interactions with food or other medications.
Verify the administered doses remained within the therapeutic range to avoid toxicity or ineffective treatment.
Five Rights of Medicine Administration
Right Medicine: Verifying the accuracy of the prescriber’s order; confirm the medication is appropriate for the patient’s condition.
Right Dose: Correct interpretation of measurements and assessment of appropriateness for the patient's age/condition.
Right Person: Identifying the patient accurately using multiple identifiers (name, date of birth, health ID).
Right Route of Administration: Confirming the proper delivery method matches the prescribed treatment.
Right Time: Administering medication within a defined time frame, no more than thirty minutes deviation from scheduled times.
Three Checks of Medication Administration
Perform checks at three critical points:
Check patient ID when retrieving the medication.
Check medication during preparation.
Check medication again before administration.
High-risk medications requiring double-checking by two registered nurses include:
Parenteral therapies, blood transfusions, opioids, digoxin, and warfarin.
Documentation Procedures
Importance of accurate documentation in preventing medication errors:
Utilizing standardized medication charts for consistent record-keeping.
Additional forms may be required for specific medications with special requirements (e.g., diabetes management).
Emphasize thorough documentation to capture all essential information systematically.
Introduction to Medication Errors
Definition: Medication errors are unintended mistakes that occur during the prescribing, dispensing, or administering of medications.
Characteristics:
Not planned or deliberate.
Occur along the entire medication pathway.
Must be viewed as preventable errors with potential to cause harm.
Impact of Medication Errors
Possible Outcomes:
No harm caused to the patient.
Minimal harm where swift interventions mitigate effects (e.g., monitoring after giving incorrect dosage).
Serious harm or death resulting from compounded errors (e.g., successive errors by different caregivers).
Causes of Medication Errors
Distractions: Noisy, busy environments can lead to lapses in attention.
Unfamiliar Settings: Agency nurses may work in unfamiliar areas, leading to increased risk.
Unfamiliar Medications: Lack of knowledge about medication mechanisms, contraindications (e.g., chemotherapy drugs).
Similar Packaging or Names: Risk of mixing up medications with similar attributes (e.g., Aldactone vs. Aldomet).
Procedural Noncompliance: Failing to adhere to established protocols can lead to errors.
Categories of Medication Errors
Admission Errors: When a prescribed medication is not administered.
Example Scenarios:
Patient not present for administration (e.g., ongoing tests).
Withholding medication for pending laboratory results.
Documentation: Use specific codes, document in medical notes, inform the healthcare team.
Procedural Errors: Missteps resulting from not following procedures.
Examples:
Wrong medication administered due to mix-up.
Incorrect dosage from illegible prescriptions.
Wrong time of administration (contraindicated co-administration).
Patient identity not verified leading to administration of another's medication.
Incorrect dosage ordered on medication charts.
Strategies to Prevent Medication Errors
Administration Safety for Nurses
Review Prescription: Ensure clarity and suitability of the prescribed medication.
Prepare Medication: Verify:
Check for the correct item,
Correct dose,
Correct strength,
Correct route,
Medication date.
Patient Identification:
Double-check patient’s full name, date of birth, and medical records.
Verify allergies (e.g., through wristband checks).
Documentation:
Sign medication charts,
Document if medication is not given and reasons promptly.
Monitoring Patient Response:
Observe for therapeutic effects or adverse effects following administration.
General Guidelines to Avoid Errors
Read Orders Carefully: Do not assume correctness based on prior administration.
Query Discrepancies: Always ask questions if unsure; collaboration is critical (e.g., consult senior nursing staff).
Use Up-to-Date References: Maintain access to current medical literature and drug databases (e.g., MIMS).
Quality Use of Medicines: Responsible medication administration requires knowledge and awareness of pharmacology.
Five Rights & Three Checks: Reiterate these fundamental practices for safe medication administration.
Check Patient Compliance: Ensure patients are taking medications correctly, such as proper swallowing of oral medications to prevent issues.
Document Thoroughly: Every action and observation surrounding medication administration should be documented to enhance accountability and patient safety.
Consequences of Medication Errors
In the Event of an Error
Stay Calm: Acknowledge the mistake to avoid panic.
Report the Error: Inform your supervisor or a senior RN immediately.
Patient Monitoring: Observe the patient for any adverse effects or deterioration in health.
Document Details: Include the incident in the patient's medical records and medication chart.
Incident Report: Follow the facility's protocol for completing an incident report.
Reassurance: Keep the patient informed and supported throughout the process.
Professional Responsibilities
Final Checkpoint Responsibility: Nurses serve as the last line of defense in medication administration.
Commitment to Quality: Uphold legal and professional responsibilities regarding medications, which includes thorough knowledge of each medication administered to patients.