The Six 'Rights' of medicine administration

1. The right drug;

2. At the right dose;

3. At the right time (and time interval);

4. By the right route;

5. To the right patient; and

6. Followed by the right documentation.

Controlled Drugs

Morphine Sulphate Injection is a Schedule 2 controlled drug which means it is subject in law to certain supply, storage, administration and recording requirements.

For paramedic use this means as a HCPC registered paramedic you are entitled to requisition, possess and administer morphine.

You are not entitled to supply morphine.

Under the law you must also keep a record of any morphine you obtain, administer or return for destruction.

In practice this means that only you, as the paramedic have access to the morphine and you must not allow anyone else access to this. Most Ambulance Trusts will have a policy that morphine is signed out to yourself at the beginning of a shift and the end, or when morphine is stored on a vehicle that you carry out a stock check at the beginning and end of every shift.

Any discrepancy must be reported to your line manager via your Trust's reporting system immediately.

This applies to any accidental breakages. In the case of accidental breakage the broken vial should be kept as evidence before disposal. Wherever possible, checks, administration and accidental breakage should be witnessed and countersigned.

It also means that any administration of morphine must be recorded on both your patient record, and in the Trust Controlled Drug book or Register. This includes the amount administered to the patient and any amount that is discarded (following Trust disposal policy).

For example, if you administer 5mg of morphine and discard 5mg this must be recorded and the morphine disposed of according to Trust policy.

You must not discard any unused out of date controlled drugs, these must be returned as per Trust policy.

Medicines Administration

The Human Medicines Regulations (2012) (HMR) allow administration of medicines under three circumstances.

1. By Patient Specific Direction (also known as a prescription). This is where a medicine is prescribed by an authorised prescriber. For paramedics this will include end of life medication. A paramedic must only administer within the instructions on the prescription and the administration must be recorded in the patients notes (and patient record) where other healthcare professionals can access them. In the case of end of life medicines this will be on the patients medicines administration record (MAR). Another example of use of patient's own medication is the use of Buccal Midazolam. (See example below).

2. By Exemption. Paramedics are allowed to administer parenteral medication in their own right for the immediate treatment of a sick or injured person. This list can be found under Schedule 17 of the HMR. Paramedics are also permitted to administer any medication found under Schedule 19. This is a list of medicines anyone can administer in a life threatening emergency. An important point to note is that medication such as Tranexamic Acid (TXA) is listed in JRCALC, but not actually covered under Schedule 17 or 19 of the HMR. Which leads to our third example;

3. By Patient Group Direction (PGD). A medicine may be administered under a PGD, for example TXA. A PGD will list a specific medicine, dose/s, indications and contraindications. A paramedic must follow a PGD as there is no legal exemption for administering a medicine outside of this PGD. In order for a PGD to be legal it must be signed by a Doctor, Pharmacist and the paramedic using it.

For example, TXA PGD will normally be for major trauma, postpartum haemorrhage and obstetric emergencies only. (Please check your local PGD as this may differ). In the case given, it may not be used for any other purpose even if you judge it to be in the patient's best interest. You must also follow the administration directions within your local PGD, either add to a bag of fluid and/or slowly infused over 10 minutes. Rapid bolus injection of TXA is not permitted.

When administering a patient's own Midazolam, please note that if the patient continues to fit then consideration should be given to obtaining IV access and giving a subsequent dose of 10mg IV Diazepam slowly over 2 minutes.

Only when given via the rectal route can 2 subsequent 10mg IV doses be given.