Medicines administration: system transformation to improve safe transfers of care (2025)

Nottingham and Nottinghamshire Integrated Care System

Project summary

Project overview:
The aim of this project was to improve patient safety, reduce delays in care and free up time for our healthcare workforce. This is enabled through development of a standardised, robust and aligned process for all providers across Nottingham and Nottinghamshire ICS (Integrated Care System) to provide and receive the authority required for community nursing teams to administer medicines.

Background:
The Medicines and Healthcare products Regulatory Agency (MHRA) requires a written direction to administer (DA), written by a registered prescriber for prescription only medicines (POMs).

A prescription is a DA but often does not specify exact doses and frequency e.g., insulin, medication administered via a syringe driver. Therefore, a detailed written instruction is good practice to ensure administration happens safely.

In our ICS, the governance in our community nursing providers requires that a written DA, with specified information and the agreed electronic or physical signature of a prescriber is in place, and visible to their nurses to authorise medicines administration.

Why did we do this project:
Prior to this project, for over 15 years, significant variation and time intense processes existed for DA. This often resulted in delays to treatment and increased workload.
We have 126 GP practices, 2 community nursing providers, 3 secondary care trusts, a mental health trust, 2 out of hours service, nursing homes and hospices, a community hospital, a specialist palliative care unit and virtual wards. They all either need to supply or receive DAs in a timely and efficient way. Four different sets of DA forms were in use, with differences in information sharing.

In primary care paper forms with wet signatures were used, collected from the GP practice by community nurses.

In secondary care the discharge prescription (to take out – TTO) was agreed as a valid DA, but the electronic version was only visible to one of the community providers. The other provider relied on the patient having a paper copy following discharge, and very often they could not find this. The nurse then had to ask the GP for a DA. This caused GP concern in writing a DA for medicines they had not prescribed, as well as adding to their workload.

What we did:
Through collaborative working we developed a primary care digital solution, as well as unblocking the access issues, allowing all community nurses to see the electronic version of TTOs. Challenges included the lack of interoperability and access to digital platforms used by each provider, developing consensus about the content of the DA forms, aligning practice for the community nursing providers about use of dose ranges for anticipatory medicines, education and communication about the new system across all stakeholders.