Training Module for Nurses

Primary & Secondary Healthcare Department

05.07.2024

1
Management of Medications

1 Medication Handling &

Safety

Medication Preparation,
2 Infection Prevention &
Control

Medication
3 Administration &
Monitoring

Adverse Drug Reaction

4 Reporting &
Management

3
Management of Medications

1 Medication Handling &

Safety 1 Management of LASA & HAMs

Medication Preparation, 2 Double checking of Medications & Verification of orders

2 Infection Prevention &
Control

3 Unit dose dispensing & Crash Cart maintenance

Medication
3 Administration &
Monitoring
4 Safe storage of Medications

Adverse Drug Reaction

4 Reporting & 5 Routine Expiry Check & Near expiry intimation to Medicine Store
Management

4
Management of LASA & HAMs

1 General Principles

2 Procurement & Storage

3 Prescribing

4 Preparation

5 Dispensing

6 Administration

7 Monitoring

5
List of High Alert Medications (HAMs)

Prepare a list of Look Alike & Sound

Alike (LASA) Drugs based on the
available medicines/incident/error reports
of your health facility and display at all the
nursing stations & doctor’s office.

6
Some common combinations of Look Alike Drugs

Inj. Lignocaine 2%,

Inj. Calcium Gluconate 1g Inj. Adrenaline 1mg Different strengths of Inj. Enoxaparin
Adrenaline
Inj. Aminophylline 250mg Inj. Atropine 1mg 20mg, 40mg, 60mg & 80mg
Inj. Lignocaine 2%

7
Double checking of Medications & Verification of orders

❑Review the order is complete, legible, and includes the medication name, dose, route, and frequency.

❑Check that order is signed by a licensed healthcare practitioner/doctor.

❑Seek clarification from the healthcare practitioner/doctor, if any part of the order is unclear or
ambiguous.

❑Use Read-back/Repeat-back Techniques to confirm verbal or telephone orders.

❑High Alert Medications List to be displayed at Doctor’s office, Nursing counter, Pharmacy & storage
areas and SOP’s for double checking.

8
 Guidelines have been
issued by DDCP for
Unit Dose Dispensing &
Crash Cart Maintenance
dated 01.09.2023

9
Cautionary Labels to be used for the tagging of LASA & HAMs
 1. Adequate number of qualified personnel available.
2. Adequate segregation to minimize the risk of mix-up.
3. Proper cleanliness, hygeine, humidity & temperature.
4. Storage should be off the floor and suitably spaced to permit
ventilation, cleaning and inspection.
5. Installed equipment should be validated and calibrated.
6. Vehicles deployed should be protected from environmental/weather
conditions.
7. Narcotic, Psychotropic & Radioactive substances be stored
Checklist for 8.
separately with proper record keeping.
First Expire / First Out Rule (“FE/FO”).
Good Storage 9.
10.
Adequate controls to prevent dispensation of expired products.
Expired, broken & damaged items be stored separetely, properly
Practices 11.
labelled and marked.
Temperature sensitive products should be kept in refrigerator and
temperature monitored with thermometer to ensure consistency
within required limits.
12. Storage conditions in compliance with the labelling instructions and
requirements.
13. Buildings shall be kept free of insects, birds, vermin and other
pests.
14. Temperatures above 40ºC & Relative Humidity above 70% are
considered extremes.
Do’s and Don’ts of Good Storage Practices that Pharmacists should follow
DON’Ts of Good Storage Practices

Large Volume Parenteral shouldn’t be used for reconstitution of Ampules shouldn’t be tapped for re-use in multiple patients - strict
Injections – strict violation of standard administration practices and violation of standard administration practices.
cause of pyrogenic response in patients.

Oral tablets & Injections shouldn’t be placed in a single box of Crash Poor maintenance of Medicine Crash Carts according to the
Cart – Increased risk of Medication Errors. Departmental SOPs/protocol.
13
DO’s of Good Storage Practices

Water For Injection of the same product must be used for Ampules are meant to be used once and then discarded, not be stored
reconstitution of dry powders/ dilutions. for any period of time.

LASA & HAMs shall be stored separately with proper labels. Medicine Crash Carts shall be labelled & maintained as per the
Departmental SOPs/protocol.
14
Routine Expiry Check & Near Expiry intimation to Medicine Store

❑Rotation of stock for implementation of FEFO Principle.

Regular Check
❑Regular check of all medications for expiry dates.

❑List of all the available medicines to be displayed in all the

Display of departments.
medicines list
❑List of Near Expiry items to be shared with Main Medicine
Store on timely basis.

15
Management of Medications

1 Medication Handling &

Safety 1 Hand Hygiene

Medication Preparation, 2 Use of Personal Protective Equipment (PPE)

2 Infection Prevention &
Control

3 Aseptic Reconstitution of Medicines

Medication
3 Administration &
Monitoring
4 Labelling of Multi-dose Reconstituted Vials

Adverse Drug Reaction

4 Reporting & 5 Procedures for handling and disposal of Medical wastes
Management

16
WHO Guidelines on Hand Hygiene

Hand rub Method Hand wash Method 17

Use of Personal Protective Equipment (PPE)

When & How to use masks: WHO guidelines WHO Gloves Use Information Leaflet
18
Aseptic Dispensing - Types
1 2 3

Sterile IV Admixtures/IV Cytotoxic Dispensing

Preparations Additive Solutions

4 5

Semi sterile Dispensing Total Parenteral

(Ear & Eye Drops) Nutrition
Aseptic Dispensing Technique

Assembling of all the products Surface cleaning of vial with Injection Reconstitution/dilution
inside the clean area aseptic solution/alcohol swab following aseptic techniques

Proper needle re-capping

Click on the below link for detailed procedure:
technique https://www.youtube.com/watch?v=u6nyf_scl4A
Aseptic Reconstitution of Medicines

❑Drug Incompatibilities (Drug-drug admixture, Y-site, Drug drug Syringe, Drug Solution incompatibility).

❑Current dilution practices vs standard guidelines.

❑Preparation of dilution and labelling.

❑Stability of safe & re-use reconstituted injections/vials.

❑ Storage conditions.

❑Precautions with needle prick injury.

Reference to be used for aforementioned topics; Micromedex, Lexicomp, Trissel’s Compatibility chart. 21
Labelling of Multi-dose Reconstituted Vials

All the health facilities shall get these labels printed as per their need and all the multi dose reconstituted vials be
tagged.
22
 Classification of
1
Medical Waste

Procedures for 2 Proper Segregation

handling and
disposal of 3 Handling & Storage
Medical wastes

4 Disposal methods

23
Management of Medications

1 Medication Handling &

Safety 1 Two steps Identification of Patient ( Patient name, MR Number etc.)

Medication Preparation, 2 “5 Rs” Principle of Safe Medication Administration

2 Infection Prevention &
Control

3 Double Check in case of LASA & HAMs

Medication
3
Administration
4 Allergy Check & Test Dose Protocol Implementation

Adverse Drug Reaction

4 Reporting & 5 Administration by Authorized Personnel only
Management

24
Two steps Identification of Patient ( Patient name, MR Number etc.)

❑Ask the patient to state their full name.

Patient Name
❑Confirm the name with the patient’s medical records.

❑Request the patient to provide their MR number, if they know it.

Medical Record
Number ❑Comparison of the provided MR number with the one in the
patient’s medical records.

25
 1 Patient

2 Medication
5 Right “Rs”
Principle of Safe 3 Dose
Medication
Administration 4 Route

5 Time

26
Double Check in case of LASA & HAMs Administration

❑Verify the medication order with the patient’s medical record.

First Check
❑Check the medication name, dosage, route, and timing against
the prescription.

❑A second nurse/healthcare professional independently verifies

the same information.
Second Check
❑Ensure both checks match before administering the
medication.

27
 Skin Prick Test Intradermal Skin Test
Punjab Healthcare
Types of Sector (Summary)
Allergy Testing

Skin Test OR

Different allergens injected into the

skin, if patient is allergic swelling,
redness, hives appears.

Allergy Testing Skin Patch

Test
Patch containing different allergens is
placed on the skin, leave for 48 hours.
Look the area every day for any signs
of allergic reaction.

Blood Test
To measure the amount of
Immunoglobulin E (IgE) antibodies
produce in your body in response to a
specific allergen.
 Intradermal Skin Test
❑Use a 27G needle/an insulin syringe at an angle
of 10-15ºC to facilitate needle entry into the
dermis.

❑Inject pre-determined volume (maximum 0.05

ml) slowly in order to raise a bleb 4-6mm in
diameter on the skin surface.

❑Results should be read 20 minutes after the test

for immediate reactions. Measure the bleb
diameter in mm.

❑Record flare.

❑An increase in wheal size of 3mm in diameter

beyond the initial bleb is considered “positive”.

Reference: Standard Operating Procedure Adult Intradermal Testing, British Society For Allergy & Clinical Immunology. 29
 Positive/Negative Allergy Skin Testing - Results

For detailed procedure of Immediate Hypersensitivity drug allergy testing, click on the below link;
https://youtube.com/watch?v=R9yWxDY3YCA 30
Allergy Check & Test Dose Protocol Implementation

Allergy card shall be available at all the nursing stations/wards and be issued to the patients experiencing Allergic
reactions, in case of positive results, accompanied by patient education/counselling by Healthcare Professionals.

31
Management of Medications

1 Medication Handling &

Staff education on recognizing signs and symptoms of Adverse
Safety 1
Drug Reactions (ADRs) and allergic responses

Availability of Suspected ADR Reporting (Yellow) & Drug and

Medication Preparation, 2
Device Complaint forms at Nursing Stations
2 Infection Prevention &
Control

3 Maintenance of ADR reporting register

Medication
3
Administration
4 Active liaison of staff nurses with Pharmacovigilance Officer

Adverse Drug Reaction

4 Reporting & 5 Ongoing Monitoring and Follow-Up of ADRs
Management

32
Suspected ADR Reporting (Yellow) & Drug and Device Complaint forms shall be
available at all Nursing Stations and outdoor outlets

Suspected ADR Reporting Form Drug & Device Complaint Form

33
Maintenance of ADR reporting register
Details to be mentioned on ADR Reporting Register:

❑ Patient Details (Name, age, gender & MR. No. etc).

❑Provisional Diagnosis

❑Medication Prescribed

❑Suspected Drug

❑Reaction Details

❑Management

❑Sign & Stamp of Nurse & Doctor

34
Thankyou.