RTs commonly administer medications via the authority granted to them by the Respiratory Therapy Act – “administering a substance by injection or inhalation” [s.4 (4)]. Dispensing occurs less often and will be explained later in this PPG. RTs are responsible for administering medications within both their personal and professional scope of practice. The safe and competent administration of medication requires the RT to have the competencies (knowledge, skill and abilities) to:

Examples of administering medication:

• Obtaining, preparing and administering a narcotic for use during conscious sedation of a patient/client
• Obtaining, preparing and administering a drug from a supervised hospital or departmental “stock” of medications (e.g. sedatives kept in a bronchoscopy suite for use during an outpatient procedure)

Administration of a substance orally or topically is not a controlled act under the RHPA and is not considered dispensing unless a supply was given to the patient/client to take at another time. An RT may assist a patient/client in taking their prescribed tablets at the time they are due; however, an RT may not leave extra tablets from a stock at the bedside for the patient/client to take. As with all other medications, to administer oral (e.g., Prednisone) and topical medications (e.g., Lidocaine) the RT needs to know the indications, contraindications, proper dosages and potential side-effects. The prescription and medication container must be checked, along with the patient/client’s identity and any potential allergies/drug sensitivities, as with any other medication. Oral medications in a tablet form should be given to the patient in a disposable container, and liquid preparations should be measured using syringes specifically designed for that purpose. The RT must ensure that the medication was taken by the patient/client as directed, and document accordingly.

OTC refers to medications that can be obtained in the community without a prescription from an authorized regulated health care professional. However, in a hospital setting an order is still required to administer an OTC medication. Many facilities also have policies requiring that any OTC medication brought in from home by a patient/client must be sent to the pharmacy for labelling, and then approved by the most responsible physician before returning it to the patient/client.

If an RT is giving out OTC medication in a community setting (e.g., nicotine replacement therapy (NRT) in an outpatient smoking cessation clinic), they are responsible for ensuring the medication is stored securely and must dispose of any medication that is past its expiry date. For more information, please see the section on Safe Storage and Handling.

RTs do not have the legislative authority to dispense medication but can receive delegation to dispense. RTs may dispense medications when it’s in the best interest of the patient/client, such as a patient/client having difficulty accessing a pharmacy.

Dispensing is a controlled act that authorizes an RT to select, prepare and provide stock medication that has been prescribed to a patient/client (or his or her representative) for administration at a later time. The process of dispensing has both technical and cognitive components. The technical component includes tasks such as receiving and reading the prescription, selecting the drug to dispense, checking the expiry date, labeling the product, and record keeping.

The cognitive component of dispensing involves assessing the therapeutic appropriateness of the prescription, applying approved substitution policies, being able to make recommendations to the prescriber and advising the patient/client.

Example:

Allowing a patient/client to take home a properly labelled metered dose inhaler from the Emergency Department stock after counselling a patient/client about their prescription and medication.

Registered Respiratory Therapists (RRTs) require delegation to dispense medication. It is important to note that Graduate Respiratory Therapists (GRTs) cannot accept delegation for any controlled act, including dispensing.

Depending on an RT’s personal scope of practice, it may be practical and in the best interest of the patient/client for an RT to accept delegation to dispense medications in certain practice settings, such as:

Example:
Providing a patient/client with a pharmaceutically supplied sample of a medication to take home from an asthma clinic. (For more information, please see the section on Dispensing Samples.)

The delegation to dispense medication requires the same steps as any other delegation process. For additional information, please see the CRTO Delegation PPG. The Regulated Health Professions Regulators of Ontario also has resource information and templates for developing delegation processes, which can be accessed here: templates for delegation.

The following are health care professions authorized to dispense medication and can delegate dispensing to RT’s:

*Pharmacists can dispense medication under the Regulated Health Professions Regulators of Ontario and can therefore delegate dispensing. However currently RT’s are not permitted to accept an order for from Members of the Ontario College of Pharmacists. For example, and physician can order a medication and a pharmacist may delegate the dispensing of the medication to a RT.

Midwives are not permitted to dispense, sell, or compound a drug, and therefore can not delegate dispensing. (College of Midwives of Ontario).

Nurse Practitioners can dispense medications however they cannot delegate prescribing, dispensing, selling, or compounding medication. (College of Nurses of Ontario).

Table 1: Who can order medication and who can order delegation to dispense medication.

*Pharmacists can perform the controlled act of “prescribing a drug” specified in the regulations (initiating therapy with varenicline or bupropion for smoking cessation) or in accordance with the regulations (adapting or renewing a previously prescribed prescription). Ref: Pharmacy Act; O. Reg. 202/94; Initiating, Adapting and Renewing Prescriptions Guideline.

**RN’S with prescribing authority are authorized to prescribe certain medications in certain practice settings. The Public Hospitals Act does not enable RNs to prescribe medications in hospital settings. Ref. College of Nurses of Ontario RN Prescribing Practice.

Note that in a hospital setting, regulations under the Public Hospitals Act determine who can order treatments for patients: “physician, dentist, midwife or registered nurse in the extended class”. Ref: RRO 1990 Reg 965.

An order to dispense must include the following:

REMINDER…

Respiratory Therapists are reminded that they are not obligated to accept delegation to dispense medications if it is, in their judgment, not appropriate to do so. For more information, please see the CRTO Delegation.

If medication is being dispensed based on a prescription, the label must meet all the requirements outlined in the Drugs and Pharmacies Regulation Act (s.156 (3) – Identification Markings), which means that The container in which the drug is dispensed shall be marked with,:

If an RT is responsible for maintaining a supply of medication, they must be sure to:

When administering medication, documentation is essential to communicate outcomes and prevent errors – such as accidentally missed doses or double dosing. When preparing and administering medications, a copy of the order (care plan) should be used as a reference to check the correct dosage three times, as follows:

When dispensing medication, the following documentation is required:

Documentation, in the event of a patient refusal of medication, is very important.

An RT’s employer may have developed, and approved policies related to substituting certain medications. Substitution policies are also known as “therapeutic interchange policies”. RTs must have the knowledge, skill and judgement to apply approved substitution policies in their practice. For more information, please refer to the Drug Interchangeability and Dispensing Fee Act.

These are drugs as defined in the Controlled Drugs and Substances Act and the Narcotic Control Regulations. The CRTO’s position is that there is nothing in current provincial or federal legislation to prevent an RT from receiving delegation to dispense a controlled substance. RTs may dispense narcotics and other controlled substances but must first obtain delegation to dispense the medication, as with other medications. For more information on delegation, please see the CRTO Practice Policy Handling, Administration and Dispensing of Controlled Substances.

Some of the factors associated with medication errors include the following:

Additional information can also be found on the Institute for Safe Medication Practices (ISMP) Canada website.

When a medication error occurs, the RT must take immediate steps to ensure the patient’s/client’s safety, resolve the problem and report it. It is essential for the RT to document the error on the patient’s/client’s chart, including: