Medication

Practice Standard for registered psychiatric nurses

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'¹accountabilities 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 or a pharmacist have prepared, except in an emergency.
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.

Preventing Medication Errors

21.	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.
22.	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

23.	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.

Applying the principles to practice

Review organizational/employer policies and processes that may place additional restrictions related to medications or require that you follow certain processes intended to support nurses to safely perform medication-related activities.

Examples:
- What client identification information can be used as a second client identifier.
- The use of a clinical decision-support tool that your organization/employer has developed to guide the nurse when administering or dispensing certain medications within the nurse’s autonomous scope of practice. These clinical decision-support tools may be referred to as a ‘nurse independent activity’ or ‘nurse-initiated protocol’ or ‘clinical practice standard and procedure’, or by another name.
- The use of barcode technology processes.
Dispensing occurs when the nurse gives medication to a client (or to their substitute decision-maker or other authorized delegate) for administration at a later time. It includes the preparation and transfer of the medication for the client, taking steps to ensure the pharmaceutical and therapeutic suitability of the medication for its intended use, and taking steps to ensure its proper use. It may also include accepting payment for a medication on behalf of a nurse’s employer, but it does not include selling a medication.

Examples of dispensing include when:
- the client is leaving the facility on a day pass and needs their medication while away.
- the client is being discharged from the emergency department and needs medication started.
Compounding medications is usually done by pharmacists. However, in British Columbia, nurses also have the authority to compound medications. Compounding means mixing a drug with one or more other ingredients. Federal and provincial regulations, standards, and guidelines have been established to ensure the safety of clients as well as the safety of health professionals who compound medications. Depending on the type of ingredients, these address such matters as requirements for competency, product preparation procedures, work environment, storage, disposal, labelling, documentation, etc. In addition to a nurse’s organizational /employer policies and processes, pharmacists, and organizations such as the College of Pharmacists of British Columbia are good resources for providing information and guidance about how to safely compound medications.
Refer to BCCNM’s Consent Practice Standard to understand your legal and ethical obligations for obtaining consent when administering or dispensing medications. Familiarize yourself with your organizational/employer policies and any applicable legal requirements or exceptions for consent. Consult with the client’s substitute decision-maker and other members of the healthcare team if the client cannot provide consent or chooses not to do so, even in those instances when consent may not be required such as under the Mental Health Act.
Reflect on how your own values, beliefs, and experiences may be influencing your clinical decisions about medications, such as when administering medications to your patients for pain.
Factors to consider when assessing the appropriateness of a medication for the client may include: health history, physical assessment data, medication history, allergies, relevant laboratory and diagnostic test data, the client’s knowledge and beliefs about the medication, and other relevant factors.
Potential actions to consider if a medication order does not seem to be evidence-informed or does not appear to reflect individual client needs, characteristics, or wishes could include:
- Following up with the health professional who gave the order.
- Obtaining more information from relevant resources or from the client.
- Consulting with a team member, clinical educator, clinical nurse specialist, or manager.
Think about potential ways to reduce the risk of medication errors in your nursing practice and in your practice setting, including (but not limited to):
- How to reduce interruptions during any step of the medication process that may result in errors.
- Being familiar with your organizational/employer list of abbreviations, acronyms, dose designations, and symbols that are not to be used or are approved for use.
- Being aware of medication names that look or sound similar (‘look-alike’/’sound-alike’).
- Being aware of high alert medications that may cause serious injury or death if used incorrectly.
- Being aware of high-alerts medications for which your organization/employer requires an ‘independent double check’ (a process in which a second nurse conducts a verification) and how to perform it.
- Reflecting on your nursing practice and considering ways to avoid unsafe practices that pose safety risks for your client. Examples of unsafe practices may include: the pre-pouring of medications, or leaving medications at the bedside or on a meal tray and therefore not observing or being able to confirm that your client received the medication; preparing medications for more than one client at the same time.
- Considering how to become involved in the implementation of system-wide efforts to support safe preparation, administration, dispensing, compounding, handling, storage, or disposing of medications in your workplace such as participating in quality assurance activities.
Seek out medication information resources that may be available in your workplace to support your practice such as online clinical medication information programs. These may be helpful to you as you learn about the medications that you are administering or dispensing to your clients. They may also provide information that you can use when teaching your clients about their medications.
Pharmacists play a critical role in medication safety by ensuring that the medication is pharmaceutically and therapeutically appropriate for the client. However, there may be instances where a pharmacist is not available, and the nurse is responsible for the pharmaceutical and therapeutic review before administering or dispensing a medication. This may happen when the nurse is acting with a client-specific order from an authorized health professional or when the nurse is acting within their autonomous scope of practice. For example:
- With a client-specific order to administer a medication: When acting with a client-specific order from a physician or nurse practitioner to administer a medication and when there is no pharmacist available, a nurse may need to use an override feature of an automated dispensing cabinet or other storage device (e.g. locked cupboard/drawer/vault or ward stock) before pharmacy verification of the medication order. In this instance, the nurse performs the pharmaceutical and therapeutic review of the medication prior to administering the medication to the client. The nurse would follow the Acting withClient-specific Orders scope of practice standard and the Medication practice standard as well as other standards applicable to meeting the client’s needs (e.g. the Consent practice standard)⁴,
- With a client-specific order to dispense a medication: A nurse may be acting with a client-specific order from a physician or nurse practitioner to dispense a medication that the client needs to take until the prescription can be filled. If there is no pharmacist available, the nurse performs the pharmaceutical and therapeutic review of the medication before dispensing the medication to the client. The nurse would follow the Acting with Client-specific Orders scope of practice standard and the Medication practice standard as well as other standards applicable to meeting the client’s needs.
- Within autonomous scope of practice: The nurse may be allowed and supported by their organization/employer to administer or dispense a certain medication within their autonomous scope of practice if the nurse is competent to do so and follows a clinical decision support tool. If there is no pharmacist available within that setting, the nurse performs the pharmaceutical and therapeutic review of the medication before administering or dispensing the medication to the client. In this instance, the nurse would follow the Acting within Autonomous Scope of Practice standard and the Medication practice standard as well as other applicable standards applicable to meeting the client’s needs.
Pharmacists can help to make the administration or dispensing of medication safer. Involve them whenever possible to improve resources, processes, and systems.
Nurses may also have responsibility for managing a medication inventory in their health care setting. In some cases, the medication inventory is large and varied (for example, in remote practice) while in other cases, it is small and specialized (such as in a private practice clinic). In addition to following your organizational/employer policies and processes, pharmacists and organizations such as the College of Pharmacists of British Columbia and the British Columbia Centre for Disease Control are good resources for providing information and guidance on how to safely handle, store, organize, secure, transport, dispose of, and record medications and vaccines.

For more information

Professional Standards for Registered Psychiatric Nurses
Registered Psychiatric Nurses’ Code of Ethics
Scope of Practice for Registered Psychiatric Nurses: Standards, Limits, Conditions
- Standards for Acting within Autonomous Scope of Practice
- Standards for Acting with Client-specific Orders
Medications Practice Standard
Boundaries in the Nurse-Client Relationship Practice Standard
Conflict of Interest Practice Standard
Consent Practice Standard
Duty to Provide Care Practice Standard
Documentation Practice Standard
Privacy and Confidentiality Practice Standard
Legislation Relevant to Nurses’ Practice
BCCNM Bylaws – (Marketing)

Other Resources

Pharmacy Operations and Drug Scheduling Act

Drug Schedules Regulation

For more information on this or any other practice issue, contact BCCNM’s Practice Support Services by email at practice@bccnm.ca or call 604.742.6200 or toll-free (Canada only) 1.866.880.7101.

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	Other examples of standards that may be applicable depending on the context of the client’s needs and the setting are given in the ‘For More Information’ section at the end of this standard.