Medication

Practice Standard for registered nurses

This standard applies to LPNs, NPs, RNs, and RPNs.

Practice Standards set out requirements related to specific aspects of nurses’ practice. They link with other standards, policies and bylaws of the BC College of Nurses and Midwives and all legislation relevant to nursing practice.

This Medication practice standard outlines nurses'¹ accountabilities for providing safe nursing care to clients when performing activities involving medication.

“Medication” refers to Schedule I, IA, II, III, and unscheduled drugs as defined in the provincial Drug Schedules Regulation under the Pharmacy Operations and Drug Scheduling Act (PODSA).

Nurses have the authority to administer, dispense, and compound certain medications under the Nurses (Licensed Practical) Regulation, the Nurses (Registered) and Nurse Practitioners Regulation, and the Nurses (Registered Psychiatric) Regulation.

Nurses may administer, dispense, or compound medications to or for a client² by:

Acting with a client-specific order from an authorized health professional (‘require an order’).
Acting within their autonomous scope of practice (‘do not require an order’).

Nurse practitioners, registered nurses, and registered psychiatric nurses also have the authority to prescribe certain medications within their autonomous scope of practice under the Nurses (Registered) and Nurse Practitioners Regulation, and the Nurses (Registered Psychiatric) Regulation.

For specific scope of practice standards, limits and conditions related to administering, dispensing, compounding and/or prescribing medications, refer to BCCNM’s:

Scope of Practice for Licensed Practical Nurses: Standards, Limits, Conditions
Scope of Practice for Nurse Practitioners: Standards, Limits, and Conditions
Scope of Practice for Registered Nurses: Standards, Limits, Conditions
Scope of Practice for Registered Psychiatric Nurses: Standards, Limits, Conditions

Employers provide the organizational supports and systems necessary for nurses to meet the Standards of Practice.

Principles

All Medication Related Activities

1.	Nurses perform only those medication-related activities as allowed by:
	a.	Relevant provincial or federal legislation or regulations,
	b.	BCCNM standards, limits, and conditions,
	c.	Organizational/employer policies and processes, and
	d.	The nurse’s individual competence.
2.	Nurses follow relevant provincial or federal legislation or regulations, organizational/employer policies and processes, and BCCNM standards, limits, and conditions when performing any medication related activity³.
3.	Nurses use current evidence to support their decision-making about medications and their medication practices.
4.	Nurses follow infection prevention and control principles when performing medication-related activities.
5.	Before performing any medication-related activity, nurses know the medication’s:
	a.	Therapeutic use/indications,
	b.	Expected effects,
	c.	Dosage(s),
	d.	Precautions,
	e.	Contraindications,
	f.	Form (e.g. tablet, liquid), and route for administration,
	g.	Interactions,
	h.	Side effects, and
	i.	Adverse effects.
6.	Nurses assess the appropriateness of the medication for the client before administering, dispensing, or prescribing a medication.
7.	Nurses assess and respect the client’s values, beliefs, personal preferences, language, learning needs, abilities, mental state, and level of understanding, to support the client (or their substitute decision-maker) to be an active participant in making informed decisions about the medication.
8.	Nurses educate the client (or their substitute decision-maker) about the medication they are receiving, including, as applicable:
	a.	The reason the client is receiving the medication,
	b.	The expected action of the medication,
	c.	The duration of the medication therapy,
	d.	Specific precautions or instructions for the medication,
	e.	Potential side-effects and adverse effects (e.g. allergic reactions) and action to take if they occur,
	f.	Potential interactions between the medication and certain foods, other medications, or substances,
	g.	Handling and storage requirements,
	h.	Recommended follow-up.
9.	Nurses identify the effect of their own values, beliefs, and experiences on their clinical decision-making about medication-related activities; recognize potential conflicts and take action for the client’s needs to be met.
10.	Nurses take action when a medication does not seem:
	a.	Appropriate, because the client’s condition, needs, or wishes have changed,
	b.	Evidence-informed, or
	c.	Reflective of the client’s individual needs, characteristics, values/beliefs, or personal preferences.
11.	Nurses collaborate, communicate, and/or consult with the health care team in making decisions about medication-related activities, including:
	a.	Consideration of the broader plan of care for the client developed by the health care team,
	b.	The follow-up needed with respect to medication when the client’s care is transferred to another health professional, or when the client transfers to another clinical or care setting or to their home,
	c.	When the client’s care would benefit from the expertise of other health care professionals,
	d.	When the needs of the client exceed the nurse’s individual competence or scope of practice, and
	e.	Documenting the plan of care.
12.	When a pharmacist has not reviewed and verified a medication’s pharmaceutical and therapeutic suitability, or if it is unclear whether this has occurred, nurses take steps to ensure pharmaceutical and therapeutic suitability before administering or dispensing a medication by:
	a.	Reviewing the client’s best available medication history and other personal health information,
	b.	Assessing the client’s known allergies and ensuring medication allergy information is documented,
	c.	Considering potential medication interactions, contraindications, therapeutic duplications, side effects, adverse effects, and any other potential problems,
	d.	Using current, evidence-informed resources to support their clinical decision-making, and
	e.	Considering the client’s ability to follow the medication regimen.
13.	Nurses administer, dispense, or prescribe medications only for clients under their care, except in an emergency.

Medication Administration

14.	Before administering a medication to a client, nurses verify, at minimum, the:
	a.	Client name and second client identifier,
	b.	Medication,
	c.	Dose,
	d.	Time and frequency,
	e.	Route, and
	f.	Reason for administration to the client.
15.	Before administering a medication, nurses ensure they have the competence to:
	a.	Monitor the client’s response to the medication, and
	b.	Recognize and manage intended and adverse outcomes of the medication.
16.	Nurses only administer medications they themselves, a pharmacist, or a pharmacy technician have prepared, except in an emergency or during large-scale immunization efforts where organizational policies and processes are in place to ensure safe practices.
17.	Nurses record the administration of medication on an individual medication profile and/or client record each time a medication is administered.

Dispensing Medications

18.	When dispensing a medication, nurses:
	a.	Ensure the product has not expired,
	b.	Label the medication legibly with:
		i.	Client name and second client identifier,
		ii.	Medication name, dosage, route, and strength,
		iii.	Directions for use,
		iv.	Quantity dispensed,
		v.	Date dispensed,
		vi.	Initials of the nurse dispensing the medication,
		vii.	Name, address, and telephone number of the agency from which the medication is dispensed,
		viii.	Name and designation of the prescribing practitioner, and
		ix.	Any other information that is appropriate and/or specific to the medication,
	c.	Hand the medication directly to the client, or, if appropriate, to the client’s substitute decision-maker or other authorized delegate.
19.	When dispensing a medication, nurses record dispensing information on an individual medication profile and/or client record that includes:
	a.	Client name and second client identifier,
	b.	Allergies and adverse medication reactions, if available,
	c.	Date dispensed,
	d.	Name, strength, dosage of medication,
	e.	Quantity of medication dispensed,
	f.	Intended duration of therapy, specified in days (if applicable),
	g.	Directions to client,
	h.	Name of prescribing practitioner, and
	i.	Signature and title of the person dispensing the medication.
20.	In response to the opioid crisis, nurses are authorized to dispense naloxone to a person who is neither their client nor their client’s substitute decision-maker or delegate, but who may encounter an individual experiencing a suspected opioid overdose.
	a.	In this instance, which is an exception, nurses would not be expected to follow all of the principles outlined above with respect to a potential individual recipient of the naloxone, to the extent it is not possible to do so when that individual’s identity is unknown.
	b.	Nurses take steps to ensure public safety by teaching the person to whom they dispense the naloxone how to respond to individuals experiencing a suspected opioid overdose.
	c.	Nurses follow all applicable organizational/employer policies and processes regarding naloxone.

Acting within Autonomous Scope of Practice (Without an Order)

21.	Nurses are accountable and responsible when they administer or dispense a medication without an order.
22.	When administering or dispensing a medication within their autonomous scope of practice (without an order), nurses:
	a.	Follow organizational policies and processes as applicable
	b.	Assess the client's health status including allergies
	c.	Make or confirm a nursing diagnosis of a condition^4,5 that can be improved or resolved by administering or dispensing a medication.
	d.	Make a decision about whether the client would benefit from the medication, having considered:
		i.	Known risks and benefits
		ii.	Other relevant factors specific to the client or situation
		iii.	Assessment of medication alternatives
	e.	Manage, monitor, and evaluate the client’s response to the medication (as applicable) including intended and unintended outcomes.
	f.	Communicate and collaborate with the client (or their substitute decision-maker) and the health care team and document the nursing diagnosis, decision, actions, and outcomes related to the medication administered or dispensed to the client.

Preventing Medication Errors

23.	Nurses identify the human and system factors that may contribute to medication errors and/or near misses, and they act to prevent or minimize them.
24.	Nurses take action, including following organizational/employer policies and processes, when an error or near miss occurs at any point of a medication-related activity.

Medication Inventory Management

25.	Nurses who have responsibility for the management of medication inventory follow organizational/employer policies and processes and, as needed, consult with, and seek guidance from expert resources and pharmacists regarding:
	a.	Handling,
	b.	Storage,
	c.	Organization of medication,
	d.	Security,
	e.	Transport,
	f.	Disposal, and
	g.	Recording of medications.

Footnotes

1	'Nurses' refers to all BCCNM nursing registrants who are nursing professionals, including licensed practical nurses, nurse practitioners, registered nurses, registered psychiatric nurses, licensed graduate nurses, employed student nurses, and employed student psychiatric nurses. It does not include midwives.
2	In this standard ‘client’ means the person being treated by the nurse, as well as any substitute decision-maker, if applicable, who is authorized under applicable legislation (e.g. a temporary substitute decision maker for an adult client under the Health Care (Consent) and Care Facility (Admission) Act, R.S.B.C. 1996, c. 181; the client’s parent or guardian, if the client is under 19 years of age, or another person authorized to exercise parental responsibilities under Part 4 of the Family Law Act, S.B.C. 2011, c. 25, subject to the client’s right to consent to their own treatment under section 17 of Infants Act, R.S.B.C. 1996, c. 223; a representative authorized by a representation agreement under the Representation Agreement Act, R.S.B.C. 1996, c. 405; or a “committee of the patient” appointed under the Patients Property Act, R.S.B.C. 1996, c. 349).
3	Medication related activities include, but are not limited to: administering, dispensing, compounding, prescribing, preparing, handling, storing, securing, disposing of, and transporting medication.
4	Registered nurses and registered psychiatric nurses with certified practice may also make a diagnosis of a disease, disorder or condition that is within the authorized autonomous scope of the nurse's certified practice designation and the nurse's individual competence
5	Nurse practitioners may also make a diagnosis of a disease, disorder or condition that is within their authorized autonomous scope of practice and the nurse practitioner’s individual competence.