Safe drug administration is an NHS priority and fundamental standard of the Care Quality Commission (CQC, 2016); this is important because midwives' errors in drug administration are reflected in Local Supervising Authority (LSA) investigations, often culminating in supervised practice (Nursing and Midwifery Council (NMC), 2014). Drug errors have also accounted for maternity claims in excess of £8 million (NHS Litigation Authority, 2012); hence, the clinical discussion in this article is focused on clinical aspects affecting safe drug administration.
The NHS has sought to reduce errors in drug administration (National Patient Safety Agency (NPSA), 2009; NHS England, 2014) and, in spite of the NHS ‘never event’ strategy (NHS England Patient Safety Domain, 2015), little is known about the extent of drug errors in maternity care since the earlier work of Birch and Culshaw (2003). However, 86 086 medication incidents were reported to the National Reporting and Learning System (NPSA, 2009) in the period 2005–10, which provides safety guidance on drug errors. Hospital trends for drug errors have been reported between 3–8% (Cousins et al, 2012); however, the reliability and accuracy of reporting systems has been questioned (Dückers et al, 2009). Drug errors may include preparing, administering and monitoring the effects of drugs (NHS Commissioning Board, 2013; NHS England, 2014); this is crucial, because at least one third of errors occur during administration i.e. at the interface of midwifery care (Smeulers et al, 2015).
Those drugs associated with most errors—all of which are used in maternity care—are (NPSA, 2009):
Therefore, midwives must be fully aware of the major factors influencing safe drug administration, of which legislation is an important aspect. It is impossible to discuss the clinical role of the midwife in this respect without considering the framework that underpins safe drug administration in midwifery practice. For example, in the course of their professional practice, midwives may administer on their own initiative any of the substances specified in medicines legislation under ‘midwives exemptions’ (NMC, 2011). Historically, midwives were exempted from the general rules by the Prescription Only Medicines (Human Use) Order 1997 and the Medicines (Pharmacy and General Sale–Exemption) Order 1980, and are required to comply with the Human Medicines Regulations 2012. From a professional accountability perspective, midwives must apply the Standards for medicines management (NMC, 2007) framework in order to minimise drug errors. In particular, Standard 8 requires midwives to clinically ascertain whether it is safe to administer any drug to women in their care (NMC, 2007: 24). Essentially, the framework requires midwives to confirm safe principles prior to administering drugs i.e. the right reason, person, drug, time, dose, route, response and documentation.
Errors in drug administration
A failure of midwives to comply with safety standards can incur tragic consequences; for example, the case of a newly delivered mother erroneously injected with an epidural agent into her arm instead of an intravenous infusion of normal saline (Lister, 2006). To minimise such events, the NPSA circulated safer practice notices for epidurals, infusions and injectable medicines (NPSA, 2007a; 2007b) and, although such alerts have had a positive impact on patient safety (Lankshear et al, 2011), serious drug errors still occur. Errors in insulin administration have resulted in an emphasis, for all clinical staff, on the importance of adequate training on safe administration (NPSA, 2010). Midwives should be aware that insulin dosing errors commonly arise owing to the use of generic syringes rather than bespoke insulin syringes, the wrong type of insulin, or the omission of insulin doses (National Diabetes Information Service, 2011). Midwives can improve their clinical proficiency in insulin administration by accessing the NHS diabetes e-learning resource (Healthcare e-Academy, 2013).
Safe drug administration and student midwives
It is known that safety can be compromised by the working environment (Francis, 2013; Kirkup, 2015). Worryingly, a recent Royal College of Midwives (2016) survey reported that, owing to exhaustion, 52% of staff witnessed errors which could harm women. Notwithstanding these issues, agencies work towards minimising drug errors in clinical practice. The Medicines and Healthcare products Regulatory Agency (MHRA) is the executive body responsible for promoting good practice in the safe use of medicines. Both the MHRA and the NMC (2011) expect midwives to assess the competency of student midwives in clinical practice; these bodies determine the drug administration tasks in which students may and may not engage. Student midwives may not under any circumstances administer controlled drugs, epidurals or intravenous medication. Student midwives are permitted to administer medication within the midwives exemptions list (except controlled drugs) under the visual and audible supervision of a midwife who must be an approved ‘sign-off mentor’ (NMC, 2011: 3). Midwives should be aware of what students can and cannot do regarding drug administration (Table 1).
| Student midwives must not under any circumstances administer: |
| Controlled drugs |
| Epidurals |
| Intravenous bolus injections |
| Drug additives into intravenous fluids |
| Intravenous fluids on their own responsibility |
| Under direct supervision from a sign-off mentor, student midwives are permitted to: |
| Administer drugs on midwives exemptions list (except those specified) |
| Administer medications prescribed by a medical practitioner on a valid prescription (except intravenous drugs) |
| Verify intravenous fluids against a valid prescription |
| Verify prescribed additives against a valid prescription (except controlled drugs) |
| Discontinue intravenous infusions/de-cannulate |
‘A failure of midwives to comply with safety standards can incur tragic consequences’
Finally, in considering the overall framework within the NMC (2007)Standards for medicines management and to minimise drug errors, it is important that midwives apply the key principles of safe drug administration. The main aspects of midwifery care, both pre- and post-drug administration, are summarised below.
Pre-administration of drugs
The key aspects of care before drug administration are as follows:
Post-administration of drugs
The key aspects of midwifery care after drug administration are:
‘Multi-agency attempts to minimise drug errors are consistently undertaken; midwives must remain up to date with these strategies and be aware of the reporting requirements for drug errors and adverse drug reactions’
Conclusion
Midwives must be fully aware that human error is responsible for drug administration problems and the consequences can be tragic. Consequently, multi-agency attempts to minimise drug errors are consistently undertaken; midwives must remain up to date with these strategies and be aware of the reporting requirements for drug errors and adverse drug reactions.
The NMC (2007)Standards for medicines management is a framework that promotes safety by determining a series of steps designed to ensure good practice. Midwives do not prescribe, but administer on their own responsibility those drugs listed in midwives exemptions, and this initiative provides midwives with specific accountability. Finally, midwives must be fully aware of their role in the delegation of duties to students in respect of drug administration. Midwives are constantly challenged by working environments that lack resources, and this can have an impact on their ability to ameliorate unsafe practice. However, it is only by attention to detail during the pre- and post-drug-administration process that midwives will help to minimise errors in drug administration.
Key Points
Revalidation claim: Continuing professional development/40 hours
This section provides an example of how this article might be used as material for reflection for use as part of a midwife's revalidation with the Nursing and Midwifery Council (NMC). Evidence for revalidation should be linked to the NMC Code and should demonstrate the impact that the learning has had on your practice.
Step 1: Context for the revalidation claim (link your learning activity to the Nursing and Midwifery Council Code)
| Nursing and Midwifery Council Code | Description | Focus of revalidation claim √ |
|---|---|---|
| Prioritise people | Act in the best interest of people (service users) at all times | √ |
| Practise effectively | Use best available evidence to assess client need and deliver treatment/care/advise on care | √ |
| Preserve safety | Work within your skills and knowledge (competence) and use your skills and knowledge to keep people (clients) safe | √ |
| Promote professionalism and trust | Act in line with the standards of practice and behaviour to uphold the reputation of the nursing and midwifery professions | √ |
Step 2: Contextualising your learning
| Questions to consider | Example answers |
|---|---|
| What did you think about on reading this clinical practice article? | This article was useful for increasing my awareness of the current legislation underpinning midwifery practice in respect of safe drug administration. I read online that drug errors are a significant cause of midwives' referral to the Nursing and Midwifery Council (2014) for unsafe practice. Hence, this article emphasised the importance of the midwife's professional accountability |
| Why do you think the content made you feel like this? | The content of the article reassured me that my current level of understanding is contemporaneous and allowed me to access further reading on safe drug administration (Care Quality Commission, 2016) Regulation 12: Safe care and treatment |
| What did you learn as a consequence of reading the article? | The article gave a general overview of medicines management, with the emphasis on good practice as referenced by the Nursing and Midwifery Council (NMC). In particular, it allowed to me reflect on the possible outcomes of not adhering to the NMC medicines management framework (NMC, 2007). This also reminded me of my professional accountability in respect of the NMC (2012) Midwives rules and standards and Rule 5: Scope of practice. It specifically made me reflect on the role of the midwife in ensuring communication and consent prior to drug administration (NMC, 2015) |
Step 3: Reflective account: the impact/influence that the article has on your practice
| Questions to consider | Example answers |
|---|---|
| What have you done to complete the learning? | I read two further articles: |
| What is the effect of your learning? | This article included an example of a tragic outcome of a drug error, whereby a newly delivered mother died following the intravenous injection of an epidural drug instead of the prescribed normal saline (Lister, 2006). I have learned that, as a result of this tragedy, safety mechanisms were introduced in the NHS (National Patient Safety Agency, 2007a) to ensure safer practice with epidural injections and infusions. This reminded me that, regardless of how busy the environment of care, there must never be shortcuts in verifying correct drug by correct route, and two people must always verify the drug |
| What will you do differently as a result of reading the article? | I will use the article with student midwives to clarify what they are and are not permitted to do in respect of drug administration, especially where midwives exemptions arise (Nursing and Midwifery Council (NMC), 2011). I will ensure all students under my care only administer drugs under the direct supervision of a registered sign-off mentor. I will also ensure students are visually and audibly supervised during this process. I will use the NMC (2007) Standards for medicines management as a framework for minimising drug errors. I am reminded of working in partnership to enhance the safety of maternity care and will ensure effective communication and client consent prior to drug administration (NMC, 2012; 2015) |