Case Study: Innovations in Medication Administration Techniques

Medication administration is an essential part of healthcare, and fundamental to the delivery of safe and effective patient care. The use of proper administration techniques improves treatment effectiveness, reduces the likelihood of treatment failure or complications, and minimises the risk of medication errors, such as incorrect dosage, administration route errors or administration of the wrong medication, all of which can place a patient’s safety at risk of harm. It also helps to mitigate legal risks and ensures accountability in the healthcare system. Healthcare professionals are under a legal and ethical obligation to ensure safe and accurate medication administration.

The Care Quality Commission (CQC) identifies medication administration as one of the six most common areas of risk with medicines across health and care. Issues that they have pinpointed include missed and incorrect doses of medicines, including inadvertently repeated doses, and poorly managed covert and ‘when required’ administration, which results in poorer outcomes.

Errors in medication administration are a serious issue. Researchers at University College London (UCL) have stated that an estimated 237 million medication errors are likely to occur each year in England alone, costing the NHS around £98 million and an estimated 1,700 lives.

In order to combat this issue, there is a constant need for research, reviews and evaluations to fuel improvements, developments and innovation that advance practices, decrease errors and have a positive effect on patient care and outcomes.

Traditional Medication Administration Techniques

The administration of a medicine is a common but important clinical procedure. The choice of medication administration techniques and routes is dependent upon a number of factors such as the medication type, the patient’s condition, any adverse effects from the medicines, and the treatment goals. Many of these medication administration techniques and routes have been tried and tested in healthcare over many years.

There are various routes of administration available to healthcare professionals to use in treating and caring for patients, each of which has associated advantages and disadvantages.

Common routes of administration include:

Oral Administration – this is the most frequently used route of medication administration and is the most convenient and economical. Oral medication forms are either solid or liquid:

• Tablets and Capsules – Patients take solid medication forms with water, and absorption occurs in the gastrointestinal tract
• Liquid Medications – This includes syrups, suspensions and elixirs, which are measured using calibrated devices and ingested orally

There are many advantages to using oral medication administration. Solid dose formats such as tablets and capsules have a high degree of medication stability and provide an accurate dosage. It is generally a safe route of administration and is non-invasive, simple and convenient for the patient, who may be able to self-administer the medication. A main advantage for patients is that the medication doses usually only need to be taken once or twice daily.

In liquid formulations, the active part of the medication is combined with a liquid to make it easier to take or to be better absorbed. In some cases, it may be flavoured to make the medication more palatable; however, many liquid medication formats are now made to be sugar-free. Liquid dosage is useful for people who find it difficult to swallow solid forms of medication. Dosage is more flexible with liquid dosage formats compared with solid dosage formats such as tablets and capsules, as measurement of a different volume can easily and conveniently adjust the dose of the medication.

The oral route is nevertheless problematic, and can have disadvantages. There is an unpredictable nature to gastrointestinal drug absorption, for example the presence of food in the gastrointestinal tract may alter the gut pH, gastric motility (digestion) and emptying time, as well as the rate and extent of the drug absorption. Very young and older patients in particular may also have variations to the extent to which they can tolerate solid dose forms. If this is the case then soluble or liquid formulations of the medication can be helpful.

There are medications that are modified-release preparations. These formulations can delay, prolong or target medication delivery and must not be crushed or broken at the point of administration. Damage to the release controlling mechanism, for example by chewing or crushing, can result in the full dose of the drug being released at once rather than over a number of hours, leading to toxicity, or the medication may not be absorbed by the patient at all.

Oral medication routes are not possible to administer in unconscious patients, and are unsuitable in patients who are vomiting.

Because liquid dosage formats are inherently unstable, their shelf-life is very often shorter than that of their corresponding solid dosage formats. In addition, breakage of containers is an issue; if the container is accidentally broken, the entire dosage is lost.

Intravenous (IV) Administration – medication administered by the intravenous (IV) route is given directly into a vein as a direct injection or infusion. IV administration may be:

• Medications that are administered directly into the bloodstream through a catheter or needle for rapid effect
• Medications that are administered slowly over a set period, often through an infusion pump, providing a continuous and controlled dosage

IV medication administration routes are usually used when other routes will not allow for an intended therapeutic outcome or goal of the treatment to be met. They have an immediate effect on the patient so are suitable for emergencies and can be given to unconscious patients. Intravenously administered medication achieves predictable and precise control over drug plasma levels compared to other routes.

There are, however, challenges and disadvantages to using IV in the administration of medication. IV administration is labour intensive and time-consuming as it often requires the expertise of healthcare professionals and the use of programmable infusion devices, limiting their use in certain settings or for self-administration by patients.

IV administration may require dose calculations, dilutions, information to be gathered on administration rates, and compatibilities with other IV solutions. Consequently, improper administration techniques or dosage miscalculations can lead to the risk of either overdose or underdose. Once administered by IV, the medication cannot be retracted.

There is also the risk of infections from the use of needles for injections if proper aseptic techniques are not followed. There may also be a risk of the patient developing phlebitis, i.e. inflammation of a vein near the surface of the skin, or extravasation, i.e. the leakage of blood, lymph or other fluid, such as an anticancer drug, from a blood vessel or tube into the tissue around it.

A major challenge to IV administration is patient reticence or fear. IV often causes patients considerable anxiety and distress, especially those patients who have to endure multiple and possibly painful and difficult cannulations – that is inserting a thin tube into the patient’s body. Some people display a fear of any medical procedures that involve needles such as vaccinations, or even blood tests, and, in extreme cases, others may develop the phobia trypanophobia. Patient fear can hamper the administration of medication via IV, potentially leading to non-compliance or avoidance of treatment.

Rectal or Vaginal Administration – medication that is administered through suppositories, enemas or pessaries.

This route introduces medication into the body and does not cause nausea and vomiting due to gastric irritation as can be the case in oral therapy. It can be used as a targeted drug delivery system, for example in the treatment of inflammatory bowel disease, haemorrhoids or vaginal infections. It can be administered to unconscious patients, and also allows for self-medication by the patient.

The rectal route has considerable disadvantages in terms of patient acceptability, particularly in the UK. It can be messy to use, can cause localised irritation, and can also have an unpredictable drug absorption rate.

Topical Administration – this is applying medication to the skin or mucous membranes that allow it to enter the body from there. Dosage formats can include:

• Ointments
• Gels
• Creams
• Lotions
• Liquids
• Powders
• Patches
• Solutions
• Shampoos
• Pastes
• Aerosol foams or sprays

Topical medications can include, but are not limited to:

• Dermatological preparations such as those for eczema or topical steroids in the management of dermatitis
• Eye drops such as those containing beta-blockers in the treatment of glaucoma
• Inhaled bronchodilators such as those in the treatment of asthma
• Shampoos used for head infestations or psoriasis

Topical administration has also become a popular way of introducing drugs into the systemic circulation through the skin such as transdermal patches that are used for conditions including the prophylaxis of angina (glyceryl trinitrate), the treatment of chronic pain (fentanyl) and hormone replacement (oestrogens).

The topical application of medications has obvious advantages in the management of localised disease. It is also a beneficial way to administer medication to patients who struggle with oral drug administration or who have a fear or aversion to either IV or oral administration.

There are also problems and disadvantages with topical administration. The patient’s skin texture can disrupt and affect how well the medication is absorbed. Thin skin absorbs more medication than thick skin. Skin thickness varies for a number of reasons such as:

• Body site, that is where on the body the skin is sited, for example skin on the face is thinner than skin on the palm of the hand.
• A person’s age, a baby’s or child’s skin is thinner than an adult, and skin becomes thinner as we age.
• The specific skin disorder, for example, a patient with dermatitis, ichthyosis, and keratolytic agents such as salicylic acid, may absorb more medication than someone with intact normal skin

Some topical formulations can be time-consuming to apply and, at times, the regimen can be complicated, especially if several different formulations have been prescribed. The applications may also be messy or uncomfortable, and some patients may experience adverse reactions to excipients (the substance used to prepare the medication so that it is suitable to administer).

Case Study 1 – Innovative Medication Administration Technique

Barcode technology was introduced as part of the NHS safety initiative. Barcode medication administration (BCMA) technology helps ensure correct medications are administered by nursing staff through scanning of patient and medication barcodes.

Derby Teaching Hospitals NHS Foundation Trust (Derby) provides acute hospital-based health services, serving a population of over 600,000 people in and around southern Derbyshire. The Trust runs two hospitals. The Royal Derby Hospital incorporates the Derbyshire Children’s Hospital and is a busy acute teaching hospital, and London Road is the Trust’s community hospital. The Trust also operates some satellite services at other hospitals. The hospital gets around 625,000 visits a year and has 1,159 beds in 59 wards, and 35 surgical theatres.

Derby Teaching Hospitals NHS Foundation Trust wanted to better manage product recalls as well as to streamline its theatre processes. By using GS1 barcode standards, Derby now captures and uses complete, accurate information to automate its operations and reduce the need for manual intervention and the risk of human error.

As with many Trusts, Derby was faced with the problem of managing product safety recalls quickly and efficiently, while minimising risk to the patient. The Trust was also concerned that they didn’t have the accurate and comprehensive information required for the efficient clinical and business management of theatre operations. Traceability was a manual paper-based process, creating a drain on clinical time. Inventory levels of theatre stocks were high to ensure that stock was always available, but this led to wastage due to obsolescence and poor product life management. It was widely recognised that patient safety would be improved by, for example, being able to easily check that out-of-date products were not used on patients.

From the start, the intention was to find a solution that could be implemented across all theatres, and even beyond, into wards and clinics, and it was clear that barcodes were essential to collect the accurate, timely and comprehensive information needed to address these issues.

Implementation consisted of integrating a cloud-based inventory management system, product catalogue and the barcode scanning solution. This was then all linked to a financial system for automatically creating orders, via EDI or email, to suppliers, based on the usage of products including medication and supplies in the theatre.

The products, staff, patient, surgical instruments and medical equipment are all scanned at the time of the surgical procedure to give a full record of the operation, including accurate timings for knife-to-skin actions and more. Information about the products used automatically updates stock levels and triggers orders, when necessary.

The changes have had a financial and clinical impact, including direct cost savings of £10,000 per month, with annual savings of around £300,000 in just the general theatre through lower inventory and reductions in the number of orders and associated delivery costs, wastage and staff costs. Other benefits include, but are not limited to:

• More accurate and detailed management information is now available.
• Automation of processes means that clinical staff can spend more time with patients.
• When recalls take place, the Trust can easily identify all products that are held within the Trust, preventing their use. It can also identify all patients that may have been affected by the products.
• Scanning everything in the theatre also means that stock levels are automatically updated, triggering automated orders, and as products, equipment and implants are recorded against the patient, by also linking cost, staff and time information, a complete and accurate procedure cost is calculated.

Implementing GS1 barcode standards at the Derby Teaching Hospitals NHS Foundation Trust is ultimately about patients, and every patient needs a barcode. Clinicians can now spend more time with those in their care, data is more accurate and the automation of theatre processes reduces human error.

The Great Ormond Street Hospital (GOSH) was founded in 1852 as the UK’s first paediatric hospital. It serves over 150,000 patients and many have rare and complex conditions. As an NHS Trust, the hospital has been exploring ways barcode technology could improve safety and efficiency. The cardiac catheterisation laboratory at GOSH utilises high-cost consumables on a daily basis, making it necessary for the lab to focus on accountability and reducing costs. To be able to achieve the efficiency needed, GOSH sought a way to computerise stock, in order to reduce the wastage of expired stock and to supply accurate costing for each procedure to commissioners that pay for GOSH services. Following the guidelines put in place by the NHS, GOSH implemented a barcode-based inventory management system called Wasp Inventory Control. The hospital quickly put in place a barcode-based stock management system and used a Wasp handheld device for mobile scanning.

In addition, a report reveals that six London NHS hospital trusts which implemented regular point-of-care barcode scanning have ensured complete traceability of healthcare items while securing millions of pounds of savings and releasing thousands of hours of clinical time. The benefits have included:

• Complete traceability; speedy and accurate recall; reduction of drug error and Never Events (these are serious, largely preventable patient-safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations); and improving routine observations and patient identification thereby improving patient safety.
• Cost and efficiency savings through more efficiency and cost-effective product ordering; happier, more efficient staff; the creation of accurate patient-level costings; and reductions in unwarranted variation.

Other NHS trusts that have implemented barcode scanning have reported the following:

• At Leeds Teaching Hospitals NHS Trust, the average time taken for product recalls has fallen from 8.33 days to less than 35 minutes following the introduction of Scan4Safety. The organisation estimates it will save £84,411.07 each year on such recalls.
• By introducing scanning in pharmacy, Royal Cornwall Hospitals NHS Trust reduced prevented-error rates by 76%, including elimination of all errors caused by wrong patient, wrong drug, wrong dose and wrong form.
• North Tees and Hartlepool Hospital NHS Trust estimated Scan4Safety had released 22,000 hours of time to care over the course of the programme. This was through a reduction in adverse drug effects and a reduction in incident reporting time.
• Across the Greater Manchester Health and Social Care Partnership, GS1 barcode standards implementation was integrated into their three-year digital strategy 2019–2022. This will enable the teams to drive adoption across the partnership’s entire footprint area.
• Manchester University NHS Foundation Trust (MFT) have implemented bar code medication administration (BCMA). Prior to Hive and the use of BCMA, administration of medication was a largely manual process that included the use of paper charts and written notes. Now, nursing staff can administer medication on the move (using their handheld Rover devices), whilst BCMA also acts as a patient safety feature. BCMA ensures that the right medication is administered to the right patient at the right time, helping to reduce patient harm. The Trust’s electronic prescribing and medicine administration processes both continue to improve, and work is underway to aid drug selection in line with the medicine formulary, in order to strengthen discharge workflows.

Case Study 2 – Advancements in Medication Delivery

Smart insulin pens are an exciting recent development for people with diabetes. They can show the person if they have missed an injection as well as how much insulin they have taken and the last time they injected. Two smart insulin pens that automatically record dosing data are now available for prescribing on the NHS for people with diabetes. NovoPen 6 and NovoPen Echo Plus are a new generation of insulin pens with dose memory function and smart connectivity that allow patients to transfer insulin dosing information to a compatible app and easily share it with their healthcare professional.

Emma Wilmot, consultant diabetologist at University Hospitals of Derby and Burton NHS Foundation Trust, said, “Integrating innovative technology as a routine part of diabetes care is an important step to improve diabetes care. Novo Nordisk’s smart connected pens are an example of how technology can support people living with diabetes to gain greater insight into the management of their diabetes, on their journey to becoming experts in their diabetes. In my clinic, the opportunity to view daily insulin data will allow me to better support the individual with diabetes to achieve their goals. It will allow for more tailored and informed advice on optimisation of glucose levels, with the ultimate goal of improving future outcomes”.

An observational study has found that using the NovoPen 6 may help give people with type 1 diabetes almost two extra hours of improved glucose levels, with a reduction in time spent in hyperglycaemia. People were also less likely to miss injections and the record of actual insulin doses was more accurate than when people manually entered them in a logbook or app.

Patient Outcomes and Safety

In 2017, The World Health Organization identified Medication Without Harm as the theme for its third Global Patient Safety Challenge, and highlighted that everyone, including patients and healthcare professionals, has a role to play in ensuring medication safety.

Following this initiative launch, estimates of the number of medication errors, and their potential financial and human impact on the NHS in England, were collected from published data up to October 2018. This data provides an indication of the challenges that NHS healthcare providers are seeking to overcome with the implementation of innovative techniques in medication administration, such as those discussed above. The statistical data below has been taken from a report from the British Medical Journal (BMJ):

• Based on all this information, they estimated that more than 237 million medication errors are made every year in England.
• Errors are made at every stage of the medication process, with over half (54%) made at the point of administration and around 1 in 5 made during prescribing (21%). Dispensing accounts for 16% of the total.
• Error rates are lowest in primary care, but because of the sector’s size, these account for nearly 4 out of every 10 (38%). Error rates are highest in care homes (42%), despite covering fewer patients than the other sectors. Around 1 in 5 medication errors are made in hospitals.
• The researchers estimated that nearly 3 out of 4 medication errors (72%) are minor, while around 1 in 4 (just under 26%) have the potential to cause moderate harm; just 2% could potentially result in serious harm.
• Around a third (34%) of potentially harmful medication errors are made during prescribing in primary care.
• The researchers calculated that “definitely avoidable” medication errors cost the NHS nearly £98.5 million every year and 1,708 lives.

In 2023, the UK government mandated NHS England to adopt barcode scanning by 2024 for all NHS Trusts based on the evidence of the positive benefits gained from pilot implementations in the NHS. By enabling end-to-end traceability and cohesive, interoperable processes throughout the entire patient pathway, the initial programme released over 140 thousand hours of clinical time back into care along with almost £5 million in recurrent inventory savings, and £9 million of non-recurrent inventory reductions. By reducing the time spent on tasks and eliminating manual processes, wards are able to release valuable time back to patient care which can improve patient outcomes.

Jackie Whittle, chief clinical information officer at Leeds Teaching Hospitals NHS Trust, commenting on the barcode implementation at her site, stated, “The S4S programme has many benefits at the clinical level in our organisation; however, the patient safety element is key. Being able to track individual patient’s locations and movements throughout their journey improves safety and contributes to safe and effective placement of patients. Accessing individual patient’s electronic health record at the bedside via scanning the wristband saves staff time, but significantly improves patient safety and reduces risk and harm.” Key results from the implementation have been highlighted above, but also included:

• ADT process completion time reduced from 2.5 hours to 30 minutes.
• Ward transfer times reduced from 10-15 minutes to less than two minutes.

In the UK, in 2017, during hospital admission, an estimated 9,600 people with diabetes required rescue treatment after falling into a coma following a severe hypoglycaemic attack. Unacceptably, 2,200 people also suffered from Diabetic Ketoacidosis (DKA) due to under treatment with insulin. Inpatient care for diabetes costs the NHS £2.5 billion per year. The advancement of technology in medication administration and management such as smart insulin pens appears to be having a positive impact on patient safety and outcomes in this area.

Diabetes UK has collected anecdotal evidence from users of smart insulin pens to highlight the positive impact that the implementation and rollout by the NHS of this medication administration technology has made to people with diabetes. These include:

Tom Dean, 33, is the founder of DiabetesChat, an online peer support community on X (formerly Twitter). Tom was diagnosed with type 1 diabetes in 2006 and began using smart insulin pens in February 2022. He says it has been a game-changer for his diabetes management. He commented, “What I love the most about the smart insulin pens, and what I find has really changed how I manage my diabetes occurs whenever I think to myself, ‘Did I take that bolus? Did I take my background insulin?’ Before the pens, I would have struggled with this. But now I can simply check my NovoPens by pressing the memory mode down or looking back on the history log on the FreeStyle LibreLink app. Now I know instantly when I injected and how much. This is a total game-changer, the technology has improved my quality of life and helped lift my worries. Moreover, I can easily share all this data with my diabetes team which can be helpful in annual reviews or urgently required appointments.”

James Ridgeway, 34, is a diabetes specialist nurse (DSN) with type 1 diabetes who has seen both the personal and professional side of using smart insulin pens. He commented, “I have been using an insulin pump for just over six months now, but before then I was using Novo smart pens. I would use the Echo Plus for my rapid-acting insulin injections, and the NovoPen 6 for my long-acting insulin.  For me, the best thing was that it became a safety net in terms of knowing when I last injected insulin. Before insulin pump therapy I had injected over 15,000 times during 10 years with type 1 diabetes and there were times when I would ask myself ‘Did I give my insulin?’. NovoPens provided me with that answer, which helped to keep me safe.”

Dr Tomas Griffin, a senior lecturer in medicine at the University of Limerick, commented, “Smart connected pens reduce the likelihood of errors, and this reduces an individual’s anxiety about giving insulin. This is very important. The people I have spoken with in clinic love having smart connected pens. They find them easy to use and tend to prefer them to their disposable pens. I have had people say to me that, sometimes, they were unsure if they had taken their insulin or not. Now they just check their smart pen to see how long it has been since the last injection was delivered.”

Future Trends and Challenges

One of the main challenges in medication administration is human error, which can occur at any stage of the process, from prescribing to dispensing to administering. New technologies and the potential for new innovations in medication administration are designed and are being designed to minimise or mitigate the risk of human error.

On 3 February 2023, the Department for Health & Social Care (DHSC) published its strategy to support the UK MedTech sector to ensure health and care systems can quickly access safe, effective and innovative medical technologies. The strategy acknowledges that using innovative medical technology to diagnose, treat and support patients will be key to clearing patient waiting lists – unlocking more clinician time, freeing up hospital beds and generally reducing pressure on the NHS. The strategy proclaims to build on the Life Sciences Vision to promote the UK as a “global science superpower”.

Amongst the plethora of exciting technology advancements, three-dimensional (3D) printing is causing a paradigm shift in pharmaceuticals and clinical pharmacy practice, transitioning away from the traditional mass production of medicines towards tailored drug products that are personalised to each individual. The concept has the potential to provide benefits for patients, healthcare professionals and clinicians, pharmacists and the pharmaceutical industry alike by enabling the on-demand design and production of flexible formulations with personalised dosages, shapes, sizes, drug release and multi-drug combinations.

In March 2021, the Medicines and Healthcare Products Regulatory Agency (MHRA) released a proposal for a new regulatory framework to enable the development of proof of concept (POC) manufacturing and supply, including 3D printing technologies for personalised medicine production. The MHRA proposed that the assurance of safety for medicines manufactured at the POC would be based on established medicines development processes, such as non-clinical studies and clinical trials, but will be adapted to suit the requirements of multiple manufacture sites.

This route of pharmaceutical production is a novel and innovative solution to overcoming some commonplace problems in medicines manufacture, and requires a shift in mindset within the healthcare sector to fully take advantage of its potential to improve patient safety and outcomes. However, benefits can include:

• The visually appealing and customised nature of the 3D medications increases children’s willingness to take their prescribed medications, leading to improved adherence.
• 3D-printed medication can be shaped to make it easier to swallow for those who have difficulties such as children and the elderly.
• Medication information in Braille can be embossed on 3D-printed medication, improving safety for the blind and partially sighted.
• The 3D printing technology allows for the creation of medications with highly accurate dosages, reducing the risk of dosage errors and ensuring optimal therapeutic outcomes.
• Patients with more than one condition often have to remember to take multiple pills to specifically combat each of their ailments; 3D-printed medication can be customised to their individual needs to contain a combination of different medications.
• 3D printing offers an eco-friendly method of medicines manufacture; formulations can be produced with little or no drug and excipient wastage, reducing costs, particularly for highly expensive drugs.
• 3D printing technology can cut the costs and the time it takes from drug discovery to a marketed formulation, currently at around 10–15 years on average, costing an average of £1.3bn. There is an urgent need to reduce time and cost to market to expedite drug development timelines, made evident during the recent COVID-19 pandemic which required rapid drug development.

Advancements in genomic research may lead to more personalised and precise medication regimens based on an individual’s genetic make-up. This could improve drug efficacy and minimise adverse effects. Projects such as the 100,000 Genomes Project are leading to ground-breaking insights and continued findings into the role genomics can play in healthcare, with new advancements being discovered and developed frequently.

Continued integration of technology into healthcare, such as the use of smart devices, electronic health records (EHRs), and Internet of Things (IoT) devices, can enhance medication administration. Automated dispensing systems and electronic medication administration records (eMAR) are becoming more prevalent.

Along with advancements come challenges and legal and ethical considerations. The risk of medication errors remains a significant challenge. Health systems must continue to focus on implementing safeguards to reduce the occurrence of errors in prescribing, dispensing and administration. There is also a growing need for robust cybersecurity measures to protect patient data and ensure the integrity of electronic medication administration systems with the increased reliance on technology. Ethical and legal concerns, such as privacy issues associated with patient data and the potential liability in case of technology-related errors, also continue to be a challenge for the healthcare sector as it expands the use of technologies in medication administration.

Final Thoughts

As the field of dynamic developments and trends in medication administration continues to evolve, and be implemented, the healthcare sector and its patients can expect to see such benefits as enhanced medication safety, improved patient outcomes, greater productivity and better cost efficiency, leading to a more effective healthcare system.