Medications
The nurse’s role in dispensing, compounding and
administering medications in British Columbia
College of
Registered Nurses
of British Columbia
2855 Arbutus Street
Vancouver, BC
Canada V6J 3Y8
T: 604.736.7331
F: 604.738.2272
Toll-free: 1.800.565.6505
MEDICATIONS
This document provides supplementary information and should be read in conjunction with the
Scope of Practice for Registered Nurses: Standards, Limits and Conditions,
Medication Administration Practice Standard
Dispensing Medications Practice Standard
Medication Inventory Management Practice Standard
CRNBC resources referred to in this document as well as additional information on this topic are
available from the CRNBC website www.crnbc.ca
2855 Arbutus Street
Vancouver, BC V6J 3Y8
Tel 604.736.7331 or
1.800.565.6505
www.crnbc.ca
Copyright CRNBC/Dec 2015
Pub. No. 3
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MEDICATIONS
Table of Contents
L e gi sla t i on
Legislation Affecting CRNBC Registrants and the Medication Process
4
4
Provincial
4
Federal
4
Administering Drugs With and Without an Order
C on tr ol s on P r a c t ic e
Examples of controls on practice applied to the medication process
Or der s
5
6
7
8
Verbal/Telephone Orders
9
Pre-printed Orders
9
Abbreviations
9
Unacceptable Orders
9
Using Technology to Transmit Orders
9
P r e scr ib in g
10
C o mp o un d in g
10
D is p e n s in g
10
M ed i ca ti on I n v en to r y M a n a g e m en t
10
D r u g S ub s ti t u t io n b y P h a r ma c i st s
11
Ad m in is t er in g
11
Off-Label Medications
12
Investigational (Experimental) Medications
12
Narcotics and Controlled Drugs
12
Placebos
12
Complementary and Alternative Therapies
13
Withholding Medications
13
Administration by Others – The RN Role
13
R ol e o f th e C R N B C - C er ti fi e d P r a c t ic e R N
14
D oc u m en ta t i on
15
Medications Not Given
15
Medications Given by Other Staff
15
M ed i ca ti on S a fe ty
16
Medication Errors
16
R e so ur c es f or N ur s es
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Legislation
LEGISLATION AFFECTING CRNBC REGISTRANTS AND THE MEDICATION
PROCESS
Provincial
Nurses (Registered) and Nurse Practitioners Regulation
Outlines the restricted activities of compounding, dispensing and administering Schedule I, IA and II
drugs assigned to registered nurses.
Drug Schedules Regulation
Classifies drugs by categories called drug schedules
Federal
Controlled Drugs and Substances Act and Regulations
Directs facilities licensed under the Hospital Act to maintain a count of narcotics, controlled drugs and
medication wastage.
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ADMINISTERING DRUGS WITH AND WITHOUT AN ORDER
B.C. PROVINCIAL DRUG
SCHEDULES
RN administers drugs
following nursing diagnosis
of a condition
RN administers drugs
following diagnosis of a
disease or disorder
Schedule I drugs require a
prescription from an
authorized health
professional.
with order
with order
Example:
RNs require an order for
antibiotics (Schedule I).
Example:
RNs require an order for
antibiotics (Schedule I).
Example:
The Nurses (Registered) and
Nurse Practitioners Regulation
specifies certain conditions
RNs may treat with Schedule I
medications without an order.
Example:
RNs with CRNBC-Certified
practices may give specific
Schedule I medications
without an order
Schedule IA drugs in the
Controlled Prescription
Program.
with order
with order
Example: RNs require an order
Example: RNs require an order
for narcotics (Schedule IA).
for narcotics (Schedule IA).
Schedule II drugs do not
require a prescription, but are
kept in an area of the
pharmacy where there is no
public access or opportunity
for patient self-selection.
without order
with order
Example: After assessing and
diagnosing chest pain (a
condition), RNs may
administer sublingual
nitroglycerin (Schedule II)
without an order to treat the
condition.
Example: RNs require an order
for insulin (Schedule II) for
diabetes (a disease or
disorder) or heparin (Schedule
II) for a deep vein thrombosis
(a disease or disorder).
Schedule III drugs may be sold
by a pharmacist from the selfselection area of the
pharmacy.
without order
with order
Example: After assessing and
diagnosing uncomplicated
pain (a condition), RNs may
administer acetaminophen to
treat the condition.
Example: RNs require an order
to administer cimetidine for a
peptic ulcer (a disease or
disorder).
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Controls on Practice
The Nurses (Registered) and Nurse Practitioners Regulation sets out a broad scope of practice.
Nursing practice is further controlled by:

CRNBC – sets standards, limits and conditions

Employer policies – may further restrict an activity in
an agency or unit but cannot broaden scope

Individual competence – nurses require the
knowledge, skill, attitude and judgment to carry out
the activity
All four levels of control are necessary for nurses to provide safe, competent and ethical care. Each
level successively narrows a nurse’s practice. For example:

Schedule II, III and unscheduled medications do not require a prescription and a nurse may be
competent to administer the medication, but agency policy may require an order before a nurse
can administer these medications.

A nurse may give a Schedule III or unscheduled medication after assessing and diagnosing a
condition, but requires an order to give the same medication to treat a disease or disorder.
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EXAMPLES OF CONTROLS ON PRACTICE APPLIED TO THE MEDICATION
PROCESS
Application to the Medication Process
Regulation
RNs may compound, dispense or
administer by any method a Schedule I or IA
drug with an order (Section 7).
An ER nurse gives Diazepam 5 mg. IV
(Schedule I) to an adult with severe
anxiety following a doctor’s order.
RNs may compound, dispense or
administer by any method a Schedule II
drug without an order (Section 6).
A residential care RN gives a
nitroglycerin sublingual tablet
(Schedule II) to a client who complains
of chest pain.
RNs may dispense or administer a Schedule
I drug without an order for the purpose of
treating:
- anaphylaxis
- hypoglycemia
Standards,
Limits,
Conditions
Example
Parts 2 and 3 in CRNBC’s Scope of Practice
for Registered Nurses: Standards, Limits
and Conditions
CRNBC Practice Standards Medication
Administration, Dispensing Medications,
Medication Inventory Management
A camp RN assesses a 12-year-old with
wheezing and shortness of breath after
a bee sting, diagnoses anaphylaxis and
gives epinephrine IM.
A medical RN assesses a diabetic client
with severe low blood glucose,
diagnoses hypoglycemia and gives
D50W IV.
An RN reviews the CRNBC Standards of
Practice and determines if she or he
can manage the intended and
unintended outcomes of giving a
particular medication.
The camp RN follows the CRNBC limits
and conditions and uses an
established DST when giving
epinephrine without an order.
The medical RN follows the CRNBC
limits and conditions and uses an
established DST when giving D50W
without an order.
Employer
Policies
RNs are familiar with employer policies
related to medication.
A surgical RN knows her agency policy
requires patients with dopamine drips
to be monitored in ICU. She consults
with the ordering physician and
arranges to have the patient transferred
to ICU as soon as possible.
Individual
Competence
RNs know and practise within their own
level of knowledge, skill and judgment
related to medications.
An RN receives an unfamiliar drug
order, checks the drug formulary and
then calls pharmacy for more
information.
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Orders
Nurses1 can take orders from physicians, podiatrists, dentists, naturopathic doctors, midwives and
nurse practitioners.
An order is an authorization to carry out a restricted activity. The ordering professional (prescriber)
must also be authorized to carry out the activity in British Columbia.
Before carrying out a medication order:

determine that the order is clear, complete, current, legible and appropriate, and

verify that the order, pharmacy label and/or medication administration record (MAR) are complete
A complete order includes:

client name

date prescribed

medication name

strength and dosage

route

dose frequency

why the drug is prescribed (when it is a PRN medication)

quantity to be dispensed (if appropriate)

prescriber signature
Clarify any incomplete order with the prescriber.
Use the pharmacy dispensing label as an order if there is no alternative. Confirm that the label is
current, accurate and appropriate.
A pharmacist may produce a list of a client’s current prescribed medications. Once the prescriber
reviews and signs the list, it becomes an order.
1 Nurse refers to the following CRNBC registrants: registered nurses, nurse practitioners, licensed graduate nurses.
1
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VERBAL/TELEPHONE ORDERS
Accept verbal/telephone orders only when circumstances require it and there are no other reasonable
options. Follow agency policy for accepting and recording these orders.

Record the time and date.

Record the order as stated by the prescriber.

Read the order back to the prescriber to confirm it is complete and accurate.

Record the prescriber’s name and title.

Sign your name and title on the order.
PRE-PRINTED ORDERS
Pre-printed orders set out the usual care for a particular client group or problem. Pre-printed orders
should be accepted only when the prescriber has:

added the client name,

made any necessary changes to reflect the needs of the client, and

signed and dated the order
ABBREVIATIONS
Abbreviations can be misused, misread and misinterpreted. Agencies should have a list of acceptable
abbreviations.
Clarify any unfamiliar or unclear abbreviations used in medication orders. Check the Institute of Safe
Medication Practices at www.ismp-canada.org for a list of dangerous abbreviations, symbols and
dose designations.
UNACCEPTABLE ORDERS
Orders that are not client-specific are unacceptable. These include standing orders or general orders
protocols placed on client charts without the prescriber reviewing, individualizing and signing them.
Orders that are not complete are unacceptable. Examples: medication as at home, resume
medications post discharge.
USING TECHNOLOGY TO TRANSMIT ORDERS
Agency systems should be secure so that client information sent using technology cannot be changed
in transit, is kept confidential and can be validated.
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When using fax or e-mail to transmit orders:

locate fax machines and printers in secure areas away from public access,

retrieve faxes and printed material immediately or ensure they are secure until collected,

keep computer screens out of public view and log off when leaving, and

use whatever means necessary to confirm the validity of the orders
Refer to CRNBC’s Nursing Documentation booklet and Privacy and Confidentiality Practice Standard
for more information.
Prescribing
Registered nurses cannot prescribe medications.
Compounding
Registered nurses may compound (mix a drug with one or more ingredients).
Dispensing
Nurses have the authority to dispense certain medications.
Dispensing is preparing and giving medication for a client to take later. Nurses dispense with or
without a pharmacist’s involvement. Nurses dispense only to clients under their care and only when
it is in the client’s best interest.
Dispensing with a pharmacist’s involvement
When a pharmacist has already reviewed a medication’s suitability and dispensed it for the client,
nurses take steps to ensure its proper use. Examples of dispensing with a pharmacist’s involvement
may include:




Providing a client, leaving a facility on a day pass, with medication to take while away.
Giving a client, as part of an outpatient treatment program, medication supplied by a
provincial agency (e.g. BC Renal Agency, BC Centre for Disease Control).
Providing a health care worker, accompanying a client to an appointment outside the agency,
with medication for the client to take while away.
Giving a client, discharged from an inpatient unit, medication (e.g. antibiotic, inhaler) to take
home with them.
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Dispensing without a pharmacist's involvement
When a pharmacist has not reviewed the medication’s suitability (or it’s unclear if this was done),
nurses take steps to ensure the medication’s pharmaceutical and therapeutic suitability for the client,
as well as its proper use. Examples of dispensing without a pharmacist’s involvement may include:



Providing a client, discharged from Emergency, with enough pain medication to manage until
the pharmacy open the next morning.
Giving a community health client an ‘over the counter’ (OTC) medication (e.g.
acetaminophen, emergency contraceptive) to take later.
Providing a client at a diagnostic and treatment centre with a course of antibiotics to treat an
infection.
When employers require nurses to dispense, employers provide the organizational supports
necessary for safe dispensing.
Dispense medications in accordance with CRNBC’s Dispensing Medication Practice Standard,
Standards for Acting Without an Order and/or Standards for Acting With an Order.
The Dispensing Medications resource page contains information and resources for dispensing.
Medication Inventory Management
A nurse may be responsible for managing a medication inventory if there is no pharmacist responsible
for this function.
The employer is responsible for providing the systems and infrastructure required for the safe
management of medications.
Refer to the Medication Inventory Management Practice Standard and CRNBC’s Nurse-Managed
Medication Inventory: Information for Employers.
Drug Substitution by Pharmacists
Refer to Pharmacists’ Authority to Adjust, Interchange and Substitute Medication Orders Joint
Statement in the CRNBC Standards section of the website www.crnbc.ca
Administering
When administering medications, registered nurses use knowledge, skill, attitude and judgment
about the client and medication to assess, plan, administer, evaluate and document the care.
Accountability and safe medication practice is supported when the nurse giving a medication carries
out all the steps involved including preparing and documenting.

Know about the effects, side effects and potential interactions.
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
Educate your client about the medication.

Follow the seven rights: right client, right medication, right dose, right time, right route, right
reason and right documentation.
Administer medication in accordance with CRNBC’s Medication Administration Practice Standard,
Standards for Acting Without an Order and/or Standards for Acting With an Order.
OFF-LABEL MEDICATIONS
Off-label use is using a Health Canada-approved drug for a reason that is not listed on the package
insert. It is the unapproved use of a legal medication.
Nurses may receive orders for “off-label” use. Before giving any medication, make sure you are well
informed about the medication, the reasons for its use and the risks and benefits to the client.
INVESTIGATIONAL (EXPERIMENTAL) MEDICATIONS
As part of a formal research program, you may receive an order for an investigational medication (not
yet listed in a drug schedule or approved by Health Canada). Before administering make sure:

the principal or co-investigator of the study (program?) has authorized the order, and

a signed and dated consent form is in the client’s health record.
As knowledge about reactions to the investigational medication may be incomplete, be particularly
alert and document any the client experiences.
Nurses do not give an investigational medication that is not part of a formal research program.
Refer to the Scope of Practice for Registered Nurses, Standards, Limits and Conditions (p. 33)
NARCOTICS AND CONTROLLED DRUGS
Agencies must have policies and procedures about: who counts narcotics and controlled drugs,

who has access to locked cupboards,

what times drugs are counted,

how the count is documented, and

how to deal with discrepancies in the count
PLACEBOS
You may give a placebo if your client has consented (e.g., as part of a clinical trial). Clients must be
informed they could receive a placebo as part of their treatment or participation in a trial.
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Administering placebos to clients without their knowledge and consent is unethical and
unacceptable.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
If you recommend or participate in these practices, you must:

provide the client with evidenced-based information;

make sure it is not of higher risk to the client than conventional treatment; and

make sure it does not interfere with other current treatments
Refer to Complementary and Alternative Health Care for additional information.
WITHHOLDING MEDICATIONS
If you believe a medication or dose is inappropriate or could harm a client, consult with a pharmacist
or colleague, clarify the order with the prescriber and advocate for the client. If the prescriber is
unavailable, consult with a manager or experienced colleague.
If you still believe the order is unsafe or inappropriate, inform the prescriber you cannot give the
medication. The prescriber may choose to give the medication independently. Make sure the issue is
referred to an administrator or appropriate committee for resolution.
Capable clients may choose not to take medications. All people are assumed capable of giving
informed consent unless assessed to be incapable. Help clients understand their plan of care and
explore other options. If a client refuses a medication, assess the client’s understanding and talk
about potential consequences. Respect a client’s choice. Do not use force, coercion or manipulation
to give medications.
For issues relating to capacity to consent and substitute decision makers, refer to CRNBC’s Consent
Practice Standard.
ADMINISTRATION BY OT HERS – THE RN ROLE
In some settings, unregulated care providers (UCPs) administer medications. For more information on
working with UCPs, refer to the CRNBC Practice Standard Delegating Tasks to Unregulated Care
Providers.
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Self-Administration of Medications
In some settings, clients take their medications themselves or with help from their family. Examples:

Clients who take oral medications kept at the bedside.

Clients who come to the nurses’ station for their medications.

Clients who use patient-controlled analgesia systems.

Clients on pass who take their medications to self-administer.
As the nurse, you are still responsible for the overall client care related to medications, including:

educating clients about the medication’s actions and possible side effects, how to take them and
monitor the effect (e.g., testing blood glucose),

determining medications are taken as ordered,

monitoring and evaluating client response and reactions, and

following agency policy for documenting.
Role of the CRNBC-Certified Practice RN
Nurses with CRNBC-certified practice designation may diagnose and treat some diseases and
disorders, including administering or dispensing specific Schedule I medications without an order.
They must follow CRNBC-approved decision support tools (DSTs).
CRNBC-certified practice nurses do not prescribe (i.e., write a prescription for a client to fill at a
pharmacy). When treating a client, CRNBC-certified practice nurses must dispense the full course of
medication as per the DST.
For more information on certified practice activities and requirements, please see the Certified
Practice page at www.crnbc.ca
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Documentation
Nurses are responsible for maintaining timely and accurate records of all medications they give.
Document on the agency record as soon as possible after giving medications. Include client name,
drug name, date (and time if appropriate), dose, route, site, signature and title. When a record has
room for initials only, sign the accompanying signature sheet (this should be filed with every client’s
permanent record).
If giving a PRN medication, document your assessment and the client’s response.
When asked to double check or verify a medication, follow agency policy and document appropriately.
Documenting by exception is never acceptable for medications.
MEDICATIONS NOT GIVEN
When you withhold or omit medications, document why, when and who was notified.
MEDICATIONS GIVEN BY OTHER STAFF
Document only the medications you give. Do not allow others to document medications for you and
do not document medications that anyone else has given. The exception is in an emergency, such as
a cardiac arrest when a nurse, designated as recorder, documents medications given by others. Those
who gave the medications should countersign this record as soon as possible.
If agency policy does not allow auxiliary staff to document on the health record, nurses record the
medications given and any related observations reported to them.
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Medication Safety
Medication safety is an important part of patient safety. Transparency and reporting are the most
effective ways to reduce errors. Shaming, blaming and punishing do not prevent errors and may
discourage reporting.
MEDICATION ERRORS
Medication errors are avoidable events that may happen during the process of prescribing,
compounding, dispensing or administering a medication. They can result in a near miss injury or
death.
A near miss or close call is an
event that could have resulted in
unwanted consequences for a
patient, but either by chance or
timely intervention did not.
These errors can involve the wrong client, medication, dose,
time, reason, route or documentation.
Medication errors often result from systems issues. Because
of this, the best way to address a medication error is to use a
just, multidisciplinary approach that focuses on why the
error occurred.
– ISMP Canada
When a medication error occurs, take immediate steps to
resolve and report it. Your primary concern is client safety.
Assess the client promptly and notify the client’s practitioner so they can assess and treat the client if
required. Document the facts of the error on the client’s chart, including what happened,
interventions carried and client response. Follow agency policy for reporting errors.
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Resources for Nurses
BC DRUG AND POISON INFORMATION SERVICES
BC Drug and Poison Information Services’ mandate is to develop and implement centralized services
to assist health professionals in providing optimal levels of drug therapy and poison management in
the province and to provide poison information request services to the public.
Twenty-four hour toll-free poison information is available for the public by calling 604.682.5050 or
1.800.567.8911. Health professionals can email info@dpic.bc.ca or call 604.682.2344 (ext. 62126).
INSTITUTE FOR SAFE MEDICATION PRACTICES CANADA (ISMP CANADA)
ISMP Canada is an independent national non-profit agency committed to the advancement of
medication safety in all healthcare settings. It works collaboratively with the healthcare community,
regulatory agencies and policy makers, provincial, national and international patient safety
organizations, the pharmaceutical industry and the public to promote safe medication practices. More
information at www.ismp-canada.org
COLLEGE OF PHARMACISTS OF BRITISH COL UMBIA
The College is responsible for registering pharmacists and pharmacy technicians and licensing
pharmacies throughout the province. Their website contains information about and links to provincial
and federal legislation and drug schedules. www.bcpharmacists.org
SAFER HEALTHCARE NOW! (SHN)
The SHN campaign offers Canadian health care organizations the opportunity to participate in and
support a campaign dedicated to improving patient safety, through the implementation of six targeted
interventions in patient care including medication reconciliation.
For more information, email westernnode@saferhealthcarenow.ca or visit
www.saferhealthcarenow.ca
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