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Registration Number: {{org_field_registration_no}}

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Syringe Driver Guidance and Best Practices for Nurses Policy

1. Purpose

The purpose of this policy is to ensure the safe, competent, and compassionate use of syringe drivers for individuals receiving care through {{org_field_name}} in their homes. Syringe drivers are used to deliver continuous subcutaneous infusions of medication, particularly in palliative and end-of-life care.  This policy is also designed to meet CQC expectations for medicines management and prescribing, including: obtaining and recording consent (and acting in line with the Mental Capacity Act 2005 where a person lacks capacity), safe administration and monitoring, managing PRN (“as required”) medicines, preventing and responding to medication errors and omissions, controlled drugs governance where applicable, safe disposal of medicines and sharps, equipment safety checks, incident reporting, and audit and oversight arrangements that ensure medication records are accurate, contemporaneous, and reviewed. Where this policy refers to “Regulation”, it means the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (including Regulation 12: Safe care and treatment, Regulation 13: Safeguarding service users from abuse and improper treatment, and Regulation 17: Good governance).

2. Scope

This policy applies to all registered nurses employed or contracted by {{org_field_name}} who are involved in setting up, monitoring, or managing syringe drivers in a home care environment. It also guides managers and senior care staff who support and oversee clinical activity involving syringe drivers.

3. Related Policies

• CH07 – Person-Centred Care Policy
• CH11 – Safe Care and Treatment Policy
• CH17 – Infection Prevention and Control Policy
• CH18 – Risk Management and Assessment Policy
• CH24 – Management of Accidents, Incidents, and Near Misses Policy
• CH27 – Staff Supervision, Training, and Development Policy
• CH38 – End of Life and Palliative Care Policy

4. Policy Statement and Principles

{{org_field_name}} ensures that syringe drivers are used appropriately, safely, and only by nurses who are trained, competent, and authorised. We uphold the highest standards of palliative care, ensuring the comfort, dignity, and informed consent of the person and their family. Syringe drivers are used when oral or other routes are inappropriate or ineffective. Our approach is grounded in best practice, clinical evidence, and a person-centred model.

4.1 Definitions and terminology

A syringe driver (also called a syringe pump) delivers a continuous subcutaneous infusion (CSCI) of prescribed medicines, typically over 24 hours, to manage symptoms (commonly in palliative and end-of-life care). For the purposes of this policy:

• “Authorised prescriber” means a prescriber legally able to prescribe the medicines required (including controlled drugs where applicable).
• “Competent nurse” means a registered nurse assessed as competent for syringe driver set-up, calculations, checking, monitoring, documentation, troubleshooting, and escalation.
• “Medicines record” includes the prescription, syringe driver chart (where used), MAR, controlled drug records, device checks, site checks, and any incident reports/forms.
• “Representative” includes a person with legal authority (e.g., Health and Welfare LPA) or an appropriate consultee where relevant.

This policy applies to all syringe driver activity delivered by {{org_field_name}} in people’s homes and must be read alongside the organisation’s medicines management, consent/MCA, controlled drugs, and medical devices policies.

4.2 Indications for Syringe Driver Use

A syringe driver may be considered when:

• The person is unable to swallow or absorb oral medications
• Persistent nausea or vomiting prevents oral intake
• Pain, breathlessness, or other symptoms require continuous control
• Medication regimens need consistent administration over 24 hours
  Use must be clinically justified, based on assessment, and documented with prescriber authorisation. Medication choices and dosages must follow guidance from a palliative care team or GP.

4.3 Nurse Competency and Training

Only nurses who have received accredited syringe driver training and have demonstrated clinical competency through supervised practice may manage syringe drivers. This includes:

• Understanding indications and contraindications
• Setting up the syringe driver (e.g. McKinley T34 or equivalent)
• Programming infusion rates and times
• Calculating medication dosages and compatibility
• Responding to alarms, occlusions, or malfunctions
• Providing emotional support and education to the person and their family
  Competency is assessed annually and overseen by the Registered Manager.

Competency must specifically include: (a) safe medicines calculation and independent checking of calculations and pump programming in line with local protocol, (b) knowledge of medicine compatibility and stability and when to seek specialist pharmacy or palliative care advice before mixing medicines, (c) safe controlled drugs practice where applicable, (d) device checks, cleaning, maintenance requirements and how to respond to safety alerts and recalls, and (e) complete, contemporaneous record-keeping that provides a clear audit trail.

4.4 Prescription and Documentation

All syringe driver use must be supported by a valid prescription clearly specifying:

• The medications to be used
• Dosages and diluents
• Infusion duration (typically 24 hours)
• Prescriber’s signature and date
  Documentation must include setup time, medication batch numbers, site of insertion, infusion start and finish time, and checks. Nurses must maintain accurate, contemporaneous records of all administration, site checks, and any changes.

The prescription/authorisation must also clearly state (where relevant):

• The indication/symptom(s) being treated and intended outcomes.
• A PRN medicines plan alongside the syringe driver (what to give, dose range, minimum interval, maximum dose in 24 hours, and when to escalate).
• Any controlled drug legal requirements (e.g., formulation/strength, dose, and clear directions).
• Review frequency and who is responsible for review (e.g., GP, specialist, or community palliative care team).

Records must be sufficient to evidence safe care under Regulation 12 and good governance under Regulation 17, including a clear audit trail of: consent and capacity discussions, prescriber authorisation, set-up and checks, ongoing monitoring, symptom evaluation, actions taken, escalation, and end-of-infusion reconciliation and disposal/return of medicines and equipment. Medicines records must be regularly reviewed for completeness and accuracy as part of the organisation’s governance arrangements.

4.5 Monitoring and Troubleshooting

Nurses must monitor syringe drivers at the start of the shift and at least every four hours, or as clinically indicated. Monitoring includes:

• Infusion site assessment for redness, swelling, leakage, or discomfort
• Confirmation that medication is being delivered at the correct rate
• Alarm checks and battery status
• Observation for adverse reactions or symptoms

Monitoring must also include symptom assessment and effectiveness (for example: pain, nausea, agitation, breathlessness, and respiratory secretions) and documentation of whether the infusion is achieving the intended outcome. Any concerns (including worsening symptoms, excessive sedation, signs of toxicity, suspected incorrect dose or rate, unexplained pump alarms, occlusion, leakage, or site inflammation) must trigger immediate action: check the line, site, and device settings, provide prescribed PRN medicines where appropriate, and escalate promptly to the prescriber, community palliative care service, or out-of-hours clinician in line with the care plan. All actions taken and outcomes must be recorded contemporaneously.

Any malfunction or unexpected event must be reported immediately and documented under CH24 – Incident Management Policy.

Where the issue relates to device malfunction, a safety defect, or a near miss involving the syringe driver, this must also be reported through the organisation’s medical devices reporting route and escalated in line with manufacturer instructions and national reporting requirements where applicable.

4.6 Infection Prevention and Site Care

All procedures must follow strict infection control practices per CH17 – Infection Prevention and Control Policy. This includes:

• Hand hygiene before and after contact
• Use of sterile gloves and dressings during cannula insertion
• Rotating sites if signs of inflammation or irritation are present

The infusion site must be checked at least once every day as a minimum and at every scheduled syringe driver check, with earlier review if pain, redness, swelling, leakage, or induration is present. The site must be changed in line with clinical need and local clinical guidance (and must not exceed the maximum duration set by local protocol/device/cannula guidance), ensuring aseptic technique and appropriate dressing/securement is used and documented.

4.7 Communication with the Person and Family

Before initiating a syringe driver, the nurse must explain the purpose, benefits, and process to the individual (or their representative), and obtain informed consent. Consent must be obtained and recorded in line with the person’s ability to decide. Where there is reason to doubt capacity for this decision, a Mental Capacity Act 2005 capacity assessment must be completed and recorded. If the person lacks capacity, the decision to commence or continue a syringe driver must be made in the person’s best interests, involving any legally authorised representative (for example, a Health & Welfare LPA) and those close to the person as appropriate, and must be clearly documented. Any consideration of covert medicines administration must follow the organisation’s covert medicines procedure and multidisciplinary best-interests decision-making and recording requirements. Written and verbal information should be offered in accessible formats. Family and informal carers should be informed of who to contact in case of concerns or emergencies. Their emotional responses should be acknowledged with empathy, particularly in end-of-life contexts.

4.8 Emergency and Out-of-Hours Protocols

Nurses must ensure families and out-of-hours services are informed of syringe driver use and given relevant contact information, including emergency GP services, community palliative teams, or on-call nurses. {{org_field_name}} ensures 24/7 availability of qualified nursing support to address urgent issues with syringe drivers.

4.9 Storage and Disposal

All medicines and syringe driver equipment must be stored securely, with access limited to authorised staff, in line with the individual’s risk assessment and agreed home storage arrangements. Where controlled drugs are in use, they must be stored, recorded, administered, and disposed of in line with controlled drugs requirements, including maintaining an accurate controlled drugs record and ensuring appropriate witnessing of relevant entries and disposal/return processes in accordance with local procedure. Unwanted or out-of-date controlled drugs must be segregated from in-use stock and dealt with via the approved return/destruction route, with records completed and witnessed as required. Sharps and clinical waste (including syringes, giving sets, and used cannulae) must be disposed of safely using approved sharps containers and clinical waste streams, with clear arrangements for collection and removal from the home documented.

4.10 Auditing and Quality Assurance

Syringe driver use is subject to regular audit by the Registered Manager to ensure safe practice, policy compliance, and continuous learning. Audits cover training, documentation, incident reports, medication records, and feedback. Any learning outcomes are shared through supervision, reflective practice, and policy updates.

4.11 Medication errors, omissions, refusals and escalation

Any medication error, discrepancy, omission, unexplained interruption, incorrect pump setting, wrong diluent or volume, incompatibility concern, or failure to administer prescribed medicines must be treated as a patient safety incident: make the person safe first, seek urgent clinical advice where needed, inform the prescriber or community palliative care service, document fully, and report via CH24 (incident reporting). Medicine refusals (where a person has capacity) must be respected, documented, and escalated to the prescriber if refusal may cause harm. Where a person lacks capacity, decisions must follow the Mental Capacity Act 2005 and best-interests process and be recorded. Learning from errors and near misses must be shared and used to improve practice and update risk assessments and care plans.

4.12 PRN medicines alongside the syringe driver

Where PRN medicines are prescribed in addition to a syringe driver, the nurse must follow a clear PRN plan: indications, dose range, minimum interval, maximum dose in 24 hours, and when to escalate for review. PRN administration and the person’s response must be recorded, and repeated PRN use must prompt timely clinical review of the syringe driver prescription and symptom control plan.

4.13 Syringe driver device safety, maintenance and checks

Syringe drivers are medical devices and must be managed through a documented system that includes: pre-use checks, cleaning/decontamination between uses, calibration/servicing schedules, battery management, secure storage/transport, tracking/asset control, and actioning of manufacturer instructions and safety alerts/recalls. Staff must know how to access the device instructions for use and who to contact if there is a device concern. Device faults, near misses, and incidents must be reported through the organisation’s incident and medical devices processes in line with local protocol and national guidance where applicable.

4.14 Governance of medicines records and clinical advice

The Registered Manager must ensure governance arrangements are in place so that medicines records (including syringe driver documentation and MARs) are accurate, complete, contemporaneous, and regularly reviewed. Nurses must have clear access to timely clinical advice (for example: the prescriber, community palliative care team, or pharmacy medicines information) and must document all advice sought and actions taken.

5. Policy Review

This policy will be reviewed annually or sooner if prompted by changes in clinical practice, legislation, or CQC expectations. This policy must also be reviewed immediately following: any serious incident related to syringe drivers or medicines, a significant change in CQC medicines guidance, a relevant MHRA safety alert/recall affecting syringe drivers, or material changes to controlled drugs requirements or local NHS palliative care guidelines. Updates will be made available to all clinical staff.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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