Download 090-14 Medicines Policy - London North West Healthcare NHS Trust

MEDICINES
POLICY
Guidelines for use of medicines
2009
Updated February 2014
Version 1.9
Trust Medicines Policy
Policy Number
EHT/DTG/018/2014
Ratifying Committee
Date Ratified
Next Review Date
Accountable Director
Policy Author
Policy Updated by
Drug and Therapeutics Group
04 March 2014
04 March 2015
Medical Director/Assistant Chief Executive
Paulette Main, Principal Pharmacist
Paulette Main, Principal Pharmacist
Gobi Manoharan, Medicines Information Pharmacist
Trust-wide
Controlled and restricted Drugs Policy
Cytotoxic Drugs Policy
The Intrathecal Drug Policy
Pharmaceutical Cold Chain Policy
All
Policy Application
Related Policies
List of Staff for
Circulation
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Equality Impact Assessment [EIA]
Policy or service being assessed : Medicines Policy
Summary of Policy / Service: Local guidance on the management of all aspects of the
handling, storage and administration of medicines throughout Ealing Hospital NHS Trust.
Lead Person: Stuart Richardson, Chief Pharmacist
Person (s) responsible for carrying out the assessment [if not the lead] :
Stuart Richardson, Chief Pharmacist
Date of assessment : August 2009
Stage 1
Question
1. Is this a new or existing policy or service?
Please tick to indicate
Existing
2. What is the expected outcome of the policy
/ service? [ e.g. aims, objectives and purpose
of the policy / service ]
3. Does the Policy / Service link to others?
If Yes please state below
4. Who is intended to benefit from the Policy /
Service and in what way?
5. How is the Policy / Service to be put into
practice? Who is responsible?
6. How and where is information about this
policy / service published [e.g. through groups,
forums, committees / the Trust’s intranet /
internet ]
7. What regular consultation is carried out with
different communities and groups regarding
the Policy / Service [e.g. groups or forums
within the Trusts’ external groups &
communities ]
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To ensure clear guidance is in place
for the management, storage,
handling and administration of
medicines throughout the Trust
Yes
All Healthcare Professionals
employed by the Trust involved
with the handling of medicines at
EHT
The Policy is to be launched jointly
by the Pharmacy Department and
the Drug and Therapeutics group
for the Trust.
Trust Intranet. Hyperlinked to
Trust Controlled and Restricted
Drugs policy for cross referencing.
N/A
8. Are there any concerns that this Policy /
Service provision could have an impact with
regard to equality legislation, that has not been
addressed as part of the policy, specifically in
relation to: Age
Yes
No
No
No
No
No
No
No
No
Disability
Gender
Ethnicity ( Race)
Sexual orientation
Religion / Belief
Dignity and Human Rights
9. If YES to one or more of the above please
state evidence
10. Do the difference amount to discrimination
11. If YES could it be justifiable e.g. on grounds
of promoting equality of opportunity for one
group? Indirect discrimination can sometimes be
justifiable when it is target at a particular or ‘hard to
reach group’.
12. If YES please give reasons
N/A
Yes
No
13. From the initial EIA at stage 1, should
there be a full Equality impact assessment
carried out, ensure you addressed those areas
identified in question 8? - Please note reasons
No
14. Please indicate who will be responsible for
leading on the undertaking of the full EIA
being conducted, and the expected date of
completion [e.g. action plan, indicated end
dates for actions]
N/A
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N/A
In developing this policy the following legislation has been duly considered:
Data Protection Act 1998
Data Protection issues have been considered with regards to this policy. Adherence to
this policy will therefore ensure compliance with the Data Protection Act 1998 and
internal Data Protection Policies.
Diversity Policies
Equality issues have been considered with regards to this policy. Adherence to this
policy will therefore ensure compliance with Equal Opportunity legislation and internal
Equal Opportunity policies.
Freedom of Information Act 2000
Freedom of Information issues have been considered with regards to this policy.
Adherence to this policy will therefore ensure compliance with the Freedom of
Information Act 2000 legislation and internal Freedom of Information policies.
Health and Safety Act 1974
Health and Safety issues have been considered with regards to this policy. Adherence to
this policy will therefore ensure compliance with Health and Safety legislation and
internal Health and Safety policies.
Human Rights Act 1998
The Human Rights Act 1998 has been considered with regards to this policy.
Proportionally has been identified as the key to Human Rights compliance. This means
striking a fair balance between the rights of the individuals and those of the rest of the
community. There must be a reasonable relationship between the aim to be achieved
and the means used.
Race Relations Amendment Act 2000
The Race Relations Amendment Act 2000 has been considered with regards to this
policy. Adherence to this policy means that the Trust will eliminate discrimination on the
grounds of race and will promote race equality and good race relations.
Equalities Act 2006
The Equalities Act 2006 requires all public sector bodies to have a general duty in the
exercise of their public functions to pay due regard to the need to eliminate unlawful
discrimination.
The Mental Capacity Act 2005
The Mental Capacity Act provides a statutory framework to empower and protect
vulnerable people who are not able to make their own decisions.
Bribery Act 2010
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The Act repeals all previous statutory and common law provisions in relation to bribery,
instead replacing them with the crimes of bribery, being bribed, the bribery of foreign
public officials, and the failure of a commercial organisation to prevent bribery on its
behalf.
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Document History
Date
Action
Person
May 2009
Updated (Version 1.3)
Paulette Main
Jan 2010
Updated (Version 1.4)
Paulette Main
August 2011
Updated (Version 1.5)
Paulette Main
July 2012
Updated (Version 1.6)
Paulette Main
January 2013
Updated (Version 1.7)
Paulette Main
July 2013
Updated (Version 1.8)
February 2014
Updated (Version 1.9)
Paulette Main
Gobi Manoharan
Paulette Main
Ratification dates
Sent to
Version
Date
Drug &Therapeutics Group
1.3
09 June 2009
Drug &Therapeutics Group
1.4
January 2010
Drug &Therapeutics Group
1.5
August 2011
Drug &Therapeutics Group
1.6
18 July 2012
Drug &Therapeutics Group
1.7
29 January 2013
Drug &Therapeutics Group
1.8
30 July 2013
Drug &Therapeutics Group
1.9
04 March 2014
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Actions taken as a
result
CONTENTS
Page
INTRODUCTION
GLOSSARY
9
14
1. MAINTAINING A REGISTER OF NAMES OF STAFF
18
2. ORDERING
A. Stock medicines
B. Non-stock medicines
C. Discharge medicines
D. Intravenous fluids
E. Medical gases
F. Emergency medicines boxes
G. Medicines prepared in pharmacy production unit
TPN
CIVAS
H. Controlled stationery
19
19
20
22
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29
31
32
32
32
33
3. SUPPLY, TRANSPORT AND RECEIPT
A. Out-of-hours advice and supply
B. Supply from Emergency Drugs Cupboard
C. Obtaining supplies of medicines from another ward or clinical area
D. Transport of medicines
E. Transport of medical gases
F. Delivery & receipt of medicines
G. Patients’ own medicines
H. Checking the identity of patient’s own medicines
I. Supply of medicines to patients for use outside the hospital
36
36
36
37
38
39
39
42
43
44
4. STORAGE AND SECURITY
A. General requirements
B. Medical gases
C. Intravenous fluids & sterile topical fluids
D. Keys
E. Emergency medicines boxes
F. Medicines no longer required
G. Total Parenteral Nutrition (TPN) and Cytotoxic items
H. The medicines trolley and other systems
I. Order and record books
J. Action to be required if threatened
K. Closure of a ward or department
L. Medicines requiring refrigeration
M. Disposal of medicines
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50
51
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52
53
53
54
55
56
57
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5. PRESCRIBING
 Writing prescriptions
Medical Prescribers
Non Medical Prescribers
Patient Group Directions
Approved forms
Writing prescription for In Patients & Day Cases
Review & Cancellation of In Patient prescriptions
Out Patient Prescribing
Doctors Self Prescribing
Gifts & Benefits
Home Oxygen
58
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58
60
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61
63
64
65
65
66
6. PREPARATION
A. Oral medicines
B. Injections and infusions
C. Suppositories, enemas and vaginal pessaries
D. Bladder instillations
E. Other medicines
67
67
67
69
69
70
7. ADMINISTRATION
A. General guidance
B. Patient consent
Covert administration of medicines
C. Non-oral medicines
D. Nebulised medicines
E. Self Administration
F. Further notes on administration
71
71
74
8. ADDITIONAL PROFESSIONAL PRACTICES
A. Issue of pre-packed or over-labelled medicines from ward / clinical areas
B. Controlled Drugs – See CD Policy 2009
C. Unlicensed medication and licensed medication for unlicensed Indication
D. Intravenous medicines
E. Storage and use of I/V potassium
F. Cytotoxic Medicines
Administration
Documentation
Chemotherapy Sub-committee of D&TG
Prescribing Chemotherapy
Authorised locations for administration
Storage & Transportation of Cytotoxics
Pharmacy Cytotoxic Reconstitution Service
Safe Handling
Spillage of Cytotoxic drugs
Oral Methotrexate
G. Reporting Adverse Reactions to medicines
80
80
81
812
82
85
90
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75
75
75
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9. ERRORS IN ADMINISTRATION OR CUSTODY OF MEDICINES
A. Dealing with medicines errors
B. Changing names from BANs to rINNs
105
105
105
10. MEDICINES DEFECTS
A. 24 Hour recall procedure for defective medicinal products
109
109
POLICY FOR DISSEMINATION
110
APPENDIX 1
APPENDIX 2
APPENDIX 3
111
112
113
MEADOW HOUSE VERBAL ORDERS
GP REFERRAL LETTER
NORTH WEST LONDON RED LIST (December 2013)
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INTRODUCTION TO THE MEDICINES POLICY
The Medicines Policy has been prepared in a ‘stand alone’ loose leaf format to aid retrieval of
and facilitate updating of the information. The latest version of the policy must be available
to all staff in all clinical areas. The latest version is also available via the Trust intranet.
The procedures are filed in sections relating to specific functions. Each section can be easily
identified by the section dividers.
Significant changes may be made when the policy is next reviewed. Always ensure you refer
to the most recent version. Feedback on the Policy to ensure it reflects current best practice
is encouraged.
All medicines are potentially hazardous to someone
This document is intended to be used as a guide to good practice for all healthcare staff
involved, in any aspect, of the use of medicines. It defines the mandatory requirements of
Ealing Hospital NHS Trust, the employing authority.
The policies and procedures aim to provide a framework for the safe use of medicines by all
staff involved and at each stage of the medicines process and ensure that:
o Medicines are correctly and appropriately prescribed by an authorised practitioner
o Medicines are correctly and appropriately dispensed or supplied by an authorised
practitioner
o Medicines are accurately and appropriately administered
o Medicines are correctly stored
o Recording and control of medicines is correctly performed to prevent the loss,
inappropriate access to and misuse of medicines by patient/clients, residents, staff or
any member of the general public
o Practitioners involved in the delivery of care carry responsibility for their actions.
Signatures and initials must be capable of identification
o Medicines are correctly disposed of when no longer required
o All aspects of handling medicines comply with current legislation and guidance issued
by the Department of Health
o Risks associated with medicines are identified and minimised
Scope of the Medicines Policy
The use of medicines is the most common intervention in hospital patients. Adverse events
associated with medicines can result in patient harm. Safe medicines use depends on
healthcare professionals working as a team to consistently high professional standards and
understanding their own and others contributions to this outcome.
This policy:
o describes regular practice
o recognises that Healthcare professionals have the right to exercise their professional
judgement and act within their competence, however, the policy should be followed
at all times except in exceptional circumstances when, in the judgement of the
professional a deviation is justified in the interest of the patient. This must be
document in the patient record.
o only considers the processes associated with the physical handling of medicines
The clinical elements of the management of medicines (choice, dose, route of
administration, frequency and duration of treatment) should be appropriate to the patient’s
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condition, taking into account allergies, metabolic limitations etc. and are beyond the scope
of the policy.
Resources which should be used in conjunction with the Medicines Policy
o The Safe and Secure handling of medicines. A team approach – Duthie 2005
(Revised)
o British National Formulary (Current)
o British National Formulary for Children – BNF-C (Current)
o Ealing Hospital NHS Trust Formulary (Current)
o Ealing Hospital NHS Trust Intravenous Drug Administration Guide (Current –
Intranet)
o Ealing Hospital Controlled and Restricted drugs Policy (current)
o Ealing Hospital Pharmaceutical Cold Chain Policy(current)
o Nurse Prescribers Formulary (Current)
o Ealing Hospital NHS Trust Cytotoxics Policy (current)
o Ealing Hospital NHS Trust Blood Products administration Policy
o RCN Standards for infusion therapy (current)
o EHT Patient Group Directions by Emergency Nurse Practitioners & Paediatric Nurse
Practitioners. Accident & Emergency Department – (current)
o Hazardous Waste (England & Wales) Regulations (current)
o Standards of proficiency for Nurse and Midwife Prescribers. NPC. (current)
o The emergency medical treatment of anaphylactic reactions for first medical
responders and for community nurses- Resuscitation council UK (current)
o EHT Non-Medical Prescribing guidelines (current)
o Policy for administration of nebulised therapies to adult patients (current)
o EDS Operational Procedure (current)
Sources referred to throughout the compilation were:
o UKCC Code of Professional Conduct for the Nurse, Midwife and Health Visitor, Second
Edition (1984) and Third Edition (1992)
o UKCC Administration of Medicines Advisory Paper (1992)
o UKCC Exercising Accountability Advisory Document (1989)
o UKCC The Scope of Professional Practice (1992)
o UKCC Standards for Records and Record Keeping (1993)
o UKCC Standards for the Administration of Medicines (1992)
o RCN Standards for infusion therapy – October 2003
o Guidelines for the Safe and Secure Handling of Medicines - Duthie 1988
o The Safe and Secure handling of medicines. A team approach – Duthie 2005
(Revised)
o Medicines Act – (1968)
o Misuse of Drugs Act – (1971)
o The West Middlesex Hospital. Medicines Policy (2002)
o King’s College Hospital Medicines Management Policy (2008)
o St Mary’s NHS Trust. Drug administration policy and guidelines (Dec 2004)
o North West London Hospitals NHS Trust. Drug Policy (Aug 2003)
o EHT Patient Group Directions by Emergency Nurse Practitioners & Paediatric Nurse
Practitioners. Accident & Emergency Department – January 2005
o Changes in the CDs affecting pharmacists. RPSGB V2 June 2006. www.rpsgb.org
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o
o
Nursing & Midwifery Council. Statement on Covert administration of medicines 2007.
http://www.nmc-uk.org/
EDS Operational Procedure (2010)
Ratification and Review of Policies and Procedures
All policies and procedures relating to the use of medicines must be ratified by the
Drug & Therapeutics Group (D&TG), who act on behalf of the Trust. This includes new and
amended procedures, both in general use and for specific locations. The Group will also have
an ongoing responsibility for The Medicines Policy and will carry out an annual review of all
policies and procedures. This Medicines Policy Document was reviewed by a Trust-wide,
multidisciplinary working party and representatives from Ealing Care Commission Group
(CCG).
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GLOSSARY
ABPI: The Association of the British Pharmaceutical Industry
Appointed Nurse in Charge: The nurse in charge carries continuing responsibility for a
ward, department or clinic. At times when he/she is not on duty, delegated responsibility is
carried by another qualified nurse.
Authorised Staff/Practitioner: Individual practitioners/members of staff are authorised in
one or more of the following ways:
o By terms and conditions of appointment and as defined in the job description.
o By possession of a recognised professional qualification necessary to carry out the
duties defined in the job description
o By being recognised as competent to carry out specific functions.
o With authority of first-line Manager and/or Senior Manager
o By definition within individual procedures.
BNF: British National Formulary (The latest edition must always be used).
BNF-C: British National Formulary for Children (Latest edition)
Clinical Trial: An investigation or series of investigations consisting of the administration of
one or more medicinal products, by one or more doctors or dentists for the purpose of
ascertaining what effects, beneficial or harmful, the products have.
Community Pharmacy: A retail pharmacy in the private sector, i.e. not attached to an
NHS hospital.
Complementary Therapies: Homeopathic and herbal medicines for the purposes of this
document will be considered as medicines
Controlled Drugs (CDs): Medicines which are subject to the prescription requirements of
the Misuse of Drugs Regulations 1985, Schedules 2 and 3
Controlled Stationery: All stationery which could be used to obtain medicines
fraudulently.
Cytotoxic: As defined by BNF codes – Chapter 8.1
Designated Manager: The person who carries managerial responsibility for a specific area.
This may be a first-line manager or a senior manager depending on the level of responsibility
DOH: Department of Health
Drug: This term is interchangeable with the term medicine
eBNF: The Trust Medicines Formulary information can be accessed on the intranet. It is
supported by an electronic version of the current BNF.
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ePro: The system used to prescribe patient TTAs and transfer information to GPs at
discharge
Healthcare Staff: Any Trust, ICO or CCG staff who are involved in the care of patients
ICO: Integrated Care Organisation. The Trust which is an organisation combining the staff
and services of Ealing Hospital and Ealing, Harrow & Brent Community Services
ISO Standards: Standards set by the International Standards Organisation
Locally Agreed/Approved: Policies and procedures for local use that have been
agreed/approved by the Drug and Therapeutics Committee. The term 'local' may apply to a
small work unit (e.g. a ward) or to a large healthcare setting (e.g. a hospital)
Matron: Senior Nurse Manager
Medical Practitioner: This covers all pre-registration and post-registration doctors and
dental practitioners who have clinical responsibility for the patient/client at any given time
Medicine: This term describes all medicinal products i.e. a substance administered by
mouth, applied to the body or introduced into the body for the purpose of treating or
preventing disease; diagnosing disease; ascertaining the existence, degree or extent of a
physiological condition; contraception; inducing anaesthesia or otherwise preventing or
interfering with the normal operation of a physiological function.
Medicine Defect: This term covers the following areas:
o Visual evidence of deterioration e.g. colour, smell, taste, physical damage,
bacterial/fungal contamination
o Unexplained lack of action or adverse reaction to a medicinal product
o Packaging errors
Medicine Error: Any occurrence that contravenes the policies and procedures laid down in
this document
MHRA : Medicines and Healthcare products Regulatory Agency. Formerly known as the MCA
(Medicines Control Agency) and incorporates the CSM (Committee for Safety in Medicines).
See www.mca.gov.uk
Nursing & Midwifery Council (NMC): Regulatory body and register of nurses, midwives
and health visitors registered and/or working in the UK (Previously UKCC).
NPSA: A Special Health Authority created to co-ordinate the efforts of the entire country to
report, and more importantly to learn from mistakes and problems that affect patient safety.
See www.npsa.nhs.uk
ODA: Operating Department Assistants (also called ODPs - Operating Department
Practitioners). Theatres staff who assist anaesthetists during surgical procedures.
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Patient: May otherwise be referred to as ‘Service users’, ‘Clients’, ‘Consumers’ or
‘Customers’
PGD: Patient Group Direction. Standardised guideline to allow appropriately trained and
accredited staff to administer or supply (or both) and agreed range of medicines for
specified indications to individual patients in line with agreed criteria.
Pharmacist: A practitioner registered with the General Pharmaceutical Council.
PODs: Patients’ Own Drugs or Medicines. Medicines which belong to a patient, that have
been brought into the hospital setting. Medicines dispensed by EHT pharmacy that have left
a clinical area and later returned must also be treated as PODs. PODs must be assessed
suitable for use by a pharmacist.
Prescriber: Person who is responsible for the writing the prescriptions for a patient. Would
usually be a medical practitioner but could also be a qualified Independent prescriber who is
a nurse, midwife or pharmacist.
Prescription: A signed order for the supply of medicine for a specific patient. Prescriptions
are written on in-patient prescription charts, out-patient prescriptions or on Epro (electronic
discharge system). Private prescriptions are written on letter headed paper.
Private Patient: A patient who is not funded by the NHS
Private Prescription: A prescription written for a private patient (non-NHS) or a
prescription for an NHS patient for a drug not available on the NHS eg. Malaria prophylaxis
Qualified Nurse: A qualified nurse is either a Registered nurse or an Enrolled nurse listed
in the second level part of the Nursing & Midwifery Council (NMC) Register.
Currently, that part of the Register includes the following:
Part 2
Enrolled nurse, general
Part 4
Enrolled nurse, mental
Part 6
Enrolled nurse, mental handicap
Part 7
Enrolled nurse
Registered Nurse: A nurse who is listed in the first level part of the NMC Register.
Currently, that part of the Register includes the following:
Part 01
Registered general nurse
Part 03
Registered mental nurse
Part 05
Registered nurse of the mentally handicapped
Part 08
Registered sick children's nurse
Part 10
Registered midwife
Part 11
Registered health visitor
Part 12
Registered nurse, adult health
Part 13
Registered nurse, mental health
Part 14
Registered nurse, mental handicap
Part 15
Registered nurse, care of the child
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Registered Medical Practitioner: A medical practitioner with full General Medical Council
registration
Restricted Drugs: Prescription only medicines which are known to have the potential to
be subject to abuse. Local policy restricts quantities ordered, method of ordering and
storage requirements
SI Units: Systems International units
TTA: ‘To Take Away’. Medicines supplied to inpatients on discharge from the hospital. The
term may be used to describe both the ‘Discharge medicines letter’ used to order the supply,
or the supply itself. Other hospital trusts may use an alternative term ‘TTO’ – ‘To Take Out’
UKCC: UK Central Council for Nursing, Midwifery and Health Visiting. Now known as NMC
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1.
MAINTAINING A REGISTER OF NAMES OF STAFF
A.
REGISTER OF STAFF NAMES
All healthcare settings involved in the direct delivery of care shall have a Register of staff.
Signatures and initials of staff must be capable of identification
A1
A1.1
Register
All staff involved in the handling of medicines, including custody, ordering,
prescribing and administration of medicines, shall be required to provide a register
entry
A1.2
A register will be maintained by:
- The designated Manager in each Clinical area.
- The Dispensary manager, for Pharmacy staff and relevant portering and transport
staff.
- Medical staffing, for medical practitioners
A1.3
Permanent staff shall make an entry on their first day of appointment.
A1.4
Temporary staff (including students) shall make an entry preferably on their first day
at the commencement of their shift, or the next week day if this should fall on a
weekend. This part of the register shall be maintained chronologically
A1.5
The register entry shall comprise:
- date
- full printed name
- designation
- signature (in full)
- signature (initials)
- name of agency (if applicable)
- contact details
A1.6
The designated managers have the authority to request a register entry from any
member of staff working within their area.
A1.7
Details should be kept current. Staff should inform the manager of any change in
details or name and a new entry should be made.
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2.
ORDERING
A.
ORDERING STOCK MEDICINES FROM PHARMACY
Each ward, department or clinical area which uses medicines routinely holds a stock of
medicines suitable for the common types of conditions being treated in those areas.
All stock orders are dealt with by Distribution and Stores section in pharmacy.
Stock medicines can be ordered in four ways:
A1. Top-up – in agreed Clinical areas
A1.1 An agreed list of medicines to be held as stock is drawn up by the Ward Manager and
the Ward Pharmacist. This list specifies standard quantities of each medicine to be
held. This list must be reviewed on at least an annual basis
A1.2
A member of the pharmacy technical staff is assigned to visit the clinical area on a
pre-arranged number of days
A1.3
On each designated day, the technician/pharmacy assistant visits the clinical area
and systematically checks each storage area, noting the amount of each medicine
required to return the stock to the level required on the list. In some clinical areas a
ward staff member will perform this task
A1.4
If extra supplies of any item are required, the nurse in charge shall inform the
technician/pharmacy assistant at the time of handing over the keys
A1.5
Where extra supplies of stock medicines are required on a regular basis, the stock
holding shall be reviewed and the list amended.
A2. Written, Signed Orders
A2.1 Stock medicines, for all wards and most clinics, may be ordered using the ‘Stock
Requisition’ order book. Some clinics have a standard pre-printed ‘Stock Requisition’
order form
A2.2
Orders should only be written for items which are on the agreed stock list. Medicines
shall only be supplied against such orders if it has been previously agreed with the
pharmacy that these medicines may be held as stock or if the Distribution Manager
feels it is appropriate to supply the medicines against a stock order
A2.3
The order must state clearly:
- Ward or clinic name
- Generic name of the medicine
- Strength
- Form required e.g. tabs, injection etc.
- Quantity required
The order must be signed (using full signature) by an authorised practitioner, with
the name and designation printed clearly under the signature
A2.4
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A2.5
Additional stocks should not be ordered after 5pm weekdays, at weekends or over
Bank Holidays unless need for the supplies is urgent. If ordered outside Distribution
opening hours, orders would be processed by the dispensary staff working the
weekend or Bank Holiday
A2.6
Orders for Controlled Drugs – Refer to Ealing Hospital NHS Trust Controlled and
Restricted Drugs Policy.
A3. Telephone or Fax Orders
A3.1 Telephone Orders
A3.1.1 Orders for stock medicines may be telephoned to the Distribution section on
weekdays and only in emergencies
A3.1.2 The caller must state:
- their name
- designation
- location
- medicines required (form, strength)
- quantity required
- reason for request
A3.1.3 A written, signed order must be sent to Distribution within 24 hours.
A3.2 Fax orders
A3.2.1 Orders for stock medicines may be faxed to the Pharmacy office on weekdays and
only in emergencies (0208 5742975)
A3.2.2 A fax of a written signed order is acceptable (see above), but must be marked
'For the attention of Pharmacy Distribution'.
A3.2.3 The original order must be sent to Distribution within 24 hours
B. ORDERING NON-STOCK MEDICINES FROM PHARMACY
Medicines which are not routinely used in a clinical area, but may be required for an
individual patient are designated 'non-stock'. All non-stock medicines are labelled with the
patient's name and are charged either to the ward/clinical area or to the consultant caring
for the patient.
Controlled or Restricted drugs must be ordered as stock items. Refer to Ealing Hospital NHS
Trust Controlled and Restricted Drugs Policy.
Non-stock medicines may be ordered in two ways:
B1. Ordering via the Ward Pharmacist
B1.1 The pharmacist responsible for the ward/clinical area, visits on an agreed number of
days, at times agreed with the nurse in charge
B1.2 Requests for non-urgent supplies may be ordered via the ward pharmacist by noting
requirements on a ‘Pharmacy request slip’ attached to the patients’ drug chart or
another locally agreed place, such as a ward diary where messages for the ward
pharmacist may also be recorded
B1.3 At each ward visit, the ward pharmacist shall check the prescription charts or diary
and supply appropriate quantities of the required items.
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B2. Ordering via the Pharmacy Dispensary
This method must only be used for items that cannot wait for the next ward pharmacist visit
B2.1 Sending a prescription chart to pharmacy
B2.1.1 Ward staff should contact the regular ward pharmacist to obtain advice. The Ward
pharmacist may ask that the chart be forwarded to pharmacy dispensary for their
attention, may agree to visit the ward to pick it up or may ask that the chart remain
on the ward until the next scheduled visit
B2.1.2 If the chart is to go to dispensary ward staff should ensure that the prescription chart
has been completed in full, signed and that the patient name, hospital number,
consultant and ward name are printed clearly on the front of the chart and that these
details are correct
B2.1.3 Complete a 'Pharmacy Request slip' for each prescription chart. The order must state
clearly:
- the patient name, hospital number and consultant
- the name, form and strength of each medicine required and directions if
applicable
- the ward
- attention ‘Ward Pharmacist Name’ if appropriate
B2.1.4 The order must be signed (using full signature) and dated by an authorised
practitioner, with the name printed clearly under the signature
B2.1.5 Attach the order slip to the prescription chart using a paper clip. Send to the
pharmacy dispensary via:
- routine ‘Pharmacy Green bag (Envopak®)’ collection
- a porter
- a member of the ward staff
- the pneumatic tube system (if available)
B2.1.6 If the medicine is required immediately, the porter/ward staff must be requested to
wait for the medicine to be dispensed so that he/she can return it to the ward.
Ensure pharmacy staff knows the person is waiting
B2.1.7 Charts will be returned to the ward as soon as possible on the next porter’s round. If
the chart is required immediately, the porter/ward staff must be requested to wait for
the chart to be checked against the request slip so that he/she can return it to the
ward. Ensure pharmacy staffs know the person is waiting. Ordered items will be sent
once dispensed and may be sent later, separately to the chart. Small items might be
sent via the pneumatic tube if requested
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B2.2 Telephone request without a drug chart
A telephone request may only be made in the event of urgency and the need to retain the
drug chart on the ward.
B2.2.1 A telephone request must be made by a doctor or a senior nurse and may only be
accepted by the relevant ward pharmacist
B2.2.2 The pharmacist must ask for the reason for the urgency and the reason for retaining
the drug chart on the ward
B2.2.3 The pharmacist must be told what else is prescribed on all sections of the drug chart
B2.2.4 The pharmacist must record the name, formulation, dose and frequency of the
medicine required on a ‘Ward Pharmacy dispensing record sheet’, together with the
names of other medicines prescribed
B2.2.5 The pharmacist retains the right to refuse to supply medicines without seeing the
drug chart if not satisfied with information supplied and has concerns about
treatment regimen. The ward pharmacist may agree to visit the ward to view the
chart but if this is not possible the drug chart must be sent to the dispensary for
review before the medicine can be supplied
B2.2.6 The pharmacist is responsible for endorsing the chart with the quantity and date of
any medicines supplied, as soon as possible
C. DISCHARGE MEDICINES (TTAs)
C1.0 Overview of System ‘Workflow’ and processes
Please also see EDS Operational Procedure and intranet page on ePro (under systems) in
conjunction with this policy.
All information contained in the electronic discharge summary must be complete and
accurate at the time of completion. The separate stages of the system based workflow are
summarised below, noting each of the “status” types as the discharge summary progresses
from “Draft” to “Complete”.
 Once the patient’s admission has been recorded on PAS, the electronic
discharge summary can start to be authored – this is referred to as “Draft”
status.
 When the decision to discharge the patient is made the clinical author can
complete the discharge summary – status is changed to “Written”.
 A member of the medical team or nursing staff should then inform the ward
pharmacist.
 A pharmacist will clinically screen the discharge summary - status changed to
“Screened”. The pharmacy team will then dispense the discharge medication
– status changed to “Dispensed” – and check it (“Checked”).
 The discharge medication is then “Ready” for collection and the nursing staff
can issue the medication to the patient and “Complete” the process.
A Discharge summary (DS) is written by the discharging doctor, summarising all the relevant
clinical details of patient’s in-patient stay. It is primarily intended for the GP. A DS will also
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contain a list of drugs on discharge. A TTA (To Take Away) or TTO (To Take Out) refers to
the discharge medication.
C2.0 Pharmacy Screening – Standard Process
Pharmacists must clinically screen all discharge prescriptions prior to the supply of discharge
medicines. The pharmacist will query any clinical concerns, e.g. unexplained or unexpected
changes found on the discharge prescription when matched against the medication chart.
Once clinically screened, the pharmacist will indicate this on the electronic discharge system
and will also sign and date the TTA section of the printed drug chart. Please note that drug
charts do not need to be taken to Pharmacy if a pharmacist has clinically checked the
discharge prescription on the ward.
The pharmacist or a Medicines Management Technician (MMT) must ensure that the bedside
medicines locker contents, fridge and or controlled drug cabinet have been checked, to
ensure that all medicines labelled for discharge are included in the completed discharge
summary.
The pharmacist or the MMT must endorse on the electronic discharge system (and/or the
pharmacy dispensing sheet) to indicate which medicines are already labelled for discharge,
along with those medicines which must either be dispensed from Pharmacy, require relabelling or are the patient’s own supply from home.
If the drug chart is sent to Pharmacy for screening, then the contents of the medicines
locker (and any fridge item) must also be sent to Pharmacy. If there are patient’s own
controlled drug(s), then a member of pharmacy team must deal with them as appropriate.
The Screening pharmacist should make sure appropriate blood results are recorded,
appropriate follow up arrangements made and counselling and treatment booklets are given
for high risk drugs such as methotrexate.
The screening pharmacist must make sure that their contact and/or bleep number is
included on the electronic discharge summary.
C2.2 Amending a discharge summary
Clinician Authors
If any amendments are required after the initial discharge prescription has been written, it is
the responsibility of the clinician making the amendment to inform their team, the ward
pharmacist, the patient’s nurse and/or pharmacist in the dispensary, as required.
Pharmacists
Any amendments to the prescription should be discussed with the prescriber or another
doctor from the same medical team before a change is made.
A pharmacist is authorised to amend a discharge prescription following a verbal instruction
from a doctor. The name of the prescriber authorising the change must be recorded on the
discharge prescription, along with their contact bleep. The details of the pharmacist making
the amendment will be automatically recorded on the electronic discharge system.
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A pharmacist may use their discretion to make a change without contacting the prescriber
(e.g. amending an inhaler device). Where a prescriber has not been contacted, the
pharmacist must indicate this on the discharge summary (recorded as ‘PNC’ i.e. prescriber
not contacted).
C2.3 Dispensing and Supply
Requesting Discharge Medication
Once the clinical author has typed up the electronic discharge summary (i.e. status is
“written”), it is the responsibility of nursing staff to provide the ward based pharmacist with
the patient’s medication chart and any medication dispensed for that patient, including fridge
items and the patient’s own medication.
A Pharmacy request slip should be filled-out and attached to the medication chart, together
with any controlled drugs prescription, to indicate to the pharmacist that discharge
medicines are required.
If the discharge prescription is written after the pharmacist’s regular visit time - and is
required before the next pharmacist visit time - the ward pharmacist will be bleeped. The
ward pharmacist may then either return to the ward or ask for the prescription and
medication chart to be sent to pharmacy.
C2.4 Pharmacy Dispensing
If all required medicines are already available on the ward, in sufficient quantities and
labelled appropriately, the pharmacist and/or MMT will assemble the TTA on the ward, check
it and mark the discharge summary status as “Ready” on the system.
If medicines are required from Pharmacy, the TTA will be sent to Pharmacy for dispensing.
The screening pharmacist will print a TTA dispensing sheet for dispensary staff to dispense
the TTA from. The TTA dispensing sheet will already have some endorsements such as
patient’s own drugs (POD) on it. The dispenser and checker will manually endorse on the
form. Once checked by the Pharmacist (or accredited checking technician) the discharge
summary status will be set to “Dispensed” and “Ready”.
When the TTA is checked it is placed into specific TTA bags, with a label including patient
details affixed to the bag. These TTA bags have two forms; please refer to Appendix 3 for
details.
Once the TTA is ready, the nursing staff or the pharmacy porter can collect or deliver the
TTA as applicable.
C2.5 Nurse Dispensing – Variations to Standard Process
It is recognised that for a small number of clinical areas there are agreed variations to the
standard workflow, e.g. Maternity (Lammas), Endoscopy Unit, Ward 3 North.
In these areas, nursing staff (including midwives) are able to “direct supply” some
prescriptions following a strict protocol, allowing for the completion of TTAs on the ward. In
order to do this they must have completed the relevant accreditation process.
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Nursing and midwifery staff must only carry out this process when they can “direct supply”
all medications on that discharge summary.
If any of the medications require pharmacy input, then the entire discharge summary will be
screened, dispensed and checked by Pharmacy staff, as per the standard process.
C2.6 Discharge Co-ordination
Nursing and midwifery staff (as applicable) must print a copy of the final electronic discharge
summary and ensure that this is provided to the patient at the point of discharge, along with
the correct medication and relevant instructions.
Discharge medicines must be matched against the details included on the printed discharge
summary. Directions for use on each labelled medicine must also be identical to those on the
prescription.
Where a patient has sufficient medication supply at home, this is to be indicated on the
printed discharge summary and the medication will not be in the TTA bag.
Once the relevant member of nursing/midwifery staff is assured that no discrepancies exist,
they must sign on to the PAS/Bed-Web system and discharge the patient.
They must then also sign on to the electronic discharge system and mark as the discharge
summary status as “Complete”.
This will result in two actions:
1. Two copies of the completed discharge summary will be printed, i.e. one for the patient
and one for the patient’s medical record;
2. An electronic copy of the completed summary will be sent to the GP by secure email.
The nurse-in-charge on the relevant ward is responsible for ensuring that these actions are
completed in a timely manner, for all inpatient/day case episodes.
C3.0 User Roles and Responsibilities
The following general rules should be followed by all in all situations;
o Users must always use their own log-in details.
o Passwords must never be shared.
Failure to comply with this instruction may result in disciplinary action, as per the
Trust’s Information Security Policy.
C3.1 Ward Pharmacist
It is the ward pharmacist’s responsibility to;
1) Screen discharge summaries (DS) on the ward as much as possible. They should
arrange the time of the visit which best suits the area they are working in and their
ward’s requirement. Liaise with ward staff to arrange how ward staff will
communicate when DS are written, and, how and when ward staff should send down
discharge medication/drug chart for dispensing to pharmacy.
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2)
‘Clinically screen’ DS from their ward. (Clinical screening involves carefully assessing
the need for each drug, checking transcribing, checking for interactions etc). After
screening they should endorse electronically that this has been done.
3) Resolve any prescribing errors/problems, ensure that CDs are written correctly (&
signed), and cytotoxic guidelines are followed.
4) Screening Pharmacist must ensure that Dietary Supplements have been initiated by
or on the advice of a Dietician and have been indicated to continue on discharge. See
Prescribing Food Supplements Guide.
5) Take ownership of DS from their ward (until 17:30). If the pharmacist is unable to
do this (in the case of meetings or other commitments), they must ensure that an
appropriate handover has taken place; in order of preference to their team,
dispensary pharmacist or the on-call pharmacist.
6) Engage with the prescribing doctor and other multidisciplinary team members and
provide appropriate pharmaceutical input in authoring DS.
7) Initial on drug chart to indicate that DS has been screened.
8) Where appropriate collect, assess & count labelled medication for the patient, PODs,
fridge items etc and electronically endorse on the system.
9) Dispense discharge medication & check discharge summaries where appropriate.
10) Print ‘TTA dispensing form’ if further dispensing is needed (it is recommend that TTA
dispensing forms are only printed when in pharmacy).
11) Mark “In Pharmacy” on ePro when TTA in Pharmacy.
12) Liaise with MMT and dispensary team as appropriate.
13) Place checked drugs into pharmacy bags allocated for discharge (please see appendix
2), affix bag label and place into appropriate pigeon hole.
14) Monitor DS progress from their ward via discharge tracker. This must be performed
throughout the working day at intervals of no more than 3 hours (i.e. before and
after lunch and 5pm). A final check must occur at approximately 5pm to ensure that
there are no outstanding DS on the system form their ward so they must either take
ownership or liaise with / handover to on-call pharmacist.
15) Communicate with nursing staff regarding collection of TTA with CD(s).
16) Follow Trust guidelines & policies with respect to the management of unlicensed
drugs, non-formulary drugs, controlled drugs and cytotoxics.
17) Ensure up to date contact details such as bleep numbers are held within the
electronic system and ensure that ward staff know how to contact them.
C3.2 Dispensary Pharmacist
Responsibilities of a dispensary pharmacist include;
1) All responsibilities of the ward pharmacist described in 3.1.
2) To manage workflow via discharge tracker.
3) To liaise with ward pharmacists, MMTs and dispensary staff in managing workflow.
4) Endorse appropriate section on the TTA dispensing sheet manually and/or
electronically where appropriate. Cytotoxics will need two checking signatures.
5) File ‘TTA dispensing form’ and any CD prescription.
6) All other current responsibilities.
C3.3 Discharge Team
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Discharge Team usually consists of one or more pharmacist(s) and technician(s). This team
will visit 4S, 5S, 5N, 6S, 6N, 7S & 7N to screen and dispense TTO. This service is only be
provided between 14:00 – 17:00.
C3.4 On-call Pharmacist
Responsibilities of an on-call pharmacist include;
1) All responsibilities of the ward pharmacist as appropriate.
2) To manage workflow via discharge tracker.
3) All responsibilities of a dispensary pharmacist as appropriate.
4) To check discharge tracker for outstanding TTA/DS before close.
C3.5 Medicines Management Technician (MMT)
It is the responsibility of the MMT to;
1) Work closely with ward pharmacist and dispensary team in managing workflow.
2) Manage workflow via the discharge tracker.
3) Collect, count, assess and electronically endorse PODs, fridge items etc. as
appropriate.
4) Print ‘TTA dispensing form’ and endorse manually where appropriate.
5) Hand over TTA to appropriate nurse on ward where appropriate.
6) Communicate with nursing staff regarding collection of TTA with CD(s).
7) Follow Trust guidelines & policies with respect to the management of unlicensed
drugs, non-formulary drugs, controlled drugs and cytotoxics.
8) All other current responsibilities.
C3.6 Accredited Checking Technician (ACT)
It is the responsibility of the ACT to;
1) Liaise with ward pharmacist, dispensary pharmacist, on-call pharmacist & MMT as
appropriate to manage workflow
2) Count, assess and electronically endorse PODs, fridge items etc. as appropriate.
3) Dispense & check where appropriate.
4) Endorse electronically that DS has been dispensed & checked where appropriate.
5) Print ‘TTA dispensing form’ and endorse manually where appropriate.
6) Place checked drugs into pharmacy bags allocated for discharge (please see
appendix), affix bag label and place into appropriate pigeon hole.
7) File ‘TTA dispensing form’ and any CD prescription.
8) Communicate with nursing staff regarding collection of TTA with CD(s).
9) Follow Trust guidelines & policies with respect to the management of unlicensed
drugs, non-formulary drugs, controlled drugs and cytotoxics.
C3.7 Technicians, Pre-registration Pharmacists & Student Technicians
It is the responsibility of the technician, pre-registration pharmacist and/or student
technician to;
1) Liaise with ward pharmacist, dispensary pharmacist, on-call pharmacist, MMT & ACT
as appropriate to manage workflow.
2) Print ‘TTA dispensing form’ and dispense any items that need dispensing & endorse
manually.
3) Count, assess and electronically endorse PODs, fridge items etc. as appropriate.
4) Communicate with nursing staff regarding collection of TTA with CD(s).
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5) Follow Trust guidelines & policies in handling unlicensed drugs, non-formulary drugs,
controlled drugs and cytotoxics.
C3.8 Pharmacy Assistants & reception staff
It is the responsibility of the pharmacy assistant to;
1) Dispense items against ‘TTA dispensing form’ and endorse manually.
2) Communicate with nursing staff regarding collection of TTA with CD(s).
3) Follow Trust guidelines & policies with respect to the management of unlicensed
drugs, non-formulary drugs, controlled drugs and cytotoxics.
It is the responsibility of the reception staff to;
1) Set status of DS as “In Pharmacy” on receipt of a drug chart/PODs and/or a TTA
dispensing sheet.
2) Monitor the discharge tracker and facilitate pharmacist/MMT awareness of DS in
written status.
D. ORDERING INTRAVENOUS (IV) FLUIDS FROM PHARMACY
Intravenous fluids are treated as stock items and may be ordered from the Distribution and
Stores section in pharmacy.
Intravenous fluids can be ordered in three ways:
D1. Top-up
D1.1 Some clinical areas are visited by a pharmacy technician or pharmacy assistant on a
regular basis
D1.2
On the designated day, they will visit the clinical area and systematically checks the
IV fluid stocks against an agreed list (see procedure for ordering stock items)
D1.3
If any extra supply of an item is required, above the agreed maximum, the nurse in
charge must inform the pharmacy staff at the time of the visit
D1.4
All IV fluids shall be supplied to the clinical area after 15:00 on the designated
delivery day – usually the following day
D1.5
The supply to each area is enough to last until the next top-up, usually in 7 days.
Pharmacy stores do not keep large quantities of these bulky items and additional
supplies required between top-ups may not be readily available
D2. Written signed orders
Clinical areas with a high usage of IV fluids may require additional supplies before the next
‘top-up’ delivery is due
D2.1 Check the IV fluid stocks systematically and indicate in the ‘Stock Requisition’ order
book the quantity required. Ensure that the correct units are used (e.g. bags or
boxes)
D2.2
Ensure that sufficient stocks are ordered. eg. stock ordered on a Friday should be in
sufficient quantities to last the whole weekend
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D2.3
Sign (using full signature), print the name and designation clearly underneath, date
the order and send to the Distribution section in pharmacy before 13.00 hours
D2.4
Orders would usually be supplied to the clinical area after 15:00 the same day
D2.5
Pharmacy stores do not keep large quantities of these bulky items and additional
supplies required between top-ups may not be readily available, or available in
limited quantities.
D3. Telephone or Fax Orders
D3.1 Telephone Orders
D3.1.1 Urgent or extra orders for IV fluids may be telephoned to the Distribution section on
week days only
D3.1.2 The caller must state:
- their name
- grade
- location
- IV fluid required
- quantity required
- reason for request
D3.1.3 A written copy of the order must be sent to Distribution using the ‘Stock Requisition’
order book the same day
D3.1.4 Orders received by 1pm will be delivered to the clinical areas after 15:00 the same
day
D3.2 Fax orders
D3.2.1 A fax of a written signed order is acceptable on week days but must be marked for
'The attention of Pharmacy Distribution'
D3.2.2 The original order must be sent to Distribution by the end of the next weekday.
E. ORDERING MEDICAL GASES
See EHT Medical Gas Policy 2008 for further advice. Medical gases are 'prescription only
medicines' and are subject to the same strict legal controls as other medicines. They are
either piped to the clinical area or supplied as free- standing cylinders.
Medical gases can be ordered in three ways:
E1. Top-up This applies to Theatres, Maternity Unit, ITU and A&E only
E1.1 An agreed list of medical gases to be held as stock is drawn up by the Ward manager
and a pharmacist. This list specifies quantities of each gas to be held and must be
reviewed on at least an annual basis
E1.2
The pharmacy porter is assigned to visit the clinical area on a pre-arranged number
of days
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E1.3
On each designated day, the porter visits the clinical area and systematically checks
the quantity required on the list
E1.4
If extra supplies of any item are required, the nurse in charge shall inform the porter
during his visit
E1.5
Where extra supplies of medical gases are required on a regular basis, the maximum
stock holding shall be reviewed and the list amended
The porter shall remove all empty cylinders and replace them with full containers on
the same day
E1.6
E2. Written, Signed Orders
For the majority of clinical areas, medical gases are ordered on an 'as required' basis via the
Pharmacy Stores or Portering Department (Medirest)
E2.1 Medical gases must be ordered on an approved order form. Medical gases will not be
supplied without this form
E2.2
The written order must be dated and indicate the location
E2.3
The order must state clearly:
- the type of gas
- the cylinder size
- the quantity required
E2.4
The order must be signed (using full signature) by an authorised practitioner, with
the name and designation printed clearly under the signature
E2.5
Medical gases shall only be supplied against such orders on a full for empty basis
E2.6
Completed order forms to be sent to pharmacy at the end of the week.
E3. Telephone Orders
Telephone orders may be placed with a Duty Porter prior to the provision of a signed order
E3.1 When a replacement cylinder is required, the Duty porter must be contacted
E3.2
The caller must state their location
E3.3
A written signed order must be given to the porter when collecting the empty
cylinder from the ward / department
For supplies of Home Oxygen see policy Chapter 5 Section A
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F. ORDERING EMERGENCY MEDICINES BOXES
Medicines for the emergency treatment of cardiac arrest must be immediately available in all
clinical areas.
- Emergency medicines for use in ADULTs are stored in blue, black or red emergency
boxes (depending on contents).
- Emergency medicines for use in CHILDREN(P) or INFANTS(N) are pale blue(P) or
green(N)
The paper seal around the box lists the contents of the box and shows the expiry date of the
shortest dated medicine.
Ward staff must check the expiry date of the emergency box on a weekly basis.
The emergency boxes may be obtained in two ways:
F1. Pharmacy Distribution Section
F1.1 One week prior to the expiry of the box or following the use of any item from the box
an authorised member of the ward staff shall telephone the pharmacy distribution
section or notify the technician/assistant completing the top-up and request a
replacement box. Pharmacy staff will also check the expiry of the boxes and identify
‘expiring’ boxes for replacement
F1.2
The used or ‘expiring’ box should be returned to the pharmacy distribution for
replacement during Pharmacy opening hours. It should be returned by a ward staff
member. A replacement box shall be sent to the ward on the next porters round (or
if required immediately the ward staff member may wait for a new box to be issued).
F2. Outside normal pharmacy hours
F2.1 Spare ADULT blue and black boxes can be obtained from the ‘Emergency Drug
Cupboard (EDC)’ located in the pharmacy outpatient waiting area. Contact Site
Manager (218 bleep) and Security for access. This method of supply should only be
necessary to replace boxes that have been used in an emergency and the ward does
not have enough complete boxes available until Pharmacy is open again
F2.2
Boxes must never be ‘borrowed’ from other clinical areas
F2.3
Leave the used box for return to pharmacy Distribution by the Pharmacy porter or a
staff member on the next working week-day
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G. ORDERING MEDICINES PREPARED IN THE PHARMACY PRODUCTION UNIT
The pharmacy Production Unit is able to prepare a range of patient specific medicinal
products such as Total Parenteral Nutrition (TPN), Cytotoxics, IV additives (CIVAS),
dermatologicals and oral liquid preparations
G1. TPN
G1.1 Referrals to commence new patients on TPN must be directed to the TPN team, by a
doctor, before 12:00 Monday - Friday only (Dietician bleep 099 or Pharmacist bleep
493)
G1.2
The team visit the patients and order the required regimen based on each patients'
daily nutritional requirements
G1.3
Any queries regarding the supply of TPN should be directed to the pharmacy
Production Unit (Ext: 5699)
G1.4
The Infection Control Nurse may be contacted for advice on all nursing aspects of
TPN e.g. dressings, line care
G1.5
TPN is not an emergency, hence will not be dealt with outside normal pharmacy
opening times
G1.6
Prepared TPN bags will be delivered to the ward and left in the refrigerator before
17:00 hours each weekday
G1.7
TPN infusion should be started within 6 hours of delivery and must not run for longer
than 24 hours unless it is clearly stated on the label that the bag is to run over a
period longer than 24 hours
G1.8
TPN will be prepared for named patients and must be administered only to that
patient
G2. CIVAS
G2.1 Some antibiotics are prepared by the pharmacy Production unit staff under aseptic
conditions and are ready to be administered directly to patients by nursing staff
G2.2
The ward pharmacist will advise nursing staff of which preparations are made by
pharmacy and will ensure that the order is placed.
G2.3
CIVAS preparations are delivered to the wards and left in the fridge before 17:00
hours each weekday.
G2.4
Antibiotics prepared for a named patient must be administered only to that patient
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G3. All other preparations, including Cytotoxics & extemporaneously prepared
medicines
G3.1 As products may take some time to prepare, items must be ordered on a weekday at
least 24 hours in advance of administration wherever possible
G3.2
The procedure for ordering non-stock medicines must be followed
G3.3
The manufacturing service is only available weekdays. Weekend orders will not be
able to be filled until the next working day
G3.4
Medicines prepared for a named patient must not be administered to other patients
H. ORDERING CONTROLLED STATIONERY
This includes all stationery which could be used to obtain medicines fraudulently. Such
stationery may only be ordered by authorised staff
H1. Pharmacy Request Slips
H1.1 A new pad must be ordered when ten slips are left on the current pad
H1.2
A new pad must be ordered using a request slip
H1.3
The order must be signed (using full signature) and dated by an authorised
practitioner, with the name and designation printed clearly under the signature
H1.4
The request slip may be given to the ward pharmacist/technician or sent to the
pharmacy dispensary in a pharmacy Envopak®
H2. Stock Requisition Books for ordering stock medicines
H2.1 A new book will be issued on completion of the final page of the existing book.
The used book will be returned to the ward and this must be stored on the ward for
at least 12 months before being discarded
H2.2
Lost or spoiled books may be replaced by contacting pharmacy distribution
H3. Controlled Drugs Order Books
H3.1 Pharmacy will issue a new order book when no order sheets are left in the book.
Speak to the dispensary manager to order a new book before the current book is
finished discussing reason for request. The used book will be returned to the ward
and this must be stored on the ward, in a secure place, for at least 24 months before
being destroyed. - Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs
Policy.
H3.2
The new book must not be used for ordering drugs until all orders in the old book
have been completed.
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H4. Controlled Drugs Registers
H4.1 These can be requested by contacting the dispensary manager. The used Register
must be stored on the ward, in a secure place, for at least 24 months before being
destroyed
H4.2 Theatres use a Controlled Drugs Register specifically designed to record
administration of part ampoules and wastage. The appropriate CD register must be
used in individual theatres.
H5. In-patient Prescription Charts
H5.1 In-patient prescription charts must be ordered from the Supplies Department on an
approved order form
H5.2
The order must be signed (using full signature) and dated by an authorised member
of staff.
H6. FP 10(HP) & FP 10(PCD)
H6.1 Requests to hold supplies of FP 10(HP) or FP 10(PCD) prescription forms must, in the
first instance, be made in writing to the Chief Pharmacist (Head of Department)
stating:
- the location of the clinical area
- the reason for requiring FP10(HP) or FP10(PCD) prescriptions
- an estimate of the monthly usage
H6.2
Supplies shall only be approved if the Chief Pharmacist is satisfied that patients will
suffer undue inconvenience if their medicines cannot be prescribed in this way
H6.3
If the criteria for supply are met, the Chief Pharmacist shall confirm, in writing, that a
designated number of FP 10(HP) or FP 10(PCD) forms may be supplied to the clinical
area per month. A copy of the letter shall also be sent to the dispensary manager
H6.4
When the first supply of the forms is required an authorised member of staff must
take the clinical area copy of the letter to the Pharmacy dispensary and sign for
receipt
H6.5
Each set of prescriptions is issued with an accompanying form which must be
completed each time an FP10(HP) or FP 10(PCD) is issued. Once all the prescriptions
have been issued, the form must be signed (using full signature) and dated by an
authorised practitioner, with the name and grade printed clearly under the signature
and taken to the Pharmacy dispensary for a further supply. Receipt must be signed
for by the authorised practitioner who is responsible for Controlled Stationery in the
Clinical area.
H7. Out-patient Prescription Forms & GP referral letters
H7.1 Out-patient prescription forms & GP referral letters must be ordered from the
Pharmacy Distribution on headed note paper
H7.2
The order must state clearly:
- the location of use
- 34 -
-
the quantity required
the date
H7.3
The order must be signed (using full signature) by an authorised practitioner, with
the name and grade printed clearly under the signature
H7.4
The prescription forms must be collected by an authorised practitioner, or delivered
by Pharmacy Distribution staff, and receipt must be signed for
For further reference see:
The Safe and Secure handling of medicines. A team approach – Duthie 2005 (Revised)
Changes in the Management of CDs affecting Pharmacists. RPSGB June 2006
- 35 -
3.
SUPPLY, TRANSPORT AND RECEIPT
A. OBTAINING SUPPLIES OF, OR ADVICE ON, THE USE OF MEDICINES OUTSIDE
NORMAL WORKING HOURS
An on-call pharmacist is available via an air-call bleep outside normal Pharmacy opening
times. The pharmacist is available for advice on all aspects of the use of medicines and to
supply urgently required medicines, which are not otherwise available
- On weekdays the hours are - before 08:30 and after 18:00 hours.
- On weekends and Bank Holidays the hours are – before 10:30 and after 13:30 hours.
A1. To obtain advice on the use of medicines
A1.1 Contact the Site Manager (218 bleep) for initial advice. If the pharmacist is required
contact Switchboard and ask them to air-call the duty pharmacist
A1.2
On receipt of a call, the pharmacist must ring the hospital and ask to be connected to
the caller
A2. To obtain emergency supplies of medicines
A2.1 Check whether the medicine is stored in any of the emergency storage areas in the
hospital (see procedure for obtaining medicines from the emergency cupboard)
A2.2
If the medicine is not kept in one of these locations or there are insufficient
quantities, contact the Site Manager who will provide information on alternate
locations
A2.3
If the medicine cannot be located then the Site Manager will recommend Nurse in
Charge of the ward contact the on-call pharmacist via switchboard for advice on how
to obtain supplies of the medicine
A2.4
If the medicine is a Controlled Drug refer to Ealing Hospital NHS Trust Controlled
and Restricted Drugs Policy.
B. OBTAINING SUPPLIES OF MEDICINES FROM THE EMERGENCY DRUGS
CUPBOARD
Small stocks of medicines which may be required outside normal working hours are kept in
the emergency drugs cupboard (EDC) located in the Pharmacy outpatients waiting area or
the emergency drugs refrigerator, located in A&E. It is the responsibility of the ward
requiring the medicine to arrange supply.
Records must be kept of issues to ensure that the stocks are replenished
promptly by pharmacy staff.
Complete the log, kept in the EDC, of what is taken giving details of ward, patient
information, hospital number and consultant.
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B1. Obtaining supplies of drugs or IV fluids from the EDC or ED- fridge
B1.1 Check whether the medicine is stored in either the EDC or ED-fridge by referring to
the stock lists in the Pharmacy Information File which is kept on every ward. Contact
the Site Manager (218 bleep) for advice on other clinical areas a drug may be kept
B1.2
A qualified member of the ward staff (not a porter) shall then proceed to contact
Security and request access to the EDC or ED-fridge. The security officer should
satisfy him/herself of the identity of the person collecting the medicines and if in
doubt check with the relevant ward
B1.3
Locate the medicine in the cupboard and remove the required quantity of full
containers. A second person should check the correct item is taken and suitable
checkers would be another qualified nurse from the ward or the Site Manager (218
bleep)
B1.4
Record the details of what has been removed in the record logs which are kept in the
EDC and ED-fridge. Ensure full details including patient name, hospital number,
consultant and ward are recorded
B1.5
Relock the EDC or ED-fridge and return the keys to the security officer.
B1.6
On the next working day, a member of the pharmacy staff shall check the
cupboard/refrigerator and replenish stocks. On the following morning ensure all
further supplies necessary for continued care of the patient(s) are obtained from the
pharmacy during opening hours.
C. OBTAINING MEDICINES FROM ANOTHER WARD OR CLINICAL AREA
Obtaining supplies of medicines from another ward or clinical area is only permitted outside
normal pharmacy hours and if the medicine is not available from the EDC or ED-fridge. At all
other times, medicines must be obtained from the pharmacy. Non-stock medicines must not
be supplied to another ward but obtained from the EDC or via the on-call pharmacist. Supply
of single doses may be permitted in emergency situations.
C1. Obtaining supplies of medicines from another ward/clinical area
C1.1 Identify a ward from which the medicine may be obtained. The Site Manager would
be available for advice
C1.2
Contact the nurse in charge of the supplying ward/clinical area to ascertain whether
sufficient stocks are available. They may ask to see the drug chart.
C1.3
Send an authorised member of the ward staff (with the drug chart) to collect the
medicine from the supplying ward/clinical area
C1.4
The nurse in charge of the ward requiring the drug must inform the ward pharmacist
or pharmacy distribution the on next weekday, giving details of the transfer of stocks,
to ensure replacement stock is charged appropriately
Controlled Drugs – Refer to Ealing Hospital NHS Trust Controlled and Restricted
Drugs Policy.
C1.5
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D. TRANSPORT OF MEDICINES FROM PHARMACY TO CLINICAL AREAS AND
OFFSITE UNITS
The safe and secure transport of medicines is essential to minimise risks to the handler and
reduce the likelihood of damage to or abuse/unauthorised use of the medicines. Transport in
sealed containers is intended to remove, from the messenger, the responsibility for the
contents
D1. Transport from pharmacy to clinical areas
D1.1 All medicines shall be transported in sealed containers manufactured from a material
suitable for this purpose
D1.2
Liquids in glass bottles shall be placed in a sealed plastic bag to minimise
contamination of other products, if damaged. Large quantities of glass bottles
transported in ward stock boxes do not need to be placed in sealed plastic bags
D1.3
Toxic medicines shall be transported in a separate, sealed container, which indicates
the type of hazard
D1.4
Items requiring refrigeration shall be transported in a sealed plastic bag marked
'Medicines for refrigeration', ‘Fridge item enclosed’ or similar. See the Pharmaceutical
Cold Chain Policy for further information.
D1.5
Controlled Drugs – Refer to Ealing Hospital NHS Trust Controlled and Restricted
Drugs Policy.
D2. Transport from pharmacy to off-site units
D2.1 All medicines shall be transported in sealed containers manufactured from a material
suitable for this purpose
D2.2
Liquids in glass bottles shall be placed in a sealed plastic bag to minimise
contamination of other products, if damaged. Large quantities of glass bottles
transported in ward stock boxes do not need to be placed in sealed plastic bags
D2.3
Toxic medicines shall be transported in a separate, sealed container, which indicates
the type of hazard
D2.4
If necessary, items requiring refrigeration shall be transported in cool boxes packed
with freezer packs. The cool boxes will be marked 'Medicines for refrigeration'. The
items shall either be placed in the cool box in a sealed container or the cool boxes
shall be sealed with tape prior to issue. See the Cold chain policy for further
information.
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E. TRANSPORT OF MEDICAL GASES
See EHT Medical Gas Policy (Current) for further advice
Handling of Medical Gases during transport
Medical gas cylinders contain highly pressurised gases which may explode if handled
inappropriately
- Cylinders must, at all times, be handled in a manner which prevents damage to the
cylinder and/or risk of explosion
- Smoking is not permitted at any time when transporting cylinders.
- Individual cylinders must be transported in the designated trolleys.
- A trolley of the appropriate size must be selected.
- Bulk quantities of cylinders must be transported in a way which prevents rolling and
knocking. They must not be transported in an upright position unless the securing
method prevents them from falling over.
- When transported in a car or van, cylinders must be secured firmly using straps or
chains, preferably in the back of the van or in the boot of the car.
- All transport vehicles must display a sign indicating that they are carrying
compressed gases.
- Cylinders must not be left unattended at any time during transport unless they are
stored in a transport vehicle.
F. DELIVERY & RECEIPT OF MEDICINES
All delivered medicines must be checked and stored in their appropriate areas, as soon as
possible, after delivery.
Envopak® bags must be opened immediately by an authorised person on a ward to ensure:
- Items which are urgently required are received by those who need them
- Patients waiting for TTAs, before discharge, can be discharged and transport ordered
as soon as possible, to avoid any delays
- Refrigerated or Cytotoxic drugs are stored appropriately
- Controlled Drugs are signed for and locked away appropriately – Refer to Ealing
Hospital NHS Trust Controlled and Restricted Drugs Policy.
F1. Stock Medicines
Upon receipt of stock medicines, the delivery note must be checked against the order
received. Any discrepancies must be recorded on the delivery note and pharmacy
distribution must be informed, to correct any discrepancies. After the checks, the delivery
note is to be signed and filed in a designated place and stored for 24 months before being
destroyed.
F2. Discharge Medicines (TTAs)
F2.1 Upon receipt of a patients’ completed TTA supply, the nurse caring for the patient
must check the medicines supplied against the discharge letter.
F2.2
-
In some cases some or all of the discharge medicines prescribed may not be supplied
against a TTA. eg.
The patient has a sufficient quantity at home.
The patient has their own supply (POD) in their bedside locker. This must be
returned to them with the rest of the dispensed items
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-
The patient is being discharged to a facility which keeps stocks of bulky items
(ie lactulose)
The item is not available at the time of discharge but an arrangement has been made
to obtain further supplies
Such variations should be clearly endorsed by the pharmacist on Epro which will be reflected
on the discharge letter printed by nursing staff.
F2.3
If the patient is not leaving immediately the medicines must be stored in a secure
area – either a locked cupboard or a locked bedside locker
F2.4
Controlled Drugs must be secured in the Ward CD Cupboard until the patient is
discharged refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
F3. Delivery to a ward/clinical area by the Pharmacy porter
F3.1 A record of all medicines, delivered by the Pharmacy porter, must be kept on ‘The
Ward Delivery Signature log’ detailing:
- The date
- Ward/clinic name
- Description (i.e. number of sealed Envopak® bags or CDs)
- ‘Received for delivery by’
F3.2
When the sealed containers reach the ward/clinical area, an authorised person must
complete the:
- Time received
- ‘Received on ward by’ sections of the delivery log
F3.3
The Delivery log must be returned to Pharmacy Dispensary at the end of each
porters delivery round, where it will be stored in the designated place for 24 months.
F4. Transport and receipt of Certain Categories of Medicines
- Controlled drugs (CDs) – Refer to Ealing Hospital NHS Trust Controlled and Restricted
Drugs Policy.
- Cytotoxic preparations – See Chapter 8 Section F
F4.1
Porters/messengers must sign that they are taking receipt of CDs for transport from
Pharmacy to another area. A signature is required on the white copy of the CD
requisition.
F4.4
Wards or clinical areas receiving supplies from the porter/messenger must sign for
receipt of delivery on the delivery log and on the pink copy of the CD requisition once
the delivery is checked.
F4.5
It is NOT the responsibility of the porter/messenger to wait whilst deliveries of drugs
that are not CDs are checked, however they must ensure that the delivery log is
appropriately signed so an audit trail can be maintained.
F4.6
Cytotoxic preparations must be transported in clearly labelled, sealed, containers.
Warning labels must be applied to the container to alert the porter/messenger and
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the recipients, to the nature of the contents, to ensure appropriate measures can be
made for safe transport and cleaning in case of spillage
F5. Delivery to an off-site hospital or clinical area by hospital transport
F5.1 All medicines delivered to off-site hospitals or clinical areas shall be received by an
authorised member of staff who shall sign for receipt
F5.2
It is the responsibility of the person receiving these categories of medicine to check
the medicines for correctness and suitability for use (i.e. no physical damage in
transit) and to contact the pharmacy if there is an error
F5.3
The driver shall be asked to sign for receipt of the medicines for transport in a book
kept in the Pharmacy
F5.4
On receipt of the medicines an authorised practitioner must sign the 'received by'
section of the delivery note and return it to pharmacy within 24 hours
F6. Collection from pharmacy by ward/clinical area staff.
- Cytotoxic preparations – See Chapter 8 Section F
F6.1
The 'messenger' must be a member of staff (or regular volunteer) with clearly
displayed identification badge. They may be asked to sign for receipt of the
medicines
F6.2
Staff collecting Controlled Drugs for supply to the ward will sign the white copy of the
CD requisition to indicate they accept the drugs for transport. Once on the ward the
pink copy should be signed by an authorised member of staff to indicate receipt on
the ward. The CDs should then be entered into the CD register. – Refer to Ealing
Hospital NHS Trust Controlled and Restricted Drugs Policy.
F6.3
Staff collecting TTA or Outpatient supplies of medicines for a patient, which includes
a Controlled Drug, must be a member of staff (or regular volunteer) who works in
the clinical area and they must clearly display their identification badge. The person
should be ‘known’ to the pharmacy staff and they may be asked to sign for receipt of
the medicines. Pharmacy may refuse to supply the medicines if there is any doubt
about the identity of the messenger
F7. Samples
F7.1 No samples of medicinal products or clinical trial materials may be accepted in clinical
areas other than via the pharmacy department or with pharmacy approval
F7.2
Pharmaceutical company representatives who wish to leave samples must be asked
to contact pharmacy
F8. Defective or broken items
F7.1 All goods must be checked for physical damage by an authorised member of staff.
The section of pharmacy where the supplies came from should be contacted if there
is a problem and to arrange a replacement
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F7.2
The medicine should be returned to pharmacy if found to be defective. If damaged, it
can be disposed of in accordance with the Hazardous Waste (England & Wales)
Regulations 2005.
G. DEALING WITH MEDICINES BROUGHT INTO THE HEALTHCARE SETTING BY
PATIENTS OR CARERS
G1. General principles
G1.1 Medicines brought in by patients are the property of the patient and must not be
destroyed or disposed of without the agreement of the patient or their
representative. Supplies of these Medicines, which have been appropriately checked,
are administered to the patient during their stay and if there are sufficient supplies,
may be returned to them on discharge as part of their TTA supply
G1.2
-
However, there are situations where it may be potentially harmful to the patient to
return their medicines to them:
the medicines cannot be positively identified and cannot, therefore be regarded as
safe to use.
the patient's therapy has changed and continued custody of their previous
medication could lead to confusion and possible inappropriate therapy.
In these circumstances, following discussion between a pharmacist and a medical
practitioner/nurse, the medicines may be destroyed. The patient/carer must be
informed and consent given. (See Ch.4 - Section M on disposal of medicines)
G2. Receiving ‘Patients’ Own Medicines’ (PODs)
G2.1 All medicines received by the admitting doctor/nurse must be placed in a plastic bag
labelled with the name of the patient and stored in an area designated for patients'
own medicines. All Controlled drugs must be stored in the CD cupboard – Refer to
Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
G2.2
If any of the medicines are not available within the healthcare setting, the patient's
own medicine may be used, provided it can be positively identified. (See ‘Procedure
for identifying and checking suitability of patients own medicines’)
G2.3
On the next ward visit, the ward pharmacist will check all patients' own medicines. If
the medicines are suitable for use they will be labelled accordingly and are then able
to be administered to the patient while on the ward.
G3. Storage of patients own medicines
As a result of the above action, the medicines may be dealt with in one of six ways:
G3.1 Store in the Clinical Area: Store the medicines in the designated secure storage area
in the ward/clinical setting until returned to the patient/carer prior to or upon
discharge or send with patients to transferring ward
G3.2
Store in a locked bedside cabinet for administration to patient on ‘Dispensing for
discharge wards’. This applies only to medicines which will be used in the healthcare
setting in the circumstances outlined in Chapter 3 Section G4
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G3.3
Store in the medicines trolley or medicines fridge. This applies only to medicines
which will be used in the healthcare setting in the circumstances outlined in
Chapter 3 Section G4
G3.4
Return Medicines to home. The medicines may be returned home via an identified
adult (older than 16 years) if the patient declines the use of suitable PODs
G3.5
Destruction on ward in accordance with the Hazardous Waste (England & Wales)
Regulations 2005. The patient/care-giver must give consent before medicines are
destroyed and this permission must be noted in the nursing or medical notes.
Send to pharmacy medicines which cannot be positively identified for appropriate
destruction
G3.6
Store in a Controlled Drugs cupboard.
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
G4. Use of Patient's own medicines (PODs) in the clinical setting
G4.1 PODs may be used once they have been checked by a Clinical Pharmacist and
labelled accordingly. On evenings and weekends, if a pharmacist has not checked
the PODs and an alternative supply is not available in the ward or clinical area, doses
may be administered to patient provided they can be positively identified (See
‘Procedure for checking the identity and suitability of medicines brought into the
healthcare setting by patients’)
G4.2
PODs remain the patient’s property and under no circumstances should they be
administered to other patients
G4.3
The permission of the patient must be sought before the medicines are used
G4.4
Upon discharge, the medicines are returned to the patient, if appropriate, and further
supplies may be issued, if required, as part of the TTA supplies
H. CHECKING THE IDENTITY AND SUITABILITY OF MEDICINES BROUGHT INTO
THE HEALTHCARE SETTING BY PATIENTS/CARERS
Patients' own medicines must only be used in healthcare settings if they can be positively
identified. A Clinical Pharmacist assigned to the ward will check the PODs and label supplies
as able to be safely administered. Prescription charts will be endorsed with an indication of
quantity. It is essential that the patient’s confidence in their GP or Community Pharmacist is
not
undermined by this process. If medicines cannot be positively identified, the patient must
receive a clear explanation of the reasons why. Permission should be sought to destroy
these medicines.
H1. Assessment of patient's own medicines
Medicines may be designated as suitable for use if:
H1.1 The container is labelled with the patient’s name
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H1.2
The name, strength and form can be positively confirmed
H1.3
They are presented in a clearly labelled container issued from a community pharmacy
or hospital pharmacy with a date of dispensing not more than 3 months ago and all
medicines in the container are identical
H1.4
Medicine presented in a foil or strip pack with the name of the medicine and an
expiry date marked on the strip may only be used after confirmation that they are
still appropriate. Loose strips may be re-labelled and boxed by pharmacy if necessary
H1.5
Open sterile products (eg eye drops) can only be used if confirmation can be
obtained that the seal has been broken for no longer than the manufacturer’s
recommendation
H1.5
The medicine is in good condition with no evidence of deterioration
H2. Outside normal working hours
If there is any doubt as to the identity or suitability for use of the medicine then it should not
be administered. The on-call pharmacist may be contacted for advice.
I. SUPPLY OF MEDICINES TO PATIENTS FOR USE OUTSIDE THE HOSPITAL
Patients often require a supply of medicines to continue or initiate treatment outside the
hospital or clinical setting
I1. Giving TTA supplies to in-patients before discharge
I1.1 Medicines will be dispensed against a discharge letter by pharmacy. Quantities of
medicines supplied against a TTA would be:
- Regular medicines;
Two weeks although often up to a month is given
- Short courses;
Total course supplies of courses of drugs such as antibiotics or steroids
- ‘When Required’ Meds:
Small supply of a single packet of drugs such as analgesics
I1.2
The TTA supply must have been FINAL checked by a pharmacist. All TTA supplies
which come from pharmacy have been FINAL checked. If the patient is on a
Dispensing for Discharge ward the supply may have been FINAL checked on the
ward. Under no circumstances must any supply of medicines be made to a
patient against a discharge letter unless it has been dispensed and labelled
for that patient AND this has been FINAL CHECKED
I1.3
When a patient is due to be discharged a trained staff member must counsel the
patient and/or carer, on the appropriate use of the medicines. The staff
member
would usually be a Registered Nurse but may also be a Pharmacist,
Pharmacy Technician, Nursing student (under direct supervision) or Medical
Practitioner
I1.4
If any of the medicines are Controlled Drugs the staff member must be sure of the
identity of the person taking possession of the medicine. If the patient is not known
- 44 -
to them or the person collecting the CD is a relative or carer the staff member must
ask to see proof of identity– Refer to Ealing Hospital NHS Trust Controlled and
Restricted Drugs Policy.
I1.5
The staff member should work down the list of medication on discharge letter,
checking the medicine supplied matches what is written on the letter and all are
correct and available. Correct use, common adverse effects and what to do if there
are problems should be discussed.
I1.6
Upon nursing staff ‘issuing’ the discharge medication on ePro two copies of the
discharge letter will be printed: one for the patient and one for the medical notes.
Nursing staff must attach the relevant discharge to appropriate section of the medical
notes. One copy will also be sent electronically to the GP.
I2. Supply of medicines on an Outpatient prescription
I2.1 Outpatient prescriptions may be written by authorised prescribers, for supply of
medicines to outpatients, in appropriate clinical settings:
- Outpatient clinics
- A&E
See Chapter 5
I2.2
The Outpatient prescription form is designed to be used in one of two ways:
- A letter to the General Practitioner (GP) requesting them to prescribe the
medication recommended. GP referral letters are also available for this purpose
- A prescription for dispensing and supply by the Ealing Hospital Pharmacy
department
I2.3
All patients should be referred back to their GP for their medication unless one of
these reasons applies:
- It is essential that Treatment must start immediately e.g. antibiotics, steroids
- It is a Specialist drug and not readily available in primary care e.g. antiretrovirals
- It is an Unlicensed drug – a drug without a UK product license e.g.
extemporaneously prepared creams or ointments
- It is a licensed drug used for an unlicensed indication (off-licensed use) e.g.
- Hospital only drug or Ealing CCG ‘red list’ drug. See Appendix 3
I2.4
The patient should present the prescription to Pharmacy for dispensing (during
Pharmacy opening times). Prescription charges will be charged, where appropriate,
for all outpatient prescriptions. ‘Exempt’ patients will be asked to provide evidence
that they are exempt from prescription charges
I2.5
A pharmacist or member of the pharmacy staff who has received appropriate
training, will counsel the patient or carer on the use of the medicine, possible
adverse effects and drug interactions as the medicine is being given to the patient.
If the supply has been sent from Pharmacy to a clinic or to A&E for supply to a
patient, a Registered Nurse or Medical practitioner must appropriately counsel the
patient on the appropriate use of the medicine, adverse effects and drug interactions
- 45 -
I2.6
If the medicine is a Controlled drug the staff member must be sure of the identity of
the person taking possession of the medicine by asking for proof of identity of the
patient or carer. If identification cannot be verified the staff member may refuse to
supply the medicine – Refer to Ealing Hospital NHS Trust Controlled and Restricted
Drugs Policy.
I3. Supply of medicines according to Patient Group Directions (PGDs)
Medical staff and appropriately qualified Nurses or Nurse Practitioners may supply medicines
directly to patients in accordance with locally agreed and D&TG approved PGDs, which are
specific to defined clinical areas.
I3.1 The staff member must be authorised to supply and/or administer the medicine in
accordance with the PGD
I3.2
The PGDs apply to specific medicines used in defined indications. The PGD must be
complied with entirely
I3.3
The patient must comply with the criteria for inclusion written in the PGD.
See individual PGD documents for further information.
I4. Supply of Pre-packs
A limited range of pre-labelled packs of medicines are available in A&E and some clinics.
Guidelines are specific to the individual clinical setting and must be approved by the D&TG.
I4.1 TTA packs may be supplied directly to patients by approved staff in accordance with
a PGD.
I4.2
TTA packs may be supplied by a doctor, or appropriately trained nurse, in
accordance with a written prescription
I4.3
Only pre-labelled packs can be used to supply medicines for patients to take away
For further reference see:
The Safe and Secure handling of medicines. A team approach – Duthie 2005 (Revised)
EHT Patient Group Directions by Emergency Nurse Practitioners & Paediatric Nurse
Practitioners. Accident & Emergency Department – January 2005
Changes in the management of CDs affecting pharmacists. RPSGB June 2006
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4.
STORAGE AND SECURITY OF MEDICINES IN A HEALTHCARE
SETTING
It is essential that all medicines are stored in designated medicine storage areas with access
restricted to authorised persons only.
All storage areas must be clean and approved as suitable for use by a senior member of the
pharmacy staff. Responsibility for storage and security rests with the designated manager of
the ward or department.
All employees of Ealing Hospital ICO NHS Trust, working in either a permanent or
non-permanent capacity are NOT PERMITTED to take drugs from hospital stocks
for their own personal use. This also applies to intended use by working
colleagues, family members or friends and relatives or visitors to
Ealing Hospital NHS Trust
Staff, who require access to medication during work time, should attend
Occupational Health. Outside Occupational Health opening hours, staff will need
to attend Accident & Emergency
Relatives/visitors should be referred to Accident & Emergency also.
Failure to comply with Trust policy will be viewed as a serious breach of policy
and will result in disciplinary action
A. GENERAL REQUIREMENTS
A1.1 There shall be lockable cupboards with separately identified and segregated storage
areas for the following categories of medicines:
- Controlled Drugs
- Internal medicines - oral medicines (tablets/capsules/oral liquids)
- Rectal medicines
- Injectables
- External medicines and dressings
- Discharge medicines to take home
- Patients' own medicines
- Epidural medicines - The National Patient Safety Agency (NPSA) recommends
that “storage of epidural infusions is in a separate cupboard or refrigerator to
reduce the risk of the wrong medicine being selected”, NPSA audit checklist for
epidural medicines, March 2007.
Under no circumstances should medicines be stored outside designated areas
A1.2 Cold Chain Storage.
A specially designed medicines Fridge (or freezer if appropriate) must be used for medicines
stored below 8oC. They must be lockable and kept locked when not being accessed. Fridges
should be fitted with a lock and fan-assisted cooling and have a temperature range of 2 to
8ºC. For Freezers the temperature range is -30 to -18 ºC.
Fridges or Freezers must be monitored with a calibrated digital thermometer with maximum
and minimum recording. Ideally the fridge should have an integrated thermometer and an
audible alarm.
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The DOH recommends Drug fridges are at least 500 mm × 600 mm × 900 mm and for large
use areas e.g. wards using TPN, a larger fridge would be more suitable. Nominal size: 1900
× 600 × 650.
Steps must be taken to ensure that the fridge/freezer is not switched off accidentally (i.e.
wired directly into the socket) or labelled “Do not switch off”.
On in-patient wards that store cytotoxic drugs a separate ‘Cytotoxic
Fridge’ should be used.
High turnover areas should consider using fridges with glass doors to improve efficiency in
product selection and reduce time the door is open.
See EHT Pharmaceutical Cold Chain Policy (2012) for additional information.
A1.3
Medicines must be stored appropriately in lockable treatment rooms or cupboards.
Cupboards must be locked when not being accessed. Cupboards when unlocked must
not be left unattended for any reason.
Metal cupboards (which comply with BS 2881) are recommended for the storage of
medicines in areas which are not staffed 24 hours a day.
Trays and baskets are considered unsuitable for storing medicines (except external
medicines and dressings and IV fluids) because they do not allow medicines to be
adequately segregated and clearly displayed and hence may increase the risk of incorrect
medicines selection.
A1.4
Separate storage must be provided for the following categories of medicines:
- Intravenous fluids and sterile topical fluids
- Inflammable fluids and gases; Flammable medicines should be stored in
lockable metal cupboards. A risk assessment should be undertaken to ascertain
whether a fire resisting cabinet is required. This will depend on the quantity and
flammability of the medicines. The smallest recommended cupboard size: 400 ×
400 × 300.
- Epidural and intrathecal infusions and other high-risk medicines;
Epidural and intrathecal infusions must be stored in a separate cupboard or
refrigerator to reduce the risk of the wrong medicines being selected. See NPSA
recommendations and Practice Safety Alert 21 – ‘Epidural injections and infusions’
(NPSA, 2007). As some epidural and intrathecal infusions are CDs, it is
recommended that cupboards used to store these medicines be constructed to
the same standard as CD cupboards.
- Diagnostic reagents including urine testing
- Patients Own Drugs (PODs); PODs must not be stored with ward or clinic
stock medicines (or in a way where they could be confused (or mixed) with stock
medicines). PODs may be stored in medicines cabinets beside the patients’ beds.
Where a patient is self administering medicines (after appropriate risk assessment) the
patient should have a key to their own bedside medicines cabinet to facilitate self
administration of their medicines.
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A1.5
Where practicable, the categories of medicines in A1.4 shall be stored in areas away
from the general public or thoroughfares
A1.6
Within each storage area, medicines shall be stored in alphabetical order (by generic
name), where possible, and in a manner which aids location and identification
A1.7
Storage areas must be kept clean and tidy at all times
A1.8
Rotation of stock shall occur such that containers with the earliest expiry date are
used first. This is the responsibility of the ward staff with assistance from the
pharmacy distribution top-up staff
A1.9
Medicines must not be transferred from an original dispensing container to another
for the purposes of storage. Only pharmacy staff may dispense medicines from one
container to another for the purpose of supply
A1.10 Systems for delivering drugs to the patient’s bedside must be locked and immobilised
when not in use
A1.11 DISPOSAL AND SPILLAGE
Policies and procedures on the disposal of medicines and action to be taken in the event of a
spill are covered in the Health and Safety Manual and the Hazardous Waste (England &
Wales) Regulations, which must be available in every healthcare setting. For Cytotoxic spills
also see Chapter 8 Section F
B.MEDICAL GASES
See EHT Medical Gas Policy 2012 (current update) for full details
B1.1 Medical gases must be kept away from stocks of combustible materials and sources
of heat, in a well ventilated area where smoking and naked flames are prohibited
B1.2
Wherever possible, they shall be placed in an area near to an exit to allow rapid
removal in an emergency
B1.3
Large cylinders (Size F and above, except ENTONOX®) must be stored vertically
B1.4
Small cylinders must be stored on shelves that will not damage the surface paintwork
of the cylinders
B1.5
All ENTONOX® cylinders must be stored horizontally at a temperature above 10oC. If
this is not possible, the cylinder must be allowed to warm up and be inverted several
times prior to use.
B1.6
All cylinders must be stored in a secure manner either in stands or by securing to a
wall with chains or straps.
C. INTRAVENOUS (IV) FLUIDS AND STERILE TOPICAL FLUIDS
C1.1 The storage area must be clearly labelled to distinguish between IV and topical fluids.
C1.2
The containers of fluids must be stored off the floor, either on pallets, shelves, or in
specially designed storage boxes. Lockable closed storage units with trays or baskets
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or open shelving can be used for bulk storage of IV fluids (for example boxes of 20
or 50 bags). Where open shelving is used, it should be located in a locked room.
Ensure there is adequate protection from light
C1.3
Fluids must not be stored above head height to prevent possible injury to handlers
D. KEYS
D1.1 Keys for each lock should be kept as part of a set ‘in use’ on a ward at any time
(except for bedside drug storage lockers – see D1.7). The keys should be kept on the
person in charge of the ward or a nominated deputy at all times.
Stock medicines cupboards (except CD cupboards) on each in-patient ward should have
locks that use identical keys. Multiple key copies may be available, to reduce the time
needed for authorised staff to unlock the cupboards.
Locking mechanisms other than keys may be used, except for CD cupboards, provided they
comply with BS 3621, where appropriate. Where keypads, electronic keys or swipe cards are
used to open medicines cupboards, systems should be in place to ensure codes are regularly
changed or swipe cards updated (for example following an incident or staff dismissal) and
dissemination of codes are restricted on a ‘need to know’ basis.
Doors should lock automatically on closing.
Locks for metal cupboards must comply with BS 3621.
D1.2
The keys should never leave the ward except in an emergency e.g. evacuation or
when the ward is closed
D1.3
Drug keys (medicine cupboards and medicine trolley) must be kept on the person of
a qualified nurse at all times unless an alternative local procedure has been agreed
D1.4
Controlled Drug cupboard keys – a number of stipulations exist.
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy
D1.5
Controlled drug keys may be given to other authorised staff, when required, for
legitimate purposes but responsibility for the custody of the keys and the medicines
remains with the nurse in charge
D1.6
A student nurse must not accept custody of the Drug keys or the Controlled Drugs
keys, except in exceptional circumstances agreed between the local manager and the
educational body
D1.7
Keys for bedside drug storage lockers may be kept separate from the rest of the
keys, according to locally agreed procedure, if necessary for ease of use. Each
bedside medicines cabinet should have a unique key, within that ward, with a master
key for that ward required for nursing (and visiting pharmacy) staff. The qualified
nurse in charge of each ward bay is responsible for the security of the keys. The
Ward Pharmacist may also be permitted to hold a key to open the bedside drug
storage lockers.
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D1.8
Spare keys, if kept, should be locked in the Ward Managers office and not accessible
to ward staff
D1.9 Loss of Keys
The loss of keys must be immediately investigated by the nurse in charge who must, in turn,
report the loss at once to the senior nurse/manager. (This includes situations where it is
believed that keys have been taken home, in error, by a nurse on a previous shift and that
nurse cannot be contacted). If the keys cannot be located, contact Estates to arrange for
locks to be changed.
A Clinical incident (DATIX) form, describing the situation, should be completed. Pharmacy
should be informed at the beginning of the next working day. If the loss of keys is related to
theft of Controlled Drugs, Pharmacy should be informed immediately by contacting the Chief
Pharmacist (or Acting head of department) or bleeping the on-call pharmacist, if out-ofhours.
E. EMERGENCY MEDICINES BOXES
E1.1 The contents of these boxes are determined by the Resuscitation Committee
E1.2
The boxes must be stored in an area which is readily accessible to users, but out of
the immediate view of the general public
E1.3
They are supplied with a tamper-evident seal. Each time the seal is broken, the box,
any unused contents and the internal packing, must be returned to pharmacy
E1.4
It is the responsibility of the ward staff to ensure that the boxes are in date. Expired
boxes are to be returned to pharmacy distribution for replacement.
See Chapter 2 Section F
For further information see ‘The emergency medical treatment of anaphylactic reactions for
first medical responders and for community nurses- Resuscitation council UK – 2010’
http://www.resus.org.uk/pages/guide.htm
F. MEDICINES NO LONGER REQUIRED
Medicines dispensed for individual patients who have been discharged; expired stock
medicines and unused discharge medicines must be stored in a secure place prior to return
to pharmacy.
F1.1
Medicines no longer required in the clinical area must be stored in a designated
restricted-access area prior to return to pharmacy
F1.2
Ask the pharmacy technician to remove the medicines and return them to pharmacy
or arrange for a porter to collect any bulky items (inform pharmacy distribution of the
arrangements)
F1.3
Medicines no longer required must not be returned to pharmacy using the Envopak®
collection or over weekends or Bank Holidays
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F1.4
Medicine for return to pharmacy must not be stock-piled in clinical areas.
F1.5
Some medicines may be destroyed on the ward, on instruction of Pharmacy staff.
Destruction must comply with the Hazardous Waste (England & Wales) Regulations
2005.
F1.6
Controlled drugs must always be kept in a locked CD cupboard. Ask the pharmacist
to return the CDs to dispensary stocks or to the dispensary for destruction. Refer to
Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
G. STORAGE AND SECURITY OF TOTAL PARENTERAL NUTRITION (TPN)
ADMIXTURES AND CYTOTOXICS
C. It is essential that these medicines are stored in designated storage areas with access
restricted to authorised persons only.
D. All storage areas must be approved as suitable for use by a senior pharmacist.
E. Storage areas must be kept clean and tidy at all times.
F. Rotation of doses shall occur such that containers with the earliest expiry date are used
first.
G1. TPN Bags
G1.1 These must be stored in a designated medicines refrigerator, or in an area
designated for TPN within the medicines refrigerator
G1.2
The TPN bag must be allowed to reach room temperature prior to use
G1.3
Unused TPN bags must be returned to the refrigerator immediately and the
pharmacy production unit informed the next working day. Under no circumstances
should unused TPN bags be left out of the refrigerator or disposed of on the ward
G1.4 The balance of partially used bags should be disposed of in an appropriate
‘sharps’ bin. Sealing the bag inside another plastic bag is recommended to stop
spillage
G2. Injectable Cytotoxic Drugs
G2.1 These must be stored in either:
- an area designated for cytotoxic drugs requiring refrigeration, within the
medicines refrigerator or
- an area designated for cytotoxic drugs within a lockable medicines cupboard
G2.2
All unused cytotoxic preparations must be kept in the correct storage area then
returned to pharmacy the next working day
G2.3
The storage of intrathecal cyctotoxic doses is governed by the stipulations in the
Trust Intrathecals Policy (see the intranet).
H. STORAGE AND SECURITY OF MEDICINES IN THE MEDICINES TROLLEY OR
BEDSIDE DRUG STORAGE LOCKERS
Medicines stored in the medicines trolley or bedside drug storage lockers should consist of
the working stock for the clinical area plus any medicines dispensed for individual patients.
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It is the responsibility of the ward staff to ensure the following:
H1.1 The medicines trolley or bedside drug storage lockers must be locked and
immobilised, when not in use, to prevent access by unauthorised persons
H1.2
They must not be left unattended at any time during use
H1.3
The 'trolley' must be of adequate size and design to allow storage of all medicines
required on a medicines administration round. Bedside drug storage lockers must be
adequate to contain the medicines required by most patients. In unusual cases it
may be necessary to store additional medicines for patients using many medicines or
‘bulky’ medicines in a designated locked cupboard
H1.4
Medicines must not be stored underneath, or in any non-lockable part of the trolley.
Bedside drug storage lockers are fixed to bedside cabinets used for storage of clothes
and personal items. Medicines must not be stored in these parts of the cabinet
H1.5
The medicines shall be stored in a manner which aids location and identification
H1.6
The trolley must be kept clean and tidy at all times. Bedside drug storage lockers
must be thoroughly emptied and cleaned between patients
I. STORAGE AND RETENTION OF ORDER AND RECORD BOOKS USED IN
CONNECTION WITH MEDICINAL PRODUCTS
Any order books or record charts which could be misused by unauthorised persons must be
stored in a secure manner in clinical areas. In addition, completed order and record books
must be stored for a period 24 months, prior to destruction
I1. Controlled stationery
The term controlled stationery includes:
- Medicines administration charts
- Controlled drugs order books
- Controlled drugs registers
- FP 10(HP) & FP 10(PCD) prescriptions
- Discharge medicines letters
- Out-patient prescription forms
- GP Referral letters
I1.1
Unused controlled stationery must always be stored in a locked secure area in a
manner which aids location and identification
I1.2
It is the responsibility of the clinical area manager to ensure no unauthorised persons
have access to controlled stationery
I2. In Use Controlled Stationery
I2.1 Medicines administration charts to be stored in a central file or end of patient’s bed
I2.2
Controlled drugs order books and registers must be stored within the controlled
drugs cupboard
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I2.3
Discharge medicines letters and out-patient prescription forms in a secure and staffed
area, out of view of the general public
I3. Completed order books and administration books
I3.1 All completed CD order books and CD registers must be stored in a designated
locked area on the ward for a period of 24 months
I.2
At the end of the 24 month period, they shall be disposed of in accordance with the
procedure for disposal of Confidential Waste
I4. FP 10(HP) & FP 10(PCD) Prescriptions
I4.1 All full and part used FP 10(HP) or FP10 (PCD) prescriptions must be stored in a
locked cupboard
I4.2
When required, only the quantity of sheets needed should be removed from the
cupboard. The patient’s name must be recorded against the sheet number on the
form attached to the book
J. ACTION TO BE TAKEN BY STAFF WHEN PERSONAL SAFETY IS THREATENED
WHILST THEY HAVE RESPONSIBILITY FOR MEDICINES
The safety of staff is paramount at all times. Staff should not risk their personal safety if
confronted by threatening behaviour.
J1.1 Assess the situation carefully
J1.2
If threatened physically in any way one or all of three courses of action may be
taken:
- Shout for help
- Depart rapidly from the scene
- Hand over the medicines
J1.3
In all cases, report the incident to your line manager and Security immediately.
Security will inform the Police, as appropriate
J1.4
The line manager must then inform senior managers, as appropriate
K. STORAGE AND SECURITY OF MEDICINES DURING WARD AND
DEPARTMENTAL CLOSURES
A ward or department may close for a very short period of time e.g. over a weekend, for a
longer period when there is a schedule for re-opening, or when there is no schedule for
reopening. If a ward, or clinical area, is closing for refurbishment or building work then the
closure must be treated as a ‘Closure for more than 7 days with a re-opening schedule’
regardless of the actual length of closure
K1. Closure up to 7 days
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The area must be locked and secure. No access by any persons, to any area, is permitted
during the time the ward is closed
K1.1 Controlled Drugs
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
K1.2 Other Medicines
K1.2.1 Other medicines may be left in locked medicine cupboards if ward security is
satisfactory to the nurse in charge and ward pharmacist
K1.2.2 Medicine cupboards must be checked to ensure that they are securely locked and the
keys are locked in the appropriate key cupboard or in accordance with local
procedures relating to key security.
K2. Closure for more than 7 days with a re-opening schedule
K2.1 Controlled Drugs
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
K2.2 Other Medicines
K2.2.1 Other medicines must be sealed in the ward stock box or another suitable container
supplied by pharmacy
K2.2.2 The medicines must be stored in pharmacy until the ward re-opens
K2.2.3 If a ward is to re-open at a weekend the medicines, including Controlled Drugs, may
be returned to the ward on the nearest available weekday providing the security of
the ward is satisfactory to the nurse in charge and the ward pharmacist
K3. Closure with no re-opening schedule
K3.1 Controlled Drugs
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
K3.2 Other Medicines
3.2.1 All other medicines must be returned to pharmacy where, if appropriate, they will be
credited to the appropriate cost centre and returned to pharmacy stock.
L. MEDICINES REQUIRING REFRIGERATION
Refer to Ealing Hospital NHS Trust Cold chain Policy 2010 for further information
L1. Storage
L1.1 Manufacturers’ recommendations on storage must be observed and care should be
taken to ensure that, on receipt, medicines needing cool storage are immediately
placed under the required storage conditions
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L1.2
Medicines received from pharmacy which need to be stored in a fridge will be
labelled “Store in a refrigerator”
L1.3
The designated manager in each area is responsible for the safe storage of medicines
requiring cool storage.
L2. Storage conditions
L2.1 Only pharmaceuticals and blood products should be stored in the medicines fridge.
L2.2 All fridges must be maintained between 2 - 8°C
L3. Recording of fridge temperature
L3.1 A maximum/minimum thermometer must be used in all fridges. The designated
manager must ensure temperature of the fridge is read and recorded.
a. every day when the fridge is first opened,
b. when the fridge has been accidentally switched off,
c. when the fridge has been defrosted, to check the correct temperature has
been reached before medicines are replaced in it
L3.2
Follow manufacturer’s instructions to reset thermometer, after reading
L4. What to do if the temperature is not within the recommended range
L4.1 Identify all affected medicines and length of time out of range.
Contact Distribution or Medicines Information in Pharmacy for advice.
L5 Defrosting fridges
L5.1 Where appropriate it is important that fridges are defrosted every three months to
ensure they function properly. Medicines should either be:
a. transferred to another fridge, which is within the temperature ranges for
storing the medicines
b. returned to pharmacy for temporary refrigeration
When the fridge has been defrosted make sure that the correct temperatures have been
reached before medicines are returned.
For further reference see:
The Safe and Secure handling of medicines. A team approach – Duthie 2005 (Revised)
M. DISPOSAL OF MEDICINES
Refer to the ‘EHT Waste Management Policy’ for full information on disposal of
pharmaceuticals
Medicines for disposal
The majority of drugs which require destruction should be disposed of in clinical areas.
These are medicines which have expired, are no longer suitable for use, damaged or are unrequired patients’ own drugs. Most medicines which need to be disposed of can be placed in
the Blue bins specifically for the disposal of medicines. Blue bins are available in clinical
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areas and are sent for incineration when full. Remove all packaging and place the tablets,
strips of tablets/capsules or ampoules (or other dose administration form) in the Blue bin.
Sharps
If the waste is a ‘sharp’ it should be disposed of in a Yellow waste/sharps bin.
Examples of sharps include:
- Needles used for reconstitution or administration of injectable medicines
- Glass ampoules which have been broken/open
- Glass vials with stoppers which have been used
- Insulin pens which have been used
- Single use syringes eg. erythropoietin, vaccines
Unopened/unbroken vials may be disposed of in blue medicines bins.
Cytotoxic and Cytostatic agents
Pharmaceutical waste is classed as Hazardous if cytotoxic, cytostatic or if it meets any other
‘hazardous’ criteria as stated in the regulations.
All materials used in the preparation and administration of Cytotoxic drugs, all empty
containers and exposed unused drugs MUST be treated as cytotoxic waste.
All drug containers, giving sets, urotainers, needles and other sharps MUST be placed in the
dedicated sharps bin. This should be clearly marked using "Cytotoxic Warning Tape" (this is
available from Pharmacy). A bin should be available in all areas where cytotoxic drugs are
being handled and administered.
Gloves, masks, aprons and other non-sharp items used during the reconstitution and/or the
administration process must be disposed of by "Double Bagging" in yellow clinical waste
bags which must then be sealed and marked with cytotoxic warning tape. All waste may
then be sent for incineration following the procedure for all clinical waste within the Trusts.
Recyclables
Patient specific data, such as names on medicine labels must be removed from
pharmaceutical containers sent for recycling.
Any recyclable waste such as paper, cardboard (cardboard boxes must be flattened after
use), plastic bottles and metal (not aerosols) should be disposed of into the recycling
containers provided.
Bottles
All glass bottles should be separated from other rubbish and placed in a box or special
strength paper bags. Empty medicine bottles should be rinsed with warm water and
detergent before disposal. Glass bottles should NEVER be put in plastic black bags.
Aerosols containing pharmaceuticals (eg inhalers, povidone iodine spray)
Aerosols containing pharmaceuticals must not be sent with other pharmaceutical waste for
incineration. Separate these items, place in a plastic bag marked ‘For Destruction’, and
return to Pharmacy for disposal.
Controlled Drugs & Restricted medicines (CDs) (eg Opiates)
See the EHT Controlled and Restricted Medicines Policy and/or speak to a pharmacist.
Disposal of ‘Patients Own’ Medicines (PODs)
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POD’s must never be used for other patients. PODs must be treated as the property of the
patient at all times and their permission must be sought before the medicine is to be
destroyed.
If a patient no longer requires a medicine it should be destroyed promptly to minimise the
risk of error due to inappropriate administration or re-introduction after discharge.
Always ask the permission of the patient or their carer before disposing of POD’s. Advise the
patient/carer to dispose of further supplies kept at home. Usually it is recommended the
medicines are returned to their community pharmacy for destruction.
PODs when the patient has died
It is recommended that all PODs be destroyed when a patient has died. Permission must be
sought from the ‘Next of Kin’ to destroy the PODs. With the exception of Controlled Drugs,
the ‘Next of Kin’ may take the PODs away with the patient’s other possessions. In these
cases the ‘Next of Kin’ should be advised that the PODs should not be used and of the most
appropriate way to dispose of further supplies kept at home. For CD’s see EHT Controlled
and Restricted Medicines Policy and/or speak to a pharmacist.
Environmental Agency
The Environmental Agency is charged with ensuring the Hazardous Waste Regulations are
enforced and to ensure that all waste classified as Hazardous is going to a suitable site and
to prevent the dumping of Hazardous material. www.environment-agency.gov.uk
The Hazardous Waste Regulations 2005 require the Hospital to register with the
Environmental Agency and Consignment notes for each load of waste removed must be
issued by the Agency. It is therefore essential that Hazardous waste is segregated from all
other waste, placed in the required receptacle and labelled so as to identify the contents.
Grundon Waste Management Ltd deal with the removal and disposal of all Hazardous waste
generated by the Trust. Queries about removal of waste from the Trust should be referred
to:
Grundon Waste Management
Lakeside Rd
Colnbrook
Slough SL3 0EG
Ph. 01753 686777
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5.
PRESCRIBING
A. WRITING PRESCRIPTIONS
This procedure is intended to help ensure that medicines are prescribed accurately and
safely, and that prescriptions comply with all legal requirements
Verbal orders are SPECIFICALLY PROHIBITED*
*
Meadow House – see Appendix 1
For further reference see:
The Safe and Secure handling of medicines. A team approach – Duthie 2005 (Revised)
EHT Non medical Prescribing Policy July 2006
- Cytotoxic preparations – See Chapter 8 Section F
A1. Medical Prescribers
Prescriptions for the treatment of In-patients may be written by Medical staff (pre and post
registration) employed by the Trust
Prescriptions for Out-patients must be written by post-registration Medical staff
A2. Non Medical Independent practitioners & Supplementary Prescribers
A2.1 Nurse/Pharmacist Independent Prescribers (IPs)
Independent Prescribing is prescribing by a practioner responsible and accountable for the
assessment of patients with undiagnosed or diagnosed conditions and for decisions about
the clinical management required, including prescribing.
Changes to regulations from May 1st 2006 enable suitably trained nurses and pharmacists to
qualify as independent prescribers
A2.2 Supplementary Prescribers (SPs)
Supplementary prescribing is a voluntary partnership between an independent prescriber
(doctor or dentist) and a supplementary prescriber, to implement an agreed patient specific
Clinical Management Plan (CMP) with the patient’s agreement. There are no legal restrictions
on the clinical condition that may be treated under supplementary prescribing. The
Supplementary Prescriber will have completed accredited training through a higher education
institution (HEI) and meet the conditions set out in the EHT Non Medical Prescribing Policy
2006
A2.3 Medicines prescribed by Non-Medical prescribers
IP/SP prescribers must adhere to the Ealing Hospital NHS Trust Formulary and Good
Prescribing guidelines. There is no specific formulary for supplementary prescribing. Provided
medicines are prescribable by a doctor or dentist, available on the EHT Formulary and
that they are referred to in the patient’s Clinical Management Plan, Non-Medical prescribers
are able to prescribe:
o All GSL and P and POM medicines
o Appliances and devices prescribable by GP’s
o Food and other borderline substances which are approved
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o Medicines for use outside their licensed indications (i.e. ‘off label’ prescribing)
‘black triangle’ drugs and drugs marked ‘less suitable for prescribing’ in the
BNF or BNF-C.
Unlicensed drugs may not be prescribed unless they are part of a clinical trail that has a
clinical trail certificate or exemption.
Both out patient and in patient prescription sheets should be marked clearly with the IP/SP
details e.g. (‘A Nurse IP/SP’). An individual cost code will be assigned to allow ease of
identification by pharmacists and GP’s.
An IP/SP can only prescribe for a patient who they have personally assessed or for whom
there is a CMP.
A2.4 Legal Requirements for IPs & SPs
To be legally eligible to prescribe IPs or SPs must fulfil all of the following:
- Be a registered nurse, midwife, pharmacist or other approved AHP
- Be employed by Ealing Hospital NHS Trust
- Have a valid registration on the relevant professional register (eg. NMC, RPSGB)
- Successfully complete a Non-Medical Prescribing course, or appropriate course
relevant to profession, including all assessments and the period of learning in
practice and have registered this qualification with the relevant professional register
- Be registered with the Trust as a prescriber
- Their job description must clearly state that prescribing is required as part of their
duties
- IPs must complete the ‘Scope of Practice’ document and have it approved by the
DTG
In addition to fulfilling the legal criteria for eligibility to prescribe, nurses who are selected
for prescribing preparation will have:
- The ability to study at Level 3 (degree level)
- At least three years post-registration clinical nursing experience working at Band 7 or
above.
In addition to fulfilling the legal criteria for eligibility to prescribe, pharmacists & approved
AHPs who are selected for prescribing preparation will have:
- At least two years post-registration clinical experience in Hospital and currently
working at Band 6 level or above
All candidates who are selected for prescribing preparation will also have the support of their
line manager to confirm that:
- Their post is one in which they will have the need and opportunity to act as a
supplementary or independent prescriber and that prescribing should form part of
their professional responsibilities
- They have identified within the Trust systems to access prescription pads or other
mechanisms for prescribing which are appropriate to the setting (for example
patients’ drug charts in hospitals)
- They will have access to a budget to meet the costs of their prescriptions on
completion of the course
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-
They will have access to continuing professional development (CPD) opportunities on
completion of the course
Arranged clinical support with the supervising medical practitioner before applying for
the relevant Non-Medical Prescribing course. The supervising medical practitioner
must be willing to mentor them throughout the programme and work within a
prescribing partnership following approval to commence prescribing.
A2.5 Non Medical Prescribing Committee
The Non Medical Prescribing Committee includes the Deputy Director of Nursing, the Chief
Pharmacist, the Principal Pharmacist – Clinical Services, IP/SP Nurse Prescribers, and
representatives from the local PCT/AHPs. Their role is to:
- Advise the Drugs and Therapeutics Group (DTG) on changes in legislation in
prescribing and the implications for the Trust.
- Develop a trust wide framework to support and co-ordinate the development of new
prescribing initiatives within the Trust
- Ensure consideration is given to areas where Independent and Supplementary
Prescribing could be of benefit
- To ensure staff working in the Trust are familiar with changes in the legal status of
prescribing, supply and administration of medicines by disseminating information
throughout the Trust
- To review all applicants for the IP/SP course - e.g. discuss how applications will be
supported during training, how successful candidates will operate once qualified
- To develop local guidance on the responsibilities of the mentor supervising the
training of IP/SP
- To keep a register/updated list of IP/ SPs in the Trust
- Liaise with the Clinical Governance committees of the Trust to ensure practice is
monitored, supported and reviewed - e.g. regular review of prescribing practice,
expenditure and Clinical Management Plans (CMPs)
A3. Patient Group Directions (PGDs)
PGDs are written instructions for the supply and administration of medicines to groups of
patients who may not be individually identified before presentation for treatment. Such
patients may be supplied with or have medicines administered in the absence of a
prescription written by a doctor provided that all criteria within the PGD are met.
The supply and administration of medicines under a PGD should be reserved for those
limited situations where this offers an advantage for patient care (without compromising its
safety), and where it is consistent with appropriate professional relationships and
accountability.
PGDs are developed with Nursing, Medical and Pharmacy input. PGDs must be approved by
the Consultant responsible for the area, Senior &/or Practice Development Unit Nursing staff
and the Divisional support pharmacist before submission for D&TC approval. PGDs are be
utilised once final approval has been given by the D&TC.
Records of supply/administration must be made according to the requirements of the PGD.
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A4. Approved forms
All prescriptions must be on an approved prescription sheet or administration record card.
Approved forms are:- Inpatient Drug chart and Administration Record
- Out-patient prescription
- GP referral letter
- Discharge letter on Epro(TTA)
- FP 10(HP)
- FP 10(PCD)
- Accident & Emergency record
- Anaesthetic record
- Day case record
- Day clinic prescription
- ITU infusion chart
- Chemotherapy prescription
- Doctors Prescription (for self-prescribing)
A5. Writing prescriptions for In-patients & Day-patients
A5.1 A new prescription chart must be used for each in-patient admission. If more than
one drug chart is required then each chart must be numbered e.g. 1 of 2 etc.
A5.2
Prescriptions must be written on the appropriate section of drug charts.
For In- patient charts these are:
- Once only drugs and Pre-medication
- Oral anti-coagulants
- Regular medication
- When required drugs (PRN)
- Oxygen
- Nebulised drugs
- Insulin Sliding scale
- Regular Insulin section
- Syringe Driver infusions
- Intravenous infusions of drugs, fluids and blood products
- Antimicrobial Prescription Chart
A5.3
The following patient details must be included on every prescription:
- Name of the hospital
- Patients name
- Ward or Clinic identity
- Age or Date of birth
- Hospital number
- Consultant treating the patient
- Known drug sensitivities
- Weight – in children
- In-patient prescriptions should also include:
o any special diets
o weight
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A5.4
When writing In-patient prescriptions the prescriber must:
- Write legibly, in blue or black ink, in CAPITAL LETTERS
- Use the generic name of the drug wherever possible and avoid abbreviations
- Complete all the appropriate sections for each prescription
- Fill in the ‘Frequency box’ – nursing or pharmacy staff may ring times
- Complete the ‘Start date’ with the date the drug was first prescribed
- Cancel prescriptions with a definite line through both the item and the vacant
administration record. Cancellations must be initialled and dated
- Any changes in drug therapy must be ordered with a new prescription.
NEVER ALTER EXISTING INSTRUCTIONS (this includes additions to instructions)
- Doses of less than 1mg (milligram) must be written in micrograms
Small S.I. units must be written in full to avoid errors
Acceptable indicators of units are:
o G
(grams)
o mg
(milligrams)
o micrograms
o nanograms
o units
o L
(litres)
o ml
(millilitres)
- Specify the driving gas for nebulisers
- Prescribe the drugs in the appropriate sections of the chart
- Specify route of administration. Drugs which may be given by multiple routes,
where the dose is the same, may have one or more routes indicated when first
prescribed. e.g. PO/PR. Addition of other routes of administration, at a later time,
requires the prescription to be rewritten.
- For ‘When Required’ (PRN) medicines specify the maximum frequency or dose
- For single doses indicate the date and time of administration
- For infusions indicate the rate or duration of infusion
A5.5
Prescriptions for private patients must be clearly marked 'PRIVATE PATIENT'.
A5.6
Prescriptions must be signed in full by an authorised prescriber. Initials must not be
used alone. Bleep or extension numbers must also be included.
A5.7
Medicines which are restricted for use to a single speciality must only be prescribed
by medical practitioners currently working in that speciality. Prescribers may be
required to indicate their current post on the prescription, to validate the
prescription.
A5.8
The date the medication is to start must be entered on all prescriptions
A5.9
The prescribing of Controlled drugs will be in accordance with the Misuse of Drugs
Act, 1971 and subsequent regulations/guidance including the Safer Management of
Controlled Practice. A guide to good practice in Secondary Care (England) October
2007. Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
- 63 -
A5.10 Medical gases must always be prescribed by a medical practitioner. If a patient is
likely to be discharged requiring home Oxygen ensure it is ordered at least THREE
DAYS in advance of their discharge. See Section A9
A5.11 It is the responsibility of the prescriber or medical practitioner to indicate, clearly, any
oral medications that must not be administered to patients who are 'nil by mouth'
A6. Review and Cancellation of In-patient or Day-patient prescriptions
A6.1 All dose or prescription cancellations must be signed and dated
A6.2
When one or more doses are to be omitted (e.g. when a patient is 'nil-by-mouth') the
prescriber must indicate this by putting a cross in the appropriate box and signing
A6.3
Prescriptions for inpatients must be reviewed regularly in conjunction with their
condition and plan of care. Courses of treatment must be clearly indicated with a
Start and Stop date
A6.4
Administration of some medicines may be dependent on the acceptability of blood
drug levels. It is accepted practice to indicate a blood sample should be taken by
putting a square around the time to remind nursing/medical staff to take the blood
sample at the correct time. The acceptable/ideal blood drug level (required range)
should be clearly indicated on the chart and in the patients’ notes. When the blood
drug level is known it can be written in the square in addition to the notes. If a dose
is to be omitted, as a result of an unacceptably high blood dug level, the attending
medical practitioner must be informed at the time of the omission.
A6.5
A pharmacist may clarify a prescription for the purpose of ensuring the safe and
effective administration of medicines. Endorsements made by a pharmacist must be
signed and dated by them. A pharmacist may ask for a prescription to be rewritten
by the prescriber if they are dissatisfied with it because it is difficult to read,
ambiguous or a source of potential error
A6.6
Where a local drug substitution policy exists, a pharmacist may rewrite a prescription.
A re-written prescription must be countersigned by an authorised prescriber within 24
hours
A6.7
When any aspect of therapy is changed, the prescription must be REWRITTEN.
Prescriptions must never be altered. This is a potential source of error.
A6.8
Prescriptions must be cancelled by a line through the drug name and across the
unused part of the administration record. This must be signed and dated with the
stop date written in the appropriate box
A6.9
Medication should be condensed to one drug chart when possible. Only medical
practitioners associated with the patient’s care can re-write prescriptions.
A pharmacist may re-write a prescription, after communicating with a medical
practitioner and this prescription must be countersigned by the medical practitioner
within 24 hours
- 64 -
A6.10 Prescription charts which have been re-written or are no-longer to be used for any
other reason must be cancelled:
- Cross a line through each page of the whole chart
- Sign and date the prescription cancellation on the front of the chart and endorse
with the words ‘Chart re-written’
A6.11 Any cancelled charts must be kept with current medical records. Medical notes have
a section where used charts should be added
A7 Writing Prescriptions for Out-patients
A7.1 There are two forms available for prescribing for Outpatients. The Out-patient
prescription form and the GP referral letter (See Appendix 2)
All out-patients should be referred back to their GPs for medication via the GP
referral letter unless there is a specific need for the patient to obtain the medicine
from the hospital pharmacy. In exceptional cases the Out-patient prescription form
may be used.
The only exceptions will be:
- Specialist drugs e.g. anti-TNFs, Imatinib
- Hospital only/Red list drugs (see Appendix 3)
- Treatment must start immediately i.e. within 3 working days
A7.2
In all other circumstances the GP referral letter should be completed and the patient
advised to take this to their GP. As therapy recommended in this way is not urgent, it
is not necessary for the patient to obtain a prescription from the GP immediately.
This GP referral letter must be LEGIBLE & IN CAPITAL LETTERS with a clear
diagnosis and name/contact number of the person filling in the form. Without this the
GP may quite legitimately refuse to prescribe
A7.3
Controlled Drugs
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
A7.4
FP 10(HP) prescriptions are available for prescribing in some clinics. Refer patient to
Community pharmacies for supply as the hospital dispensary is unable to dispense
against these prescriptions.
A7.5
FP 10(PCD) prescriptions are available for supply of Controlled drugs from a
Community pharmacy. Use is restricted to palliative care in emergency situations.
Maximum period of supply is 28 days.
A8 Writing prescriptions for Controlled Drugs
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
- 65 -
A9 Doctors Self Prescribing
This service is provided to help doctors obtain essential medicines in emergency.
Prescriptions for medical staff will only be dispensed in situations where it is difficult for the
doctor to obtain supplies from their GP.
A9.1
Doctors employed by Ealing Hospital NHS Trust may prescribe short term treatment
for themselves for an acute illness however it is recommended they seek advice from
their GP or Occupational Health
A9.2
Long term maintenance prescriptions will not be provided by the Trust
A9.2
Prescriptions for members of the Doctors’ immediate family will be dispensed only in
emergency (Immediate family = Spouse/Partner, Children, Parents & younger
Siblings who live with Parents)
A9.3
Prescriptions are subject to NHS prescription tax except where exemptions apply
A9.4
Doctors Prescription forms are kept in Pharmacy Reception. Doctors must show Staff
Identification badge to the receptionist in order to prescribe. This service is available
only during Pharmacy opening hours
A9.5
Prescriptions for Controlled and Restricted Drugs (including Temazepam),
Benzodiazepines or Cytotoxic drugs (including Methotrexate) are not allowed to be
self prescribed
A9.6
Prescriptions are limited to drugs allowed by the Ealing Hospital NHS Trust Formulary
A9.7
Doctors who want to obtain medicines to administer in private practice should obtain
these outside the hospital wherever possible. If this is not possible such medicines
will only be supplied by prior arrangement and will be charged as private
prescriptions
A10 Gifts and benefits
A10.1 The advertising and promotion of medicines is strictly regulated under the Medicines
(Advertising) Regulations 1994, and it is important that all health professionals make
their choice of medicinal product for their patients on the basis of clinical suitability
and value for money alone. Any complaints about promotional practices should be
referred to the MHRA or ABPI
A10.2 As part of the promotion of a medicine or medicines, suppliers may provide
inexpensive gifts and benefits, e.g. pens, diaries, mouse mats. Personal
gifts are prohibited, and it is an offence to solicit or accept a prohibited gift or
inducement. See ABPI Code of Practice www.abpi.org.uk
A10.3 Companies may also offer hospitality at a professional meeting or at meetings held to
promote medicines, but such hospitality should be reasonable in level and
subordinate to the main purpose of the meeting. See ABPI Code of Practice
www.abpi.org.uk
- 66 -
A11 Supply of Home Oxygen
After 1st February 2006 oxygen can no longer be prescribed on FP 10 prescriptions. A Home
Oxygen Order Form (HOOF) must be used. This HOOF is ongoing and will remain valid
unless a further HOOF supersedes it.
Patients should be reviewed regularly to determine whether they still require oxygen.
The supply of home oxygen for North West London is provided by Air Products
A11.1 Ordering Home Oxygen Supplies:
- The oxygen order must be in place for a patient 3 DAYS prior to discharge
- Fill out a Home Oxygen Ordering Form (HOOF) and a Home Oxygen Consent
Form (HOCF). These can be downloaded from
http://www.primarycarecontracting.nhs.uk/118.php. Paper copies of these forms can
be found on Level 6 wards of the hospital and in Meadow House. Please note that a
copy of the consent form must be given to the patient and one must be filed away in
the patient’s medical notes.
- Please ensure all sections are filled out concisely. Patient’s GP and PCT details can be
found on PAS under patient enquiries
- The PIN requested on the bottom right hand corner of the HOOF refers to the
clinician’s professional registration number
- Once the form has been completed please fax directly to Air Products on 6288. This
number should be accessible from all fax machines within Ealing Hospital
- If oxygen is being initiated by anyone other than the Respiratory team please ensure
a copy of the HOOF is sent to the Respiratory Consultant as the patient must be
reviewed regularly under this new system
- Any enquiries can be answered by phoning Air Products on 0800 373 580 (dial 9 for
an outside line)
- In some palliative care cases Emergency oxygen can be ordered. This service runs
24 hours a day with a maximum response time of 4 hours. This is an expensive
option and must be reserved to URGENT PALLIATIVE CASES
- Patients are responsible for their oxygen supplies. If they have any trouble with
existing supplies they should contact the company directly on 0800 373 580.
- 67 -
6.
PREPARATION OF MEDICINES PRIOR TO ADMINISTRATION
-
Hands must always be washed prior to preparation of medicines
Only suitably trained and authorised staff may prepare medicines
All medicines must be prepared in an environment which protects both the medicine
and the member of staff from possible contamination.
Where medicines are prepared, smooth, impervious work surfaces should be
provided.
All medicines must be prepared in a manner which is suitable for the intended route
of administration
Manufacturers' and/or pharmacists' instructions for the preparation of medicines
must be complied with
Only one patient's medication may be prepared at a time
Cytotoxic preparations – See Chapter 8 Section F
A. PREPARATION OF ORAL MEDICINES
A1.1 Ensure that the medicine trolley or cabinet is clean and tidy
A1.2
Ensure that the following are available:
- all medicines required for the patient
- current editions of British National Formulary (BNF or BNF-C) and EHT Formulary
(on-line)
- jug of fresh water and tumblers, by each bed
- graduated measures and/or oral syringes for liquid medicines
- receptacle for used medicine pots
B. PREPARATION OF INJECTIONS AND INFUSIONS
B1. Preparation of equipment
B1.1 Follow the principles of aseptic technique
B1.2
Prepare the injections in a designated preparation area
B1.3
Clean the work surface prior to and following use
B1.4
Check and follow the instructions for reconstitution or dilution in the EHT Intravenous
Administration Guide (if the drug is not included, use the manufacturers instructions)
B1.5 Ensure that equipment is available as follows:
- clean trays or receivers in which to place medication and equipment
- syringes of appropriate size
- needles of appropriate size (see A2.2)
- sterile alcohol impregnated swabs (if indicated)
- required medicine and diluents
- patient prescription chart or administration record
- suitable administration equipment with instructions for use e.g. syringe driver
- sharps bin
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B2. Selection of needle size
- White
(19G) for ease of reconstitution and drawing up of certain solutions &
liquids
- Green
(21G) for the administration of IM injections to adults
- Blue
(23G) for the administration of IV injections to children and adults
and IM injections to children and to adults with very reduced muscle mass. The
use of a blue needle in adults with normal muscle mass will actually cause greater
pain than the use of a green needle
- Orange (25G) for the administration of SC injections
B3. Preparation of medicines in ampoules
Prior to commencing preparation of the actual medicine, ensure that the packaging of any
sterile equipment is intact and that liquid medicines or diluents have no visible particulate
contamination or cloudiness.
When reconstituting or drawing up a medicine, observe the following principles:
B3.1 Ensure that all the solution is in the main body of the ampoule
B3.2
Always cover the neck of an ampoule with an alcohol impregnated swab whilst
snapping it open. After breaking open an ampoule check that no glass particles are
present in the solution
B3.3
Ensure that the contents of ampoules are completely dissolved/mixed after
reconstitution
B3.4
After withdrawing the required amount of solution remove the air bubble and any
excess liquid by aspirating the syringe on a sterile swab to prevent contamination of
the preparation area with drug solution. NEVER RE-SHEATH NEEDLES.
B3.5
Always change the needle prior to administration. Remove the old needle and
immediately put it into the sharps bin. Attach the new needle (inside the guard) or
syringe bung to the end of the syringe as appropriate
B3.6
If appropriate, clean the patient's skin with a sterile alcohol impregnated swab and
allow to dry prior to administration, unless specifically contra-indicated by the
manufacturer of the medicine
- 69 -
B4. Preparation of medicines in vials
Prior to commencing preparation of the actual medicine, ensure that the packaging of sterile
equipment is intact and that liquid medicines or diluents have no visible particulate
contamination, or cloudiness.
When reconstituting or drawing up a medicine, observe the following principles:
B4.1 Prior to inserting a needle, clean the rubber bung of a vial with a sterile alcohol
impregnated swab and allow the area to dry
B4.2
After inserting a needle through the rubber bung of a vial check that no rubber
particles are present in the solution
B4.3
Ensure that the contents of vials are completely dissolved/mixed after reconstitution
B4.4
After withdrawing the required amount of solution remove the air bubble and any
excess liquid by aspirating the syringe on a sterile swab to prevent contamination of
the preparation area with drug solution. NEVER RE-SHEATH NEEDLES.
B4.5
Always change the needle prior to administration. Remove the old needle and
immediately put it into the sharps bin. Attach the new needle (inside the guard) or
syringe bung to the end of the syringe as appropriate
B4.6
If appropriate, clean the patient's skin with a sterile alcohol impregnated swab and
allow the area to dry prior to administration (unless specifically contra-indicated by
the manufacturer of the medicine)
C. PREPARATION OF SUPPOSITORIES, ENEMAS AND VAGINAL PESSARIES
C.1
The following items are required:
- clean tray or receiver in which to place medication
- prescribed medication
- patient prescription chart or administration record
- gauze swabs or tissues
- disposable gloves
- suitable applicator if necessary
C.2
A lubricating agent suitable for the medicine must be selected (see the
manufacturers' recommendations)
D. PREPARATION OF BLADDER INSTILLATIONS
D.1
The following items are required:
- the prescribed solution
- a suitable delivery and collection system
- patient prescription chart or administration record
- disposable gloves
D.2
Principles of aseptic technique must be observed throughout
- 70 -
E. PREPARATION OF OTHER MEDICINES
Particular items of equipment need to be prepared for other specific medicines
E.1 Topical Applications
- The prescribed medicine
- Disposable gloves
- Flat wooden spatula or other applicator
E.2 Inhalations
- The prescribed solution
- Recommended diluent
- Syringe(s) and needle(s) for drawing up the solutions
- Administration equipment (e.g. nebuliser, face mask, connecting tubing)
E.3 Ear, eye and nasal drops/ointments
- The prescribed medicine
- Gauze swabs or tissues
- Applicator, if appropriate
E.4 Mouthwashes and gargles
- The prescribed solution
- Tumbler
- Receiver for "spitting out"
- Tissues
For further reference see:
The Safe and Secure handling of medicines. A team approach – Duthie 2005 (Revised)
Standards for infusion therapy (RCN 2003)
Ealing Hospital NHS Trust Intravenous Drug Administration Guide (Latest edition)
- 71 -
7.
ADMINISTRATION OF MEDICINES
A. GENERAL GUIDANCE
It is the responsibility of the member of staff administering a medicine to ensure that the
correct medicine is administered to the correct patient/client, in the correct form, by the
correct route, at the correct dose, at the times specified by the prescriber.
A1.1
A registered nurse, medical practitioner or other authorised practitioner may
undertake single-person administration of medicines with the following exceptions in
the hospital setting:
- a second authorised person must be involved in all stages of the checking process
for Controlled Drugs
- a second authorised person must be involved with the administration of all
medicines prescribed for children
- a second authorised person must be involved in the administration of all Cytotoxic
drugs. At least one person must be a suitably trained staff member who is on the
Cytotoxic drug administration register
- a second authorised person must be involved in the administration of all
parenteral drugs
- a second authorised person must be involved in all situations where calculations
are required
Student nurses may administer medicines under the close supervision of an
appropriately experienced registered nurse who is responsible for their training.
A1.2
The correct procedure for the administration of medicines is as follows:
1. Wash hands prior to commencing preparation and administration and at such
other times as are necessary, to minimise the likelihood of cross-infection (e.g.
before and after administering eye preparations and after administering
suppositories and pessaries)
2. The medicines trolley or other suitable delivery system must be used whilst
administering oral medicines to more than one patient
3. Injections, external applications and rectal or vaginal preparations must not be
administered at the same time as oral medicines
4. Prior to administration, check each prescription chart or administration record for
all of the following:
- Patient's full name, hospital number and ward
- Any recorded allergy or dietary restrictions
- Name of medicine
- Dose and Strength
- Formulation
- Route
- Special instructions
- Date that therapy is due to commence
- Duration of therapy, if specified
- Signature of prescriber
- 72 -
5. Read ALL SECTIONS of the chart/prescription. Do not proceed if there is any
suspected clinical contra-indication or the prescription is incomplete or illegible. In
such instances, contact the medical practitioner responsible for the patient or the
ward pharmacist for clarification
6. Check the prescribed administration time and that the dose has not already been
given. Ensure the maximum dose is not exceeded on ‘when required’
prescriptions.
7. Identify the patient by checking full name and hospital number on the patient's
identity band. Patients who are able to respond must also be asked to state their
name. Medicines must not be given to patients who cannot be positively
identified.
8. Select the required medicine and check that the strength and form are the same
as on the prescription. Check the medicine has been stored correctly and the
expiry date. If there is no expiry date (e.g. tablets) then only administer drugs
dispensed from the hospital pharmacy within the last 6 months
9. Measure out, or draw up, the correct dose. For oral medicines, use a separate
medicine pot for each patient and do not mix liquid medicines
10. Do not interfere with a medicine in its prepared form (e.g. by crushing) unless
this has been discussed with a pharmacist and they have endorsed on the
prescription chart that it is safe to do so
11. Take the medicine and the prescription chart/administration record to the
patients’ bedside
12. Re-check the patient’s identity and any known allergies. The nature of the allergy
must be established before proceeding
13. Ensure that the patient has an understanding of the medicine about to be
administered and offer appropriate explanation if necessary
14. Ensure that the patient and environment have been appropriately prepared with
regard to positioning and privacy
15. Administer the medicine
16. Do not leave any medicine at the patient's bedside. It is the responsibility of the
person administering the medicine to ensure the patient takes the medicine. A
student nurse, ATO or carer/parent may help in encouraging patients to take
medicines however the responsibility remains with the qualified nurse
17. Record the completed administration on the prescription chart/administration
record, using clear initials. Ensure the year, month and day are recorded at the
top of the drug chart
- 73 -
18. If the medicine is not administered at the prescribed time then record the time of
administration on the chart
19. For "as required" medicines, also record the dosage, date and time of
administration
20. If a medicine is not administered indicate the reason as stated on the prescription
chart / administration record and clearly document this in the patient record.
Inform prescriber or medical practitioner responsible for the patient that the drug
has not been administered and the reasons why, so they may take appropriate
action as necessary. See F1.12



To reduce harm from omitted and delayed medicines in hospital, if a critical
medicine is not available on the ward contact your ward pharmacist or for
ward stock items, contact pharmacy distribution team.
If a critical medicine is not available out of hours, inform nurse in charge and
if appropriate, contact the duty manager (218) to obtain medicine from
another ward or emergency drug cupboard/ fridge. When advised by duty
manager, contact on-call pharmacist via switch board.
If unsure if the unavailable medicine is critical, refer to “Critical list of
medicines” guide available on the Medication Safety Intranet site. If unsure
contact the ward manger, duty manager, prescriber or on-call pharmacist.
21. All batch numbers and expiry date of Vaccines and Blood products, such as
Human Albumin or Immunoglobulins, administered to patients must be recorded
in the patients’ health care record and on the drug chart. Records must also be
kept in Pharmacy for Blood products. Immunoglobulins must only be given to the
patient named on the label to comply with Department of Health regulations. See
Immunoglobulin management plan 2008.
22. In areas where Human Albumin is a Stock item ensure the patient details are
recorded on the label attached to the bottle and that this label is returned to the
Distribution manager so a record can be made
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B. PATIENT CONSENT
B.1.1 In most circumstances treatment may only be given with the patients consent.
‘Consent’ is defined as ‘the voluntary and continuing permission of the patient to
receive a particular treatment, based on a adequate knowledge of the
purpose, nature, likely effects and risks of that treatment including the likelihood of
its success and any alternatives to it’.
Medical, Pharmacy and Nursing staff have a duty to give patients an explanation of the
nature, purpose, effects and risk of medical treatment and to obtain the patients consent
before administering such treatment. The patients must be allowed to consent voluntarily to
the treatment and must not be subject to coercion. The patient must have the capacity to
understand the information that has been given and be able to make a decision.
B1.2
The exceptions to this are:
- Emergency situations where to withhold treatment would endanger a patients’
life or health
- Where the patient lacks the capacity to give consent, is in need of medical care
and where medical treatment is in the patients’ best interests (i.e. to save life,
prevent deterioration or ensure an improvement in a person’s health).
If a patient is unable to give consent the responsibility for decision making
falls to the attending physician who, in discussion with the relevant colleagues,
is required to act in the patients’ best interest
In the case of adult patients, family and carers do not have the right
to consent on the patients behalf
B1.3
-
-
Covert administration of medicines - Disguising medicine in food and drink.
By disguising medication in food or drink, the patient is being led to believe that they
are not receiving medication, when in fact they are.
Covert administration of medicines must be deemed necessary in order to save life,
prevent deterioration or ensure an improvement in the patient’s physical or mental
health. In other words, it must be in the best interest of the patient.
All healthcare professionals involved in the practice of administering medicines
covertly should be fully aware of the aims, intent and implications this practice and
be accountable for their actions. The healthcare professionals will need to be certain
they have the support of the multi-professional team.
Healthcare professionals should not make a decision to administer medication in this
way in isolation.
Records must be made in the patient notes. Summaries of discussions documenting
all views and resulting actions/decisions must be documented in the current care
plan.
In some cases, the only proper course of action may be to seek the permission of the
court to administer medicines covertly. If a person is lawfully detained under a
section of the relevant mental health legislation the practice of administration of
disguised medication may be recognised by law. Such approvals must be
documented clearly including relevant dates as these provisions are subject to
review.
- 75 -
C. ADMINISTRATION OF NON-ORAL MEDICINES
The general principles outlined in the ‘Procedure for the Administration of Medicines’ applies
to all dosage forms. However, for the groups of medicines listed below, clinical practice may
differ from one healthcare setting to another. In these instances, reference must be made to
locally approved Clinical Procedures
Groups of medicines:
- Ear drops
- Eye Drops/Eye Ointment
- Inhalations
- Injections (IV,IM,SC)
- Medical Gases
- Mouthwashes
- Suppositories and enemas
- Topical preparations
- Vaginal pessaries
- Bladder instillations
Refer to local procedures for information relating to infusion devices
D. ADMINISTRATION OF NEBULISED DRUGS
The general principles outlined in the procedure for the Administration of Medicines apply.
Refer to:
Policy for administration of Nebulised therapies to adult patients (current).
For further reference see:
The Safe and Secure handling of medicines. A team approach – Duthie 2005 (Revised)
E. SELF ADMINISTRATION
Refer to the Self Administration policy (Current)
F. FURTHER NOTES ON ADMINISTRATION
F1.1 The responsibility for the administration of medicines usually rests with the
Registered nurse
F1.2
Other healthcare staff may have responsibility for the administration of medicines
delegated to them in accordance with locally agreed procedures or Patient Group
Directions
F1.3 Nursing Auxiliaries and Care Assistants
Nursing auxiliaries and care assistants are not permitted to verify or dispense any Medication
(in any form), for administration, within the acute hospital setting
The task of aiding oral administration by encouraging patients to take tablets or liquids may
be delegated to nursing auxiliaries and care assistants by a Senior Nurse. The authorised
nurse practitioner is responsible for the administration and must sign the chart.
- 76 -
F1.4 Nurses in Training
For learning purposes, a nurse in training may be involved, with an authorised nurse
practitioner, in the administration of medicines. However, the responsibility for the
administration of the medicines still attaches to the authorised nurse practitioner
F1.5 Single Nurse Drug Administration
F1.5.1 Qualified Nurses
Single Nurse Drug Administration can be carried out by individual, appropriately qualified
nurses with the agreement of the Ward/Department Manager and of the individual
practitioner. The hospital procedure relating to Single Nurse Drug Administration must
always be adhered to.
In preparing to undertake this procedure, the qualified nurse must:
1. Be aware of their accountability
2. Have read the Medicines Policy and Procedure file
3. Have read the NMC documents
- Standards for the Administration of Medicines
- Code of Professional Conduct
- Accountability
- Standards for Records and Record Keeping
- Standards for infusion therapy
F1.5.2 Criteria
- Registered nursing staff who undertake Single Nurse Drug Administration, must
be assessed as competent by the Ward/Department Manager.
- A record of competencies achieved needs to be maintained and kept on record.
Attendance and passing requirements of a study day or course may be necessary
according to local procedures
- Registered Nursing Staff who undertake single nurse drug administration should
be qualified for at least three months. This is an area which should be considered
within the preceptorship period and could be identified as a learning outcome
F1.5.3 Supervision/Assessment
- Supervision for newly qualified staff should be carried out by an identified
preceptor. When the individual and preceptor feel that the nurse is competent,
they should be assessed by a qualified assessor, and cover all aspects of
administration of medicines
- Staff who are not newly qualified should be assessed by the Ward/Department
Manager. Areas covered should follow the format of the Bank/Agency Nurse Drug
Administration as set out in the Medicines Policy/Procedure file
- 77 -
F1.5.4 Administration
- The nurse will understand the nature of the drug administered and the side effects or
have available a current British National Formulary to refer to.
- The Medicines Policy and Procedures will be adhered to at all times.
- It will automatically occur that double check of administration will be reintroduced at
the request of any individual practitioner, enabling him/her to maintain practice in a
safe professional environment.
- Learners, at the appropriate stages in their training, should be involved in drug
administration to enable them to develop the appropriate skills
F1.6 Medical Practitioners
Trained medical practitioners (not medical students) can administer medicines
according to agreed procedures. On certain occasions it is the sole responsibility of
the medical practitioner to administer particular medicines (see IV Administration
guide and Cytotoxic policies)
F1.7 Other disciplines
Chiropodists, podiatrists, dieticians, pharmacists, registered dental nurses, radiographers and
physiotherapists may be responsible and accountable for the administration of medicines
within their designated sphere of practice. Such administration must be in accordance with
procedures approved for that speciality and PGDs
F1.8 Self-administration of medicines by patients
Self-administration of medicines by patients is allowed in designated healthcare settings in
accordance with approved local procedures. See Self Administration Policy.
F1.9 Single-Person Administration (in hospitals)
A registered nurse, authorised enrolled nurse, medical practitioner or other
authorised practitioner may undertake single-person administration of medicines, in
the hospital setting, with the following exceptions:
- a second authorised person must be involved in all stages of the checking process
for Controlled Drugs
- a second authorised person must be involved with the administration of all
medicines prescribed for children
- a second authorised person must be involved with the administration of all
parenterally administered medicines
- a second authorised person must be involved in the administration of all blood
and blood products
- a second authorised person must be involved in all situations where the dose,
concentration or rate of administration have to be calculated
- 78 -
F1.10 Bank and agency staff
Qualified, 'Bank' and agency staff may be authorised for single-nurse administration
only in the following circumstances:
- They are a Registered Nurse already in permanent employment with the Trust
- Written authorisation has been given by the appointed nurse in charge or a line
manager. Such authorisation shall be given only if the 'Bank' or agency nurse
has:
o been made familiar with the Policies & Procedures relating to the
administration of medicines.
o been judged competent by the appointed nurse in charge or a line
manager and a record of competency is
o expressed willingness to undertake single-nurse administration
F1.11 The responsibility of the member of staff administering medicines
- It is the responsibility of the member of staff administering a medicine to ensure
that the correct medicine is administered to the correct patient/client, in the
correct form, by the correct route, at the correct dose, at the times specified by
the prescriber
- Where there is any doubt as to the accuracy, completeness or appropriateness of
an individual prescription, it is the responsibility of the member of staff to confirm
the details with the prescriber and/or a pharmacist before administering the
medicine
- If the member of staff is still not satisfied, their line manager must be notified
immediately. Any concerns and details of the action taken must be recorded in
the nursing record or case notes
- If the medical practitioner insists that the medicine must be given, that medical
practitioner shall be responsible for administration and any resulting
consequences
F1.12 Non-administration of medicines
In certain situations it may not be possible to administer a medicine to a patient at
the prescribed time.
- The reason for non administration must be recorded on the medication record
and the nurse in charge informed.
- The nurse in charge shall then contact the prescriber to verify whether nonadministration will compromise patient care
F1.13 Nil by Mouth
- Patients who are ‘nil by mouth’ may be given oral medicines with a small amount
of water unless the prescriber has clearly indicated administration is not
necessary
- The person responsible for administering the medicine(s) shall administer all
doses as prescribed, unless the prescriber indicates clearly on the medication
record that a dose(s) of a medicine(s) must not be administered to a patient who
is 'nil by mouth'
- 79 -
F1.14 Condition of patient
Depending on the condition of a patient, it may be deemed necessary to withhold the
medicine at the time when it is due to be administered. In this case, further
verification must be obtained from a medical practitioner
For further reference see:
The Safe and Secure handling of medicines. A team approach – Duthie 2005 (Revised)
- 80 -
8.
ADDITIONAL PROFESSIONAL PRACTICES
A. ISSUE OF PRE-PACKED OR OVERLABELLED MEDICINES FROM WARD/
CLINICAL AREAS
A1 Supply against a prescription
In certain healthcare settings, small supplies of discharge medicines are made available for
supply, against a prescription and given to patients. These medicines should only be issued
where it is essential that the patient receives immediate therapy.
A1.1 The independent prescriber, responsible for the patient, must write a prescription
according to the written procedure for prescription writing
A1.2 Medicines may only be issued from the healthcare setting if they are labelled with
the following details:
- name of the medicine
- form
- strength
- quantity
- directions for use
- space to write the patient's name and date of issue
- name and address of the hospital
A1.3 A maximum of one container may be given for each medicine.
A1.4 An independent prescriber must write the patient's name and date of issue in the
space provided on the label.
A1.5 The person issuing the medicine must indicate on the prescription the quantity
supplied and must countersign (using full signature) the prescription with the name
and designation printed clearly underneath. This person must have been trained and
accredited to perform this task by the nurse/midwifery manager and Pharmacy.
A1.6 The dispensed medicine must be checked against the prescription by a second
authorised person. This person must have been trained and accredited to perform
this task by the nurse/midwifery manager and Pharmacy.
A1.7 The medicine may then be given to the patient
A1.8 The prescriptions must be sent to pharmacy on the next working day
A1.9 A record of trained nurses and midwives involved in the supply of medicines to
patients against prescriptions and clinical areas where this supply may occur, must
be kept and regularly updated by the Senior Nurse Manager for each, relevant,
clinical area.
A2 Supply according to a PGD
A2.1 The independent prescriber must write a directive for supply in the patient notes for
a specific medicine in a specific indication that an approved PGD is valid for.
A2.2 The supplier must be appropriately trained and authorised to supply the medicine in
accordance with the PGD. A record of valid PGDs, who may administer or supply
medicines against these PGDs and clinical areas where this supply may occur, must
be kept and regularly updated by the Senior Nurse Manager for each, relevant,
clinical area.
For further reference see:
Clinical area specific, local, relevant PGDs and PGD guidance.
- 81 -
B. CONTROLLED AND RESTRICTED DRUGS
Refer to Ealing Hospital NHS Trust Controlled and Restricted Drugs Policy.
C UNLICENSED MEDICINAL PRODUCTS (UMPs) USE OF LICENSED MEDICATIONS
FOR UNLICENSED INDICATIONS
This section is under revision. Speak to a pharmacist for advice if required.
D. MEDICINES WHICH MAY BE ADMINISTERED BY AUTHORISED
PRACTITIONERS BY INTRAVENOUS ROUTES
D1. Practitioners authorised to administer intravenous medicines
The following people may prepare and administer intravenous medicines:
o All medical practitioners, including pre-registration house officers
o Qualified nurses who are recognised as professionally competent
-
Intravenous medicines may be administered by nursing staff who have:
a)
Attended a course of study on the administration of intravenous medicines
and associated risks
Achieved competencies necessary to complete course, as assessed by
course organisers
Passed the courses’ Calculation test, including IV calculations
AND
b)
Been assessed as competent by a nurse manager at the unit/ward in which
the nurse is currently working. A written record of the assessment must be
kept on file
-
Before administering any medicine the nurse must ensure they are familiar with any
specialist monitoring and/or equipment required. Any required equipment must also
be available before administering the medicine
There is no restriction on the doses of medicines which may be administered by
suitably qualified nurses except in situations where the nurse is concerned on
grounds of safety to the patient. See section on Administration of Medicines
Before being allowed to give intravenous medicines to children, a qualified nurse who
is recognised as competent to administer intravenous medicines must additionally be
assessed as competent by the Senior Nurse Paediatrics or the paediatric ward
sister/charge nurse. A written record of the assessment must be kept on file
-
-
D2. Intravenous administration
It is the responsibility of the qualified nurse or medical practitioner when setting up any drug
or fluid for intravenous administration to:
- Check the prescription is valid and complies with the ‘EHT Intravenous Drug
Administration Guide’ (Latest edition available in clinical areas and on Trust Intranet)
- Check the container and fluid show no obvious faults or contamination
- Check the correct medicine is administered to the correct patient
- Observe whether the administration line remains patent
- Inspect the site of injection for signs of abnormality
- Control the rate of administration
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-
Observe the condition of the patient
Report and/or solve any problems appropriately
Maintain all necessary records
- 83 -
D3. Intravenous fluids which may be administered by any qualified nurse
D3.1 Intravenous Infusions
These medicines may only be administered in accordance with a legitimate prescription.
An established and patent line must be used.
D3.1.1 Fluids
Via a Peripheral or Central line
o Glucose 5%, 10%
o Sodium Chloride 0.9%
o Glucose 4% and Sodium Chloride 0.18% (Dextrose/Saline)
o Glucose 10% and Sodium Chloride 0.18%
o Glucose 2.5% and Sodium Chloride 0.45%
o Volplex® or Gelatin solutions
o Hartmann's - Compound Sodium Lactate
o Potassium 0.15% or 0.3% in glucose or saline or dextrose/saline prepared by
a pharmaceutical manufacturer
Via a Central line
o Glucose 20%, 50%
The list is not exhaustive. Check with Pharmacy Medicines Information (ext 5303) for help
with appropriate use of fluids not listed in the ‘EHT Intravenous Drug Administration Guide’
(Latest edition)
D3.1.2 Blood and blood products
Common Blood products
o Blood, Packed red cells, Platelets and other blood fractions
o Human Immunoglobulin (IVIG)
o Human Albumin
o Anti-D Immunoglobulin
The list is not exhaustive. Check with Pharmacy Medicines Information for help.
A second person must be involved in all stages of checking and at the commencement of
administration of all blood and blood products
Staff must complete accredited training and competent to administer blood and blood
products.
A record of staff accredited to administer blood and blood products must be kept and
updated by the Senior Nurse Manager for each clinical area.
Refer to the current ‘Blood transfusion policy’
See NPSA & MHRA recommendations - www.mhra.gov.uk
D3.1.3 Flushing of peripheral intravenous cannulae
o Sodium Chloride 0.9% injection - up to 5ml per dose
o Water for injection – up to 5ml per dose
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E. POLICY FOR THE STORAGE AND USE OF IV POTASSIUM
E1. Introduction
Intravenous administration of concentrated potassium solutions is associated
with deaths when used improperly. NPSA (National Patient Safety Agency)
requirements were published in July 2002 (Patient Safety Alert 01. July 2002.
www.npsa.nhs.uk ) and include the introduction of local controls to reduce the risks
associated with concentrated intravenous potassium solutions.
Ealing Hospital NHS Trust clinical areas and all units served by the Ealing Hospital NHS Trust
Pharmacy Department are required to comply with this policy.
E1.1 Aim
To ensure the safe storage, handling, preparation, prescribing, checking and administration
of intravenous potassium solutions in order to minimise the risk of associated errors and
adverse events and to meet the requirements of the NPSA Patient Safety Alert (July 2002).
E1.2 Definition
For the purposes of this policy “concentrated” intravenous potassium solutions used in the
Trust are:
o Potassium chloride 15% injection
o Potassium phosphate 17.42% injection
o Potassium chloride 40mmol in sodium chloride 0.9% 100ml.
Other intravenous solutions of potassium (strengths and/or salts) introduced subsequently
may also be included.
Prior to the introduction of such preparations, the necessity of including them in this policy
will be considered. (Further advice should be obtained from the Chief Pharmacist)
E2. Potassium Chloride 15% injection and Potassium Phosphate 17.42%
injection
E2.1 Availability
These preparations will be supplied and should only be used in the following clinical areas:
o ITU
o 10 North
o SCBU.
ITU
-
-
Potassium chloride 15% injection is available on ITU to enable the addition of
potassium to haemodiafiltration fluids. It should not be used on ITU for intravenous
potassium supplementation for which an alternative preparation is available
Potassium phosphate 17.42% injection is available on ITU for use when there is a
clinical need for intravenous supplementation of both potassium and phosphate.
It must be appropriately diluted before administration and must be administered via
a central venous catheter
N.B. Sodium phosphate injection is the preparation of choice if there is a clinical need for
intravenous supplementation of phosphate only
- 85 -
10N & SCBU
- Potassium chloride 15% injection is available on 10 North and SCBU to enable the
addition of potassium to intravenous fluids for the purpose of supplementation where
there is no suitable commercially manufactured dilute solution. See E2.3
N.B. A comprehensive range of commercially manufactured intravenous infusion solutions
containing potassium are stocked in the hospital and these must be used preferentially in all
areas whenever practicable.
E2.2 Ordering, Storage and Handling of Potassium Chloride 15% injection and
Potassium Phosphate 17.42% injection.
- Both the above injections must be ordered, stored, handled and administered in
accordance with full Controlled Drugs regulations and must not be transferred
between clinical areas unless authorised by a pharmacist. All supplies out of hours
must be discussed with the on-call pharmacist
- Stocks in Pharmacy are stored, handled and supplied subject to Controlled Drugs
regulations
- Potassium Chloride 15% injection and Potassium Phosphate 17.42% injection are
only available for use in the clinical areas outlined above for the indications outlined
above. They are not to be supplied to other clinical areas. Neither should they be
used in the permitted clinical areas for alternative indications. The use of such
solutions outside the clinical areas agreed above or for alternative indications must
be approved and/or reported to the Principal Pharmacist Patient Services or Chief
Pharmacist. Outside normal hours any issues should be discussed with the on-call
pharmacist in the first instance.
E2.3 Administration
In rare circumstances, when it is necessary to use concentrated potassium injections, the
concentrated solution must be diluted, by addition to a large volume infusion bag (see
current Ealing Hospital Trust Intravenous Drug Administration Guide for details).
- The following steps must be followed to minimise the risk of incomplete mixing which
has resulted in rapid administration of potassium with serious clinical consequences.
o
Hold the additive port of the infusion bag upwards
o
Inject potassium injection downwards
o
Mix the contents thoroughly by gently inverting the bag on at least five
occasions
o
Do not inject potassium injection into a hanging bag or the burette of a giving
set under any circumstances
o
A second practitioner must always check the preparation and administration
of a solution of potassium made up in clinical areas.
o
The checks undertaken must include:
1. That there is a genuine need for the use of a concentrated potassium solution
and there is not a suitable commercially manufactured preparation available
2. Prescriptions should be written to enable the use of pre-mixed solutions and
nursing staff should query prescriptions with prescribers where this does not
appear to be the case.
3. That the correct products were chosen to make the dilution i.e. the correct
ampoule of potassium injection and the correct bag of infusion fluid
4. That the dosage prescribed is appropriate for the patient
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-
5. That the dilution carried out is as prescribed on the drug chart
6. That thorough mixing has taken place as described above
7. That the diluted solution is labelled, correctly with a fully completed IV
additive label
All of these checks must be carried out during the preparation of the solution and
again immediately prior to beginning administration
All potassium containing intravenous infusions must be administered through an
infusion pump
E3. Potassium chloride 40mmol in sodium chloride 0.9% 100ml
This commercially prepared low volume (100ml) sodium chloride infusion containing 40mmol
potassium is supplied to a limited number of clinical areas where there is a clinical need for
the availability of an intravenous potassium infusion with a concentration of potassium
greater than 40mmol per litre.
It is not subject to Controlled Drug regulations although careful handling is required to
minimise risk.
E3.1 Availability
This preparation will be supplied and should only be used in the following clinical areas:
o ITU
o Theatres
o 4South
o Wilmot ward (8South)
E3.2 Ordering, Storage & Handling of Potassium chloride 40mmol in sodium
chloride 0.9% 100ml
- This preparation will be supplied only to the listed clinical areas
- Stocks must never be transferred to any other clinical area, other than those listed
- This preparation must not be used in any other clinical area
- It must only be used for intravenous potassium supplementation when there is not a
suitable, commercially available dilute solution
- In the clinical areas above :
o Stocks will be supplied via the pharmacy distribution top-up service
o It is not available for use in any other clinical area and must not be transferred to
other clinical areas unless authorised by a pharmacist. (This must be discussed
with the on-call pharmacist in out-of-hours situations).
o It is not subject to Controlled Drug regulations
o It must be stored in lockable designated areas, separate from other intravenous
infusion fluids, in order to minimise the risks of inadvertent administration
- 87 -
E3.3 Administration of Potassium chloride 40mmol in sodium chloride 0.9%
100ml
- Infusion must be via a central venous catheter
- The maximum rate of administration should not exceed 20mmol potassium per hour
- Continuous ECG monitoring must be performed during the infusion
The use of ‘concentrated’ intravenous Potassium solutions outside of the
stipulated clinical areas or indications must be reported to the Principal
Pharmacist Patient Services or Chief Pharmacist as a ‘Clinical incident’ on the
relevant form
E4. Large volume IV infusions containing potassium
E4.1 Recommendations for use
General recommendations for the concentration, route and rate of administration of
potassium infusions
- 20mmol of potassium should usually be administered in at least 500ml of the
appropriate fluid
- The usual maximum rate of infusion of potassium is 20mmol per hour
- ECG monitoring is essential when administering more than 20mmols potassium/hour
to an adult or more than 0.5mmol/kg/hour to a child.
- Intravenous potassium solutions up to a concentration of 40mmols per litre can be
administered peripherally. (Potassium solutions more concentrated than this should
be administered via a central intravenous cannula)
- Pain or phlebitis may occur during administration of solutions containing 30mmol or
more of potassium per litre
- Administration of concentrations exceeding 40mmol/100ml over a period of less than
one hour poses a serious risk of serious adverse cardiac effects e.g. asystole
- All potassium infusions must be administered through an infusion pump
E4.2 Availability of large volume IV infusions containing potassium
The range of intravenous infusion solutions containing potassium that are available in the
trust is outlined in the table on page 119:
- Such solutions must be used for patients requiring intravenous potassium
supplementation in all circumstances in most clinical areas. The exceptions are
outlined in E2 and E3
- If a commercially manufactured preparation is available this should be used
whenever possible. Prescriptions should be written to enable the use of such premixed solutions and nursing staff should query prescriptions with prescribers where
this does not appear to be the case
- These solutions must be stored in a lockable storage area, separate from other
infusion fluids in clinical areas. This is to minimise the risk of inadvertent
administration of unnecessary potassium solutions
- Pharmacy should be contacted to obtain any of these fluids which may not be
ordinarily stocked in a specific clinical area. Outside normal working hours the on-call
pharmacist should be contacted for advice on how a particular infusion can be
obtained
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-
If the solutions listed are considered unsuitable for a particular patient, pharmacy
should be contacted for advice. Outside normal hours the on-call pharmacist should
be contacted
E4.3 Potassium containing infusion solutions stocked at Ealing Hospital NHS Trust
Fluid
Volume
(ml)
1000
1000
Potassium
(mmol)
20
40
Glucose 5% + potassium chloride 0.15%
Glucose 5% + potassium chloride 0.3%
1000
500
20
20
Sodium chloride 0.18% & Glucose 4% + potassium
chloride 0.15%
Sodium chloride 0.18% & Glucose 4% + potassium
chloride 0.3%
1000
20
1000
40
Glucose 10% + potassium chloride 0.15%
500
10
Glucose 2.5% & Sodium Chloride 0.45% + potassium
chloride 0.15%
500
10
Sodium chloride 0.9% + potassium chloride 0.15%
Sodium chloride 0.9% + potassium chloride 0.3%
N.B. It is acceptable for a proportion of a bag to be infused if the exact volume prescribed in
unavailable e.g. if a 500ml bag containing 10mmols potassium is required, 500ml of a
1000ml bag containing 20mmol may be used. Further advice can be obtained from
Medicines Information (ext 5303) in the pharmacy or outside normal working hours from the
on-call pharmacist.
E5. Training
The risks associated with the storage, prescribing, preparation and administration of
concentrated intravenous potassium chloride solutions must be included in:
o IV training days
o Nursing staff induction training, including agency / bank staff
o Medical staff induction training, including locum staff
o Pharmacy staff induction training, including locum staff
o Site Managers / Night Practitioners induction training
The medical, nursing and pharmacy professional leads have each nominated a lead person
to ensure appropriate delivery of this training.
For further reference see:
The Safe and secure handling of Potassium Chloride – NPSA Alert July 2002
- 89 -
F. CYTOTOXIC MEDICINES
Refer to full guidance in the EHT Cytotoxic Policy 2008(Current) which has been authorised
by the Chemotherapy Sub-group of the Drug and Therapeutics Group.
F1. Administration
F1.1 Main Routes
F1.1.1 Intravenous.
Three methods can be used; IV push, rapid IV infusion via a fast running drip, IV pumpcontrolled IV infusion. Administration may be via a peripheral line or a central venous
catheter
F1.1.2 Intramuscular
This technique is rarely used for the administration of cytotoxics. Methotrexate is the most
commonly prescribed drug by this route.
F1.1.3 Sub-cutaneous
Reserved for the least irritant drugs and small volumes e.g. methotrexate, asparaginase (not
a cytotoxic)
F1.1.4 Oral
Tablets, suspensions or solutions e.g. Methotrexate, Hydroxycarbamide, Cyclophosphamide,
Chlorambucil
F1.2 Other Routes
F1.2.1 Intrathecal
This involves the insertion of a needle into the lumbar region and the injection of the drug
through the dura and arachnoid into the sub-arachnoid space, thereby allowing direct access
to the CNS by drugs which normally only cross the blood-brain barrier in small amounts. The
only agents used are, cytarabine and methotrexate.
Drugs for intrathecal administration MUST be prescribed on the relevant intrathecal
chemotherapy prescription form. Intrathecal doses must be administered at different times
from other parenteral doses and in a designated location.
Refer to the Trust Intrathecals Policy for the full guidance.
F1.2.2 Intraperitoneal
Use reserved for treatment of tumours that have invaded the peritoneal lining. Agents that
have been used include: bleomycin, carboplatin, cisplatin, fluorouracil, mitomycin C,
mitoxantrone.
F1.2.3 Intravesical
This technique allows a high concentration of the antineoplastic agent to come into contact
with the urothelium in the bladder over a relatively long time. Typically, the agent is instilled
into the bladder through a urinary catheter, and retained for about 1 to 3 hours. Agents that
have been used include: doxorubicin, epirubicin, mitomycin C, mitoxantrone, BCG (not
cytotoxic)
- 90 -
F1.2.4 Intrapleural
This route can deliver drugs to a site where systemic penetration is poor. It can alleviate
symptoms of pleural disease associated with some malignancies. Agents which have been
used include: bleomycin, BCG, doxorubicin, mitoxantrone, mustine, and fluorouracil.
Other routes of administration can be used. Further information should be sought from
clinician/pharmacy if required.
The method of administration chosen will depend on a number of factors such as:
1. Site of intended action
2. Vesicant properties of drug
3. Potential for vein irritation
4. Potential for immediate or delayed complications of the drugs
5. Logistics of specific treatment protocol
6. Pharmaceutical considerations of stability and compatibility
F2. DOCUMENTATION
Documents for inclusion in the Cytotoxic Policy will be authorised by the Chemotherapy Subgroup of the Drug and Therapeutics Group after full consultation with all relevant parties e.g.
Cancer Board, Drug and Therapeutics Group of West London Cancer Network.
F2.1 Location
The master copy of the Cytotoxic Policy will be kept in the Pharmacy department, Technical
Services. There will be one complete copy in;
o Haematology Day Unit
o Wilmot ward (8S)
o Robert Dann unit (8N)
o Consultant Haematologist’s office
o Consultant Oncologist’s office
o Princess Amelia ward (10S)
o Charlie Chaplin ward (10N)
F2.1.1 Review
The whole document will be reviewed annually, and changes made to specific sections, as
required.
F2.2 Register of Chemotherapy Authorised Staff
The master copies of all registers are retained in the Pharmacy department.
Other copies are also available in:
o Haematology Day Unit
o 8S
o 8N
o 10S
o 10N
- 91 -
The list of registers kept is:
- Chemotherapy Prescribers
-
- Haematology
- Other
Parenteral Chemotherapy Administrators
- Medical
- Nursing
Intrathecal – Prescribers
Intrathecal – Dispensers
Intrathecal – Issuers
Intrathecal – Checkers
Intrathecal – Administrators
The Principal Pharmacist – Haematology/Oncology, as the Lead Trainer is responsible for
distribution of the most recent copy of each register to the designated areas, as delegated
by the Trust Designated Lead (Consultant Haematologist).
F2.2.1 Review
Each register will be reviewed annually, by the person listed below and the Trust Designated
Lead. (The Designated Lead has overall responsibility for induction, training and CPD related
to intrathecal chemotherapy)
Changes to the register can be made as below:
Register
1. Prescribers - Intrathecal
Authorise
Additions/Deletions
Lead Trainer
Annual review by
Haematology Consultant
2. Dispensers - Intrathecal
Principal
Pharmacist,Tech.Serv.
Chief Pharmacist
3. Issuers – Intrathecal
Lead Trainer
Chief Pharmacist
4. Checkers - Intrathecal
5. Administers - Intrathecal
Chemotherapy Nurse
Practitioner & Lead Trainer
Lead Trainer
Chemotherapy Nurse
Practitioner
Haematology Consultant
6. Chemotherapy prescribers
Lead Trainer
Haematology Consultant
7. Parenteral chemotherapy,
to administer
Chemotherapy Nurse
Practitioner & Lead Trainer
Haematology Consultant,
Chemotherapy Nurse
Practitioner
- 92 -
F3.
F3.1
-
CHEMOTHERAPY SUB-GROUP OF D&TG
Composition
Haematology Consultant
Oncology Consultant
Principal Pharmacist, Haem/Onc Lead
Chemotherapy Nurse Practitioner
F3.2
-
Functions
Review and authorisation of new chemotherapy and protocols, and production of
submission documents for Drug and Therapeutics Group, Division of Medicine,
Cancer Board and West London Cancer Network.
Review of Cytotoxic policies annually.
Production of new policies related to chemotherapy
F4.
F4.1
PRESCRIBING CHEMOTHERAPY
Cytotoxic drugs
This policy applies to all medication in BNF categories:
8.1.1
8.1.2
8.1.3
8.1.4
8.1.5
Busulphan, Carmustine, Chlorambucil, Mustine, Cyclophosphamide,
Estramustine, Ifosphamide, Lomustine, Melphalan, Thiotepa, Treosulfan
Aclarubicin, Bleomycin, Dactinomycin, Daunorubicin, Doxorubicin, Epirubicin,
Idarubicin, Mitomycin, Mitoxantrone
Capecitabine, Cladribine, Cytarabine, Fludarabine, Fluorouracil, Gemcitabine,
Mercaptopurine, Methotrexate, Raltritrexed, Tegafur +uracil,
Etoposide, Vinblastine, Vincristine, Vindesine, Vinorelbine
Amsacrine, Altretamine, Asparginase, Dacarbazine, Temozolamide, Hydroxyurea,
Pentostatin, Carboplatin, Cisplatin, Oxaliplatin, Porfimer, Procarbazine, Razoxane
This list is not exhaustive
F4.1.1 Who may prescribe Cytotoxic drugs for PARENTERAL administration
(includes IV, SC, IM)
- Haematology Consultants
- Oncology Consultants
- Rheumatology Consultants
- Dermatology Consultants
- Specialist Registrars, authorised at Ealing Hospital NHS Trust
They are responsible for the choice of protocol, accurate dosing, appropriate time intervals
being allowed between treatments, correct administration details and the evaluation of
whether the patient can safely be given treatment (e.g. bloods, U&Es, liver function)
F4.1.2 Who may prescribe Cytotoxic drugs for INTRATHECAL administration
- Haematology Consultants, authorised at Ealing Hospital NHS Trust
- Oncology Consultants, authorised at Ealing Hospital NHS Trust
- Specialist Registrars, authorised at Ealing Hospital NHS Trust
- 93 -
F4.1.3 Who may prescribe Cytotoxic drugs for INTRAVESICAL/INTRAPLEURAL
administration
- Consultants
- Specialist Registrars
Prescriptions on In-patient drug charts for oral Cytotoxic drugs must be signed,
by an Authorised prescriber, usually the Consultant.
When rewritten the new prescription must also be signed by the Authorised
prescriber. See Prescribing Oral Methotrexate pg. 130
F4.1.4 Who may prescribe Cytotoxic drugs for ORAL administration
- Consultants
- Specialist Registrars, authorised at Ealing Hospital NHS Trust
- Senior House Officers, authorised at Ealing Hospital NHS Trust
F4.1.5 Authorisation
Authorised Registrars or Senior House Officers will have attended the Chemotherapy training
session, as in F4.1.6 and received a certificate. Their names are included on the relevant
register of accredited prescribers. They are responsible for the choice of protocol, accurate
dosing, appropriate time intervals being allowed between treatment, correct administration
details and the evaluation of whether the patient can safely be given treatment (e.g. bloods,
U&Es, liver function)
- A junior house officer must NEVER prescribe cytotoxics.
- All prescriptions for cytotoxics must be written to the usual standards. They must
include patient’s name, address, DOB, dose, form and length of treatment. If another
team initiated the treatment, then specialist review must be sought from the clinical
team who were originally responsible for the patient’s therapy in order to check the
dose, frequency and duration of therapy. If possible written prescribing protocols
should be available for all oral cytotoxic regimes.
F4.1.6 Training Session
All new Medical staff who will be involved in the prescribing and / or administration of
chemotherapy, will receive the general induction training and will sign the log.
- To become accredited for prescribing and / or administering intrathecal
chemotherapy new Haematology/Oncology Consultants must, in addition, read the
National Guidance on the Safe Administration of Intrathecal Chemotherapy. New
Consultants should also familiarise themselves with the whole contents of the
Cytotoxic Policy and sign the log accordingly.
- Haematology/Oncology Registrars must fulfil the above requirements and complete
the general induction training satisfactorily before receiving a certificate accrediting
them to prescribe and / or administer chemotherapy.
- The Haematology Consultant will assess and give written confirmation of the
Registrar’s competence to administer intrathecal chemotherapy before their name
may be added to the registers for prescribing and administering them.
- Senior House Officers and House Officers CANNOT PRESCRIBE, DISPENSE, CHECK
OR ADMINISTER INTRATHECAL CHEMOTHERAPY, and are made aware of this during
the training program.
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-
F4.2
-
-
To remain on the register of accredited personnel, each doctor will read the National
Guidance on safe administration of intrathecal chemotherapy and Ealing Hospital
NHS Trust policy on Intrathecal chemotherapy ANNUALLY, and sign the log as
designated.
Protocols
A copy of all chemotherapy treatment protocols in use at Ealing Hospital NHS Trust
should be available in pharmacy.
If a treatment protocol is being used for the first time, a copy must be sent to
pharmacy with the initial prescription. Pharmacy staff will need to check the dose
against the protocol before dispensing the medication.
Any deviation from the standard protocol must be highlighted on the prescription,
with the reason given, and pharmacy informed. Deviations from the standard
protocol must be authorised by / confirmed with the consultant in charge of the case.
F4.3 Prescription Forms
Standard Chemotherapy Prescription forms are available.
(Contact Pharmacy for current list)
- Chemotherapy Prescription,General
- Fludarabine
- ABVD
- CHOP
- R-CHOP
- FMD
- VAD
- Etoposide mobilization
- Cyclophosphamide mobilization
- Intrathecal cytarabine
- Intrathecal methotrexate
F4.3.1 Parenteral chemotherapy
Parenteral chemotherapy should be prescribed on a Chemotherapy Prescription Form (see
the list)
ALL sections of the form MUST be completed so that the prescription can be accurately
checked before preparation of the drugs. Drugs will NOT be dispensed if details are missing.
This is a separate document from the usual in-patient chart
F4.3.2 Intrathecal chemotherapy
Intrathecal doses must be prescribed on either the Intrathecal Methotrexate or Cytarabine
Prescription Form
Intrathecal doses will not be issued from pharmacy until all parenteral chemotherapy doses
for the same day have been administered, and the signed Chemotherapy Prescription Form
confirming this has been received. See latest guidelines.
Reference to intrathecal doses must be noted on the Chemotherapy Prescription form in the
relevant section
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F4.3.3 Intravesical/intrapleural chemotherapy
Intravesical/intrapleural doses and adjuvant therapy should be prescribed on the
standard inpatient prescription chart
F4.4 Timing
- All requests for parenteral and intrathecal chemotherapy MUST be sent to Pharmacy
Technical Services (Ext. 5699) at least 24 hours prior to the planned administration.
This is to ensure that stock is available and allow time for it to be ordered in if
necessary.
- Courses of chemotherapy should be started so that dispensing and administration
can occur during normal working hours Monday to Friday, except in special
circumstances (see ‘Out of hours’ policy F4.5).
F4.5 Supply & Administration ‘Out of hours’ and at Weekends
- Whenever possible, chemotherapy courses should be prescribed and planned to allow
reconstitution and administration during normal working hours (Monday to Friday)
- Outside of normal pharmacy opening hours, the on-call pharmacist should be contacted
for advice (via switchboard) if a cytotoxic is requested. The Lead Haematology/Oncology
Pharmacist may need to be involved in the decision-making.
- The same applies at weekends, when only urgent requests from an authorised
consultant may be accepted.
- Intrathecal doses MUST be given during normal working hours, except in emergencies as
decided and prescribed by the Consultant Haematologist.
- The ‘Designated Lead’ must be informed of any intrathecal chemotherapy administered
out-of-hours and receive written justification for the departure from agreed practice.
F5. AUTHORISED LOCATIONS FOR ADMINISTRATION OF CHEMOTHERAPY
F5.1.1 Intravenous chemotherapy may only be administered in the following locations,
by authorised personnel
- Princess Amelia ward (10 South)
- Charlie Chaplin ward (10 North)
- Wilmot ward (8 South)
- Robert Dann Unit (8 North)
- Haematology Day Unit
- ITU
F5.1.2 Intrathecal chemotherapy may only be administered in the following locations, by
authorised personnel
- Wilmot ward (8 South)
- Haematology Day Unit, treatment room
F5.1.3 Subcutaneous and intramuscular chemotherapy
No specific locations, but must only be administered by authorised personnel.
F5.1.4 Intravesical/intrapleural chemotherapy
There are no specific locations.
F5.1.5 Oral or topical chemotherapy
There are no specific locations.
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F6 STORAGE AND TRANSPORTATION OF CYTOTOXICS
F6.1 Storage
- Prepared/dispensed doses will always be packed into a sealed outer package.
- All packages will be identified as cytotoxic by the yellow ‘CYTOTOXIC’ tape on it.
- Doses requiring refrigeration must be stored at the bottom of the fridge or in a
separate designated fridge. They should be placed inside a tray to avoid
contamination of the area in the event of a leak.
- Doses stored at room temperature must also be stored in a tray in a designated
location.
- Intrathecal doses will be stored in pharmacy in a designated box in the pharmacy
fridge, reserved for this purpose alone, until required for administration. Intrathecal
doses will not be stored in any other location. The dose will only be issued by an
authorised pharmacist to the doctor who will administer the dose, as per policy
07.03.01, AT A DIFFERENT TIME FROM ALL OTHER CHEMOTHERAPY DOSES.
- Oral/topical cytotoxic medication will have a label identifying them as such, whether
being sent to an in-patient ward or for outpatient use.
- There are no special storage requirements for these.
F6.2 Transport
- Parenteral chemotherapy doses prepared in pharmacy will normally be delivered to
the designated location by pharmacy staff who has received chemotherapy induction
training. They may also be collected from pharmacy by nursing unit staff who have
had chemotherapy induction training.
- Intrathecal chemotherapy doses may only be issued by a pharmacist authorised and
on the register, to a doctor authorised and on the register for administering
intrathecal chemotherapy.
- Oral/topical cytotoxics are treated as regular medication, for the purposes of
transportation.
F7 PHARMACY CYTOTOXIC RECONSTITUTION SERVICE
All requests for chemotherapy MUST be sent to Pharmacy Technical Services
(Ext. 5699) as far in advance as possible. This is to ensure that stock is available and allow
time for it to be ordered in if necessary. Courses of chemotherapy should be started so that
reconstitution and administration can occur during normal working hours Monday to Friday,
whenever possible.
F7.1 Hours
The Pharmacy Department provides a Cytotoxic Reconstitution Service Monday to Friday
9am to 3.30pm. If ordered during these hours, drugs may also be supplied for
administration at weekends and in the evenings depending on the stability of the requested
chemotherapy.
F7.2 Out of Hours
ALL doses of cytotoxic drugs required should be ordered from the Technical Services section
of the Pharmacy Department, extension 5699.
Outside of normal opening hours, if a cytotoxic is requested then the on-call pharmacist
should be called (via switchboard) to advise on how to proceed.
- 97 -
There is a very limited service available at the weekends for urgent requests only. This
should be discussed in advance with Pharmacy. Whenever possible, courses of
chemotherapy should be started so that reconstitution and administration can occur during
normal working hours.
There are very few occasions when chemotherapy will be required urgently.
F7.3 Preparation outside Pharmacy
Medical or nursing staff are not involved in the routine reconstitution of cytotoxic drugs. Very
occasionally, in extremely exceptional circumstances, it may be necessary for a dose of
chemotherapy to be prepared outside the pharmacy. If this happens, it is essential that this
is done safely - in order to protect the operator, the patient and the environment from
contamination with the drug and the drug from microbial contamination. In order for this to
be achieved the procedures detailed in ‘The Cytotoxics Policy’ must be followed fully.
F7.4 Pharmacy Information or Advice
Any queries regarding any aspect of cytotoxic therapy e.g. the dose, method of
administration or side-effects can be addressed either to the pharmacist in Pharmacy
Technical Services (Ext 5699) or to Medicines Information (Ext 5303, Bleep 215).
Out of hours the on-call pharmacist should be contacted via the hospital switchboard.
F8 SAFE HANDLING OF CYTOTOXIC DRUGS
F8.1 Handling of Cytotoxic Drugs at Ward Level
It is well recognised that most cytotoxic drugs are potentially hazardous to staff involved in
their handling and administration. This is due to:
- Local effects caused by direct contact with the skin, eyes or mucous membrane
- Potentially harmful long or short term effects due to inhalation, ingestion or injection
of the cytotoxic agents during preparation or administration.
- Women who are pregnant, breast-feeding or actively seeking pregnancy should not
be involved in the preparation or administration of cytotoxic drugs.
- It is also necessary to remember that patient’s body fluids also represent a potential
significant source of contamination to staff.
- All necessary measures must be taken to protect staff from occupational exposure.
The guidelines provided in ‘The Cytotoxics Policy’ give the information required to
achieve this
F8.2 Monitoring of staff handling Cytotoxic Drugs
- Staff members regularly involved in the preparation and administration of cytotoxics
should have a full blood count every 12 months. The Occupational Health department
will co-ordinate this.
- It is the responsibility of the managers of sections preparing and administering these
drugs to inform Occupational Health which staff members require monitoring.
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F9 SPILLAGE OF CYTOTOXIC DRUGS
F9.1 Equipment
The following items should be readily available, in the form of a ‘Cytotoxic Spill Kit’, in all
areas where cytotoxics are being handled and administered:
- disposable apron
- overshoes
- gloves (latex and PVC)
- surgical face mask
- safety goggles
- dedicated cytotoxic sharps bin
- paper towels
- sterile water
- sodium chloride 0.9% eye-wash
- plastic bags - labelled “cytotoxic waste - for incineration”
- sharps bin
- plastic tweezers
F9.2 Action in event of spillage
F9.2.1 All spills
In the event of a cytotoxic spillage the following procedure should be followed:
- Act immediately - do not leave spills to be cleared up later
- Ensure that all staff are aware of the spillage and therefore avoid inadvertent spread.
- Collect together the necessary equipment and put on protective clothing
- If there is a powder spill ensure that the face mask is worn
F9.2.2 Spillages on yourself or other people
- On clothing - remove the affected clothing as soon as possible and send to laundry
as “soiled linen”
- On skin - wash contaminated area liberally with soap and cold water
- In eyes - irrigate affected eye(s) with 0.9% sodium chloride Eye Wash and seek
medical advice immediately
- Report incident to Occupational Health
F9.2.3 Spillages on hard surfaces
- Put on surgical gloves, apron (and overshoes if necessary)
If the spillage is:o LIQUID - mop up liquids which have been spilled on hard surfaces with paper
towels and dispose of them in yellow “high risk” waste bags immediately and
label it as ‘Cytotoxic Waste’
o POWDER - put on surgical face mask to avoid inhalation as well as the rest of
the protective clothing. Wipe up powder spill carefully with well dampened
paper towels and dispose of them in yellow “high risk” waste bags
immediately
- Wash all hard surfaces well with copious amounts of cold, soapy water and dry well
with paper towels. All cloths and towels used should be placed in the plastic disposal
bag immediately after use.
F9.2.4 Spillages on bed linen
If spillage is on bed linen, change it immediately and send to laundry as “soiled linen”. The
mattress or pillow affected should be cleaned as for liquid spills on hard surfaces.
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F9.3 Incident Reporting
Any accident or spillage involving direct skin / eye contact with a cytotoxic drug must be
reported to Occupational Health Department through the Hospital’s Accident Report
Procedure.
F10 ORAL METHOTREXATE
Refer to: ‘The Cytotoxic prescribing policy’ and the ‘Methotrexate dispensing policy’ for
further information.
F10.1 Prescribing
To comply with the NPSA alert on oral Methotrexate and to prevent inappropriate daily
administration which is classed as a “Never Event” by the Department of Health, Hospital
Physicians need to ensure the following take place:
- All Consultants may prescribe oral methotrexate. They are all on the Trust Oral
Methotrexate Prescribing Register kept in pharmacy.
- Only Registrars (FY3) and above whose names are on the Trust Oral Methotrexate
Prescribing Register may prescribe oral methotrexate. This register will be updated
regularly to include staff new to the Trust.
- House Officers MUST NEVER prescribe cytotoxic drugs
1. Initiate prescribing of oral methotrexate, making sure that;
 the dose is written both in milligrams and number of 2.5mg or 10mg tablets to be
taken for each dose,
 it is emphasized that the dose must be taken WEEKLY, on the same day of
each week. For in-patients days when a dose is not to be administered
must be crossed out (X) on the prescription chart.
 this information is recorded in the patient-held monitoring and dosage record(PMDR)
card (available from pharmacy department).
2. Agree on shared care arrangements with the GP of the patient, for continuing supplies
and for routine monitoring.
3. Ensure patient is made aware of each point covered in the ‘Patient Information Leaflet’
(available from pharmacy department).
 Why it is being prescribed
 How to take the dose
 Safe handling
 Why regular bloods are needed
 Possible side effects
 Which symptoms to alert the doctor to.
4. Ensure that the patient has a PMDR card;
 With the correct dose recorded
 With the monitoring results updated and explained
5. Ask to see the PMDR card at every consultation or in-patient admission and update it on
discharge.
6. Enquire about side effects signs and symptoms
- 100 -
7. When patients present at the pharmacy department, all of the above points will be
reiterated and the PMDR card will be examined. If the patient does not have a card they will
be asked to go back to the clinic to have this remedied.
Patients admitted to hospital normally on oral methotrexate;
 Confirm the dose from patient-held monitoring and dosage record card.
 Only prescribe once confirmation has been received.
 Consider the reason for admission and whether the methotrexate should be withheld
during admission.
 Ensure that it is prescribed by a Registrar or above, on the drug chart and/or on the
TTA.
 Ensure that the dose is prescribed as WEEKLY, on the same day of each week on the
drug chart or TTA.
F10.2 Supply Process
See the Methotrexate Dispensing Policy for further information.
F10.2.1 Screening of Out-Patient Prescription
- Check Patient-held Dosage and Monitoring Record (PDMR) to confirm
o Dose
o Strength
o Frequency of dose (ONCE A WEEK)
- If patient does not have a PDMR ask them to return to the clinic doctor.
- Check that the prescription has been signed by an authorised prescriber (See F10.1)
- Assess individual patient needs
o Packaging
o Labeling
o PIL requirements.
- Patients may have reduced manual dexterity and larger containers, or ribbed easy-togrip lids may reduce the likelihood of patients decanting the tablets into an
unsuitable container once at home
- The strength of tablet supplied to the patient must remain consistent to prevent any
confusion for the patient over the number of tablets they need to take
- Confirm with patient that they have had a recent blood test.
- Endorse prescription with specific information required for dispensing, gained from
consultation with patient (e.g. tablet strength must be specified).
F10.2.2 Screening of In-Patient Prescriptions
The Ward pharmacist must carry out a thorough drug history with the patient
- Check the Patient-held Dosage and Monitoring Record (PDMR) to confirm dose,
strength and frequency (including day of the week) of methotrexate. If the patient
has not brought their PDMR into hospital with them, the pharmacist should ask for it
to be brought into hospital.
- Confirm dose, tablet strength and frequency from at least two different sources if
PDMR is not available e.g. patient, GP, community pharmacist, out-patient clinic etc.
- Doses may change according to blood test results and thus it is imperative that the
most recent information regarding dosage is obtained.
- 101 -
-
-
Document dose, tablet strength, frequency and any other important information on
the front of the drug chart, along with the source of the information
Appropriate endorsements must be made inside the drug chart against any
prescribed methotrexate, including a ‘cytotoxic’ warning for nursing staff.
Days were methotrexate is not to be administered should be crossed off (X).
Ward pharmacists should be vigilant of methotrexate patients presenting with signs
of methotrexate toxicity or intolerance e.g. breathlessness, dry persistent cough,
vomiting or diarrhoea
In-patient supplies for oral methotrexate should be made either on the day before or
on the morning the dose is due. This should be done on a weekly basis with only
enough tablets for one dose supplied.
F10.2.3 TTA Supply on Discharge
- Ward pharmacists must ensure that the dose, tablet strength and frequency
(including day of the week) are all specified for methotrexate TTAs.
- If the TTA is sent to Dispensary the pharmacist must check that the drug history
section on the front of the drug chart is complete (it is not practical for the PDMR to
be sent to pharmacy with the drug chart, but the pharmacist must be sure that
thorough checks have been made by the ward pharmacist). If the drug history
section on the front of the drug chart is not complete then the dispensary pharmacist
will not know if the PDMR has been checked on admission. The ward pharmacist
should be asked to check this and screen the TTA personally before the methotrexate
on the TTA can be dispensed.
- Clinically screen prescription in the usual way, checking the entry for methotrexate
against the entry inside the drug chart and finally, check that this correlates with the
information on the front of the drug chart. Any discrepancies should be queried with
the prescribing doctor.
- Endorse details regarding dose, tablet strength and frequency (including day of the
week) of oral methotrexate on the TTA.
- Four weeks supply will be given unless otherwise specified.
F10.2.4 Labeling
- Standardise dosing instructions as follows
o Methotrexate tablets 2.5mg
Take 2.5mg (one tablet) ONCE a week on X day
Take 5mg (two tablets) ONCE a week on X day.
o Methotrexate tablets 10mg
Take 10mg (one tablet) ONCE a week on X day
- For all oral methotrexate products this caution will appear on the computer screen:
tablets usually taken ONCE A WEEK as a single dose, use this as an additional
warning on the label.
Warning: Methotrexate is a Cytotoxic.
Handle tablets carefully (disposable gloves are available) and use only
designated ‘Cytotoxic’ counting triangle and tweezers.
Wash equipment after use.
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F10.2.5 Dispensing
- Check label against prescription. Dispense from prescription, not label.
- Ensure additional instructions are followed regarding suitable containers etc.(see
10.2.1)
- Ensure that packaging of oral methotrexate is different to folic acid (if prescribed)
e.g. blister pack and bottle or highlight methotrexate drug name and frequency on
label. (Both methotrexate 2.5mg tablets and folic acid are round yellow tablets)
- Include suitable PIL.
F10.2.6 Checking
- TWO final checks of dispensing are required
- Dispenser to check as per usual checking procedure taking note of any additional
instructions on prescription
- Second check of dispensing must be carried out by accredited checking technician or
pharmacist as per usual checking procedure
F10.2.7 Counselling
- Counselling of In-Patients by the Ward pharmacist should occur before the patient is
ready for discharge. Further counselling by the ward pharmacist or nurse should
occur at the point of discharge.
- Handing out of oral methotrexate, in the dispensary, must only be carried out only by
a senior technician or pharmacist familiar with this procedure and the use of oral
methotrexate.
- Identity of patient must be ascertained by matching docket to that on the
prescription or wrist band. Name and address or date of birth must be asked for as
final confirmation.
- Check PDMR card against prescription to confirm correct dosage and tablet strength
have been issued. Ask patient to carry their PDMR with them and ensure that their
doctor, pharmacist and dentist know that they take methotrexate.
- Check if patient has taken methotrexate before and knows how to take it.
- Discuss dosage and tablet strengths for both methotrexate and folic acid if
prescribed.
- Ask if the patient takes any other medication – check for interactions.
- Confirm that patient understands rationale for use of methotrexate and possible sideeffects (use PDMR as aide memoire if necessary).
- In particular tell patient to report signs of:
o infection e.g. sore throat,
o bleeding / bruising (signs of blood dyscrasias / bone marrow damage)
o breathlessness, cough or fever (signs of pulmonary toxicity)
- Advise patient to take the methotrexate after food.
- Issue appropriate PIL.
Warning: Methotrexate is a Cytotoxic.
Handle tablets carefully (disposable gloves are available) and use only
designated ‘Cytotoxic’ counting triangle and tweezers.
Wash equipment after use.
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G REPORTING ADVERSE REACTIONS TO MEDICATION
If a patient suffers a suspected adverse reaction to a medicine it should be reported
immediately to the Consultant responsible for the patient.
If there has been any detrimental effect on the patient a Clinical incident form should also be
completed and it is recommended a Yellow Card is also completed and forwarded to the
MCA
- The Yellow Card Adverse Drug Reaction (ADR) Reporting Scheme is a voluntary
scheme through which doctors, pharmacists, nurses, AHPs and patients notify the
Medicines Control Agency (MCA) / Committee on the Safety of Medicines (CSM) of
suspected adverse drug reactions. The Yellow Card is found in the back of the BNF &
BNF-C or online on the web BNF at
http://www.bnf.org/bnf/bnf/current/openat/0.htm
- 104 -
9.
ERRORS IN ADMINISTRATION OR CUSTODY OF MEDICINES
A. DEALING WITH MEDICINES ERRORS
Medicines errors may occur for a variety of reasons. As part of providing high quality care
and managing risk, it is essential that all medicines incidents and near misses are reported in
line with the Trust’s Incident and Near Miss Reporting Policy. This includes omission of doses
and loss of any medication previously supplied.
The accurate reporting of incidents will aid the detection of patterns or types of errors to
which there may be an easy solution. An annual report of incidents will be prepared for the
Trust Boards.
- The person identifying the error should
o Immediately report it to a senior member of staff (if appropriate)
- The senior member of staff should
o Identify the nature of the error
o Identify possible adverse effects
o Take all immediate action necessary to ensure the patient's safety is
maintained
o Complete a Clinical incident report form (or Medicines Incident report form)
and forward to the designated person in the Clinical area within 24 hours,
who will lead an investigation
o Send a copy of the completed form to the Chief Pharmacist and Clinical
Governance for recording and follow up
B. CHANGING NAMES FROM BANs TO rINNs
Some errors occur due to the drug name not being written clearly or spelt correctly. Some
drugs have changed their names and this may be a cause of error. The following is a list of
medicinal substances for which the British Approved Names (BANs) have been changed to
match the corresponding recommended International Non-Proprietary Names (rINNs). These
changes were published in the ‘British Pharmacopoeia 2003’, which became effective on 1
December 2003. BANs have been changed to match rINNs where the names differ to
achieve consistency in the names of medicines available in the UK and ensure compliance
with EC legislation.
Former BAN
Acrosoxacin
Amethocaine
Amoxycillin
Amylobarbitone
Amylobarbitone sodium
Beclomethasone
Bendrofluazide
Benorylate
Benzhexol
Benztropine
Busulphan
Butobarbitone
Carticaine
New BAN (rINN)
Rosoxacin
Tetracaine
Amoxicillin
Amobarbital
Amobarbital sodium
Beclometasone
Bendroflumethiazide
Benorilate
Trihexyphenidyl
Benzatropine
Busulfan
Butobarbital
Articaine
- 105 -
Cephalexin
Cephamandole Nafate
Cephazolin
Cephradine
Chloral betaine
Chlorbutol
Chlormethiazole
Chlorpheniramine
Chlorthalidone
Cholecalciferol
Cholestyramine
Clomiphene
Colistin Sulphomethate Sodium
Corticotrophin
Cyclosporin
Cysteamine
Danthron
Desoxymethasone
Dexamphetamine
Dibromopropamidine
Dicyclomine
Dienoestrol
Dimethicone(s)
Dimethyl sulphoxide
Dothiepin
Doxycycline Hydrochloride (Hemihydrate
Hemiethanolate)
Eformoterol
Ethamsylate
Ethinyloestradiol
Ethynodiol
Flumethasone
Flupenthixol
Flurandrenolone
Frusemide
Gestronol
Guaiphenesin
Hexachlorophane
Hexamine Hippurate
Hydroxyurea
Indomethacin
Lignocaine
Lysuride
Methimazole
Cefalexin
Cefamandole Nafate
Cefazolin
Cefradine
Cloral betaine
Chlorobutanol
Clomethiazole
Chlorphenamine
Chlortalidone
Colecalciferol
Colestyramine
Clomifene
Colistimethate Sodium
Corticotropin
Ciclosporin
Mercaptamine
Dantron
Desoximetasone
Dexamfetamine
Dibrompropamidine
Dicycloverine
Dienestrol
Dimeticone
Dimethyl sulfoxide
Dosulepin
Doxycycline Hyclate
Formoterol
Etamsylate
Ethinylestradiol
Etynodiol
Flumetasone
Flupentixol
Fludroxycortide
Furosemide
Gestonorone
Guaifenesin
Hexachlorophene
Methenamine Hippurate
Hydroxycarbamide
Indometacin
Lidocaine
Lisuride
Thiamazole
- 106 -
Methotrimeprazine
Methyl Cysteine
Methylene Blue
Mitozantrone
Mustine
Nicoumalone
Oestradiol
Oestriol
Oestrone
Oxpentifylline
Phenobarbitone
Pipothiazine
Polyhexanide
Potassium Clorazepate
Pramoxine
Procaine Penicillin
Prothionamide
Quinalbarbitone
Riboflavine
Salcatonin
Sodium Calciumedetate
Sodium Cromoglycate
Sodium Ironedetate
Sodium Picosulphate
Sorbitan Monostearate
Stibocaptate
Stilboestrol
Sulphacetamide
Sulphadiazine
Sulphamethoxazole
Sulphapyridine
Sulphasalazine
Sulphathiazole
Sulphinpyrazone
Tetracosactrin
Thiabendazole
Thioguanine
Thiopentone
Thymoxamine
Thyroxine Sodium
Tribavirin
Trimeprazine
Urofollitrophin
Levomepromazine
Mecysteine
Methylthioninium Chloride
Mitoxantrone
Chlormethine
Acenocoumarol
Estradiol
Estriol
Estrone
Pentoxifylline
Phenobarbital
Pipotiazine
Polihexanide
Dipotassium Clorazepate
Pramocaine
Procaine Benzylpenicillin
Protionamide
Secobarbital
Riboflavin
Calcitonin (salmon)
Sodium Calcium Edetate
Sodium Cromoglicate
Sodium Feredetate
Sodium Picosulfate
Sorbitan Stearate
Sodium Stibocaptate
Diethylstilbestrol
Sulfacetamide
Sulfadiazine
Sulfamethoxazole
Sulfapyridine
Sulfasalazine
Sulfathiazole
Sulfinpyrazone
Tetracosactide
Tiabendazole
Tioguanine
Thiopental
Moxisylyte
Levothyroxine Sodium
Ribavirin
Alimemazine
Urofollitropin
- 107 -
All drugs which have changed their names will now be labelled with the new name. Some
presentations/packaging may show both names.
- 108 -
10.
MEDICINES DEFECTS
A. 24 HOUR RECALL PROCEDURE FOR DEFECTIVE MEDICINAL PRODUCTS
A1. Procedure for recalling a suspected defective medicine
London Regional Health Authority, Pharmaceutical Service operates a 24 hour recall system
for defective medicinal products. All recalls are coordinated through the Regional Quality
Control Laboratory. They disseminate the information to all hospital pharmacies in the
Region using a cascade system.
- On receipt of a recall alert, Pharmacy staff must follow an agreed procedure which
determines:
o the urgency of the recall
o whether the medicinal product is or has been stocked in the pharmacy
o where the drug may have been issued to.
- If the medicine is in use in any of the ward/clinical areas, pharmacy staff will contact
all ward/clinical areas to ensure completion of the action required by the recall alert
In cases where information needs to reach health professionals especially quickly, the
Chief Medical Officer (CMO) issues urgent advice electronically via the 'Public Health Link
System'. There may be useful information on current and previous medicines defects
available on www.dh.gov.uk
A2. Procedure for reporting a suspected medicine defect
- On identification of a suspected medicine defect, all medical, nursing and paramedical
staff must report it to the most senior pharmacist on site, as soon as practical
- Ensure that whatever remains of the medicine / medical device in question and
packaging, is retained and returned to pharmacy. This will preserve evidence for
future need as enquiries progress.
- Complete a clinical incident reporting form giving full details of what happened and
who was involved and affected.
o to distinguish events caused by defective products from those due to adverse
drug reactions, accidents or errors
o to differentiate between events relating to medicinal products from those
relating to non-medicinal plant, and equipment, and medical and non-medical
supplies
- Discontinue use of batch of medicine in question unless advised otherwise, to prevent
the use of a defective or possibly defective medicinal product and if samples are
required for analysis or other purposes, they should ideally be obtained from another
part of the same batch
- The pharmacist will require as much information about the defect as possible to allow
a full assessment of the seriousness of the defect and what is to be reported. When
reporting a serious defect, it is important to report it to the MHRA as soon as possible
and there must be sufficient detail to determine if national action is be required.
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POLICY FOR DISSEMINATION
Medicines Policy
Ealing Hospital NHS Trust
April 2009
Who should read the objectives of this policy/procedure
 All staff who are involved with the prescribing, handling or administration
of medicines
The objectives of this policy/procedure are
 To ensure that all medicines are dealt with in a legal, ethical and safe
manner
Director responsible for ensuring this document is implemented
 Chief Pharmacist / ADO CLINICAL SUPPORT SERVICES
 MEDCAL DIRECTOR
For further information contact
 Drugs and Therapeutics Group
 Medicines Information - Pharmacy
The formal/legal documents forming the basis of this document are:
 Duthie Report (Revised March 2005)
 Medicines Act
 Misuse of Drugs Act
 NMC
 RPSGB Medicines, Ethics and Practice
Training and communication plan:
Communication to:
 Chief Executive
 All Executive Directors
 All Assistant Directors
 All Medical Consultants
 All Ward/Clinical Departmental Managers
Training for all staff as a workshop style seminar
Equal Opportunities statement:
This policy / procedure has been developed taking the following points into
account:

Promotion of good relations between people of different racial groups

Elimination of unlawful discrimination based on someone’s race, gender or
disability

Elimination of all other forms of discrimination such as age, marital status
or sexual orientation promotion of equality of opportunity
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Appendix 1
Verbal prescription orders at Meadow House
There is a list of drugs on the Meadow House chart which may be administered by
designated nurses after a verbal order from a Medical practitioner if required out of hours.
The standard list of medicines (located at the top of the last page on the chart) needs to be
checked and signed by a doctor at admission or if there is a possibility the drugs may be
required in the near future. This list must be signed before any of the drugs can be
administered. Any of the medicines not appropriate for the patient should be crossed off the
list at this time.
There are two lists of medicines. The first where a Single dose of the drug may be given and
the second, where up to 3 doses can be given at different times.
In extreme circumstances, single doses of drugs which are not prescribed may be given
against a verbal order. The verbal order must be confirmed by a faxed note (containing
patient details, dose and drug details and the prescribers’ signature) which must be referred
to at the time of administration. The faxed note should be kept in the patients records. The
administration should be recorded on the drug chart by the prescriber as soon as possible.
Controlled drugs may not be prescribed by a verbal order under any
circumstances.
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Appendix 2
GP referral letter
EALING HOSPITAL NHS TRUST
Uxbridge Road, Southall, Middlesex UB1 3HW Tel: 020 8967 5000
To the patient
THIS IS NOT A PRESCRIPTION
PLEASE TAKE THIS LETTER TO YOUR GP
He/she will write a prescription for you in the normal way. The treatment does not need to be
started immediately so you do not need to call out the doctor for this or seek an urgent appointment.
Date
_____________________________
Dear Doctor
_____________________________
Re: Patient
__________________________________ Date of Birth ____________
Address
__________________________________ Unit No:
____________
___________________________________
___________________________________ Clinic
____________
Thank you for referring this patient, who was seen in clinic today. This note is sent to avoid delay in
essential information reaching you and to request that you prescribe the medication recommended
below:
The diagnosis / clinical impression is:
__________________________________________________________________________
__________________________________________________________________________
I recommend the following treatment (PLEASE PRINT CLEARLY)
MEDICATION
DOSAGE & FREQUENCY
DURATION
PLEASE NOTE: Only medication from the Ealing Formulary can be recommended with this
form.
Thank you for your co-operation
Yours sincerely
Signature of Hospital Clinician _____________________________________
PRINT NAME
Bleep or Hospital Extension
_________________________________________
_________________________________________
Updated Feb 2006
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Appendix 3
NWL Red List version 25; 6.12.13
Ensure you are using the most recent version. See Trust Intranet
North West London Red List
Medicines that Hospital Doctors should not ask GPs to prescribe
1.0 Background
Hospital New Drugs Panels or Drug and Therapeutics Committees (NDP or D&TC) consider
published evidence on the effectiveness of a new medicine and its cost-effectiveness before
deciding whether to add it to the hospital’s formulary. All such committees in North West
London (NWL) have representation from local Clinical Care Groups (CCGs). When a medicine
is added to a hospital formulary, the committee will also consider whether it is reasonable
for a hospital doctor to ask a GP to prescribe the medicine, or whether it should be added to
the red list.
The NWL Medicines Management Pharmacy Network (NWLMMPN) is a network of Clinical
Commissioning Group/ Commissioning Support Unit Senior Pharmacists from NWL, Acute
and Mental Health Trust Chief Pharmacists from all Trusts in NWL and Community Health
Care Pharmacists representatives from NWL. It meets at least 4 times a year to provide a
mechanism for formal liaison in order:
 To work together to improve prescribing of medicines at the interface between
primary, secondary/tertiary care and be involved in service redesign.
 To share ideas on cost improvement programmes (CIP) for drugs and QIPP plans
 To share information about the managed entry of new drugs To keep all parties
informed and aligned with regard to prescribing priorities and local policies for
primary and secondary care
 To respond to NHS policies including NICE guidance that affect prescribing and
medicines management across the interface
 To identify ways of improving medicines management in both sectors
 To maintain the North West London red list and shared care tracker and make
recommendations to the NWLIF NDP and to Trust New Drugs Panels
 To share information on medicines expenditure
 To share ideas on cost improvement programmes (CIP) for drugs/QIPP.
The NWLMMPN has an advisory role on whether medicines are suitable for addition to or
removal from the ‘red list’ and makes recommendations to the relevant decision making
bodies.
2.0 Criteria for adding a medicine to or removing from the red list:




The following criteria are used by NDPs, D&TCs and the NWLMMPN in deciding
whether a change to the red list should be made:
Safe or effective use of the medicine, throughout its use, requires expertise or
facilities that a GP will not normally have.
Medicines added to the red list will normally be ‘specialist medicines’ that a GP will
see infrequently.
Relevant changes to a medicine’s licensing or to national policy (e.g. NICE guidance).
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PART A: Red list
GPs should not be asked to take on the prescribing of any of the following drugs. It relates
to all formulations unless a specific formulation is given.
BNF
BNF Section Title
Generic Name
Section
2.1.2
Phosphodiesterase
Enoximone, milrinone
inhibitors
2.5.1
Vasodilator
Ambrisentan, bosentan, iloprost, sildenafil,
antihypertensive drugs
sitaxentan, tadalafil
2.8.1
Parenteral anticoagulants
Dalteparin sodium, enoxaparin sodium,
tinzaparin sodium, bivalirudin,
epoprostenol, fondaparinux
2.10.2
Fibrinolytic drugs
Alteplase, reteplase, streptokinase,
tenecteplase, urokinase
3.3.3
Phosphodiesterase type-4
Roflumilast
inhibitors
3.4.2
Allergen immunotherapy
Grass pollen extract (Grazax®),
omalizumab,
3.4.3
Allergic emergencies
C1-Esterase inhibitor, conestat alfa,
icatibant
4.1.1
Hypnotics
Sodium oxybate
4.2.1
Antipsychotic drugs
Clozapine
4.6
Drugs used in nausea and
vertigo
Control of epilepsy
Nabilone
Apomorphine
5.1
Dopaminergic drugs used
in parkinsonism
Drugs used in essential
tremor, chorea, tics and
related disorders
Antibacterial drugs
5.1.7
5.2
5.3.1
Other antibacterials
Antifungal drugs
HIV infection
5.3.2.2
Cytomegalovirus
5.3.3
Viral hepatitis
4.8.1
4.9.1
4.9.3
Rufinamide
Botulinum toxins type A and B
All IV antibacterials (or according to
locally agreed primary care services –
contact your local CCG for further
information)
Linezolid
Posaconazole, voriconazole, IV antifungals
All antiretroviral drugs for
treatment/prophylaxis of HIV infection
Lamivudine (for chronic hep B)
Cidofovir, ganciclovir, foscarnet,
valganciclovir
Adefovir, boceprevir, entecavir, interferon
alpha, peginterferon alfa, ribavirin
,lamivudine, telaprevir, telbivudine,
tenofovir
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5.3.5
Respiratory syncytical virus
Palivizumab, ribavirin
5.4.8
Drugs for pneumocystis
pneumonia
Hypothalamic and anterior
pituitary hormones and
anti-oestrogens
Corifollitropin alfa,
follitropin alfa and beta,
human menopausal
gonadotrophins, lutropin
alfa, urofollitrophin
Pegvisomant
Pentamidine
Calcitonin and parathyroid
hormone
Bisphosphonates and other
drugs affecting bone
metabolism
Drugs affecting
gonadotrophins
Teriparatide
6.7.4
Somatomedins
Mecasermin
7.4.5
Drugs for Erectile
Dysfunction
8.1
Cytotoxic Drugs
8.2.1
Antiproliferative
immunosuppressants
Corticosteroids and other
immunosuppressants
Alprostadil, apomorphine, sildenafil,
tadalafil, vardenafil (unless for indications
in Schedule 2).
Oncology use of all I.V, intracavitary and
oral cytotoxics; all use if injectables
Mycophenolate mofetil
6.5.1
Infertility
treatments
Growth
hormone
receptor
antagonists
6.6.1
6.6.2
6.7.2
8.2.2
Chorionic gonadotropin,
choriogonadotropin alfa
Disodium pamidronate, ibandronic acid
(injection), zoledronic acid
Cetrorelix, ganirelix
Basiliximab, belatacept, ciclosporin,
sirolimus, tacrolimus
8.2.3
Rituximab and
alemtuzumab
Alemtuzumab, ofatumumab, rituximab
8.2.4
Other immunomodulating
drugs
Interferon alfa, peginterferon alfa,
interferon beta, interferon gamma,
aldesleukin, BCG bladder installation,
canakinumab, fingolimod, glatiramer,
histamine, lenalidomide, thalidomide,
mifamurtide, natalizumab
8.3.4
Hormone Antagonists
Fulvestrant
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9.1.3
Drugs used in hypoplastic,
haemolytic, and renal
anaemias
Darbepoetin alfa, epoetin alpha, beta,
theta and zeta, methoxy polyethylene
glycol-epoetin beta, deferasirox,
deferiprone, desferrioxamine, eculizumab
9.1.4
Drugs used in platelet
disorders
Drugs used in neutropenia
Eltrombopag, romiplostim, anagrelide
9.1.7
Drugs used to mobilise
stem cells
Plerixafor
9.4.1
Foods for special diets
Saproterin dihydrochloride
9.5.1.2
Hypercalcaemia and
hypercalciuria
9.8.1
Drugs Used in metabolic
disorders
9.8.2
Acute porphyrias
Cinacalcet (secondary
hyperparathyroidism in patients with endstage renal disease)
Agalsidase alfa and beta, imiglucerase,
velaglucerase alpha, galsulfase,
idursulfase, laronidase, mercaptamine,
algucosidase alpha, nitisinone, carglumic
acid, sodium phenylbutyrate, betaine,
miglustat
Haem arginate
10.1.3
Drugs that suppress the
rheumatic disease process
10.2.1
Drugs that enhance
neuromuscular
transmission
Tetrahydrocannabinol/cann
abidiol
9.1.6
10.2.2
Filgrastim, lenograstim, pegfilgrastim
Abatacept, adalimumab, anakinra,
belimumab, certolizumab, etanercept,
golimumab, infliximab, leflunomide,
methotrexate injections, tocilizumab
Amifampridine, fampridine
Sativex
11.4.1
Corticosteroids
Dexamethasone intravitreal implant
11.8.2
Ocular diagnostic and perioperative preparations and
photodynamic treatment
Aflibercept, ranibizumab, pegaptanib,
verteporfin, bevacizumab (unlicensed
indication)
13.5.1
13.5.2
13.5.3
Alitretinoin
Acitretin
Ustekinumab
13.6.2
Preparations for eczema
Preparations for psoriasis
Drugs affecting the
immune response
Oral preparations for acne
14.5
N/A
Immunoglobulins
Anabolic steroid
Normal immunoglobulin
Oxandrolone (not in BNF)
Isotretinoin
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Template Request for the North West London Medicines Management
Pharmacy Network to Consider Adding a Medicine to the ‘Red List’ of Medicines
The following criteria are used to decide whether a change to the red list should be made:
Criteria for adding a medicine to the red list
 Safe or effective use of the medicine, throughout its use, requires expertise or
facilities that a GP will not normally have.
 Medicines added to the red list will normally be ‘specialist medicines’ that a GP will
see infrequently.
 Relevant changes to a medicine’s licensing or to national policy (e.g. NICE guidance).
Criteria for removing a medicine from the red list
 Guidance from NICE states that it is reasonable for GPs to prescribe the medicine,
perhaps in the context of a shared care agreement.
 New trial evidence or a change in licence has made the medicine easier to use than
at the time it was added to the red list (e.g. by demonstrating that less monitoring is
needed than previously thought).
A medicine will not be added to the red list:
If, although the medicine should only be initiated by a hospital specialist, it is reasonable for
a GP to continue to prescribe it once the patient and treatment are stable (e.g. monitoring,
dose changes and stopping treatment require no specialist expertise or facilities).
Simply because it is expensive, if the criterion for adding a medicine to the red list (above) is
not met.
-
Name of medicine
Presentation
Indication
Specialist expertise needed to prescribe safely
Special facilities required to prescribe safely
Details of recent change to license or national
policy
Form completed by
Date of completion
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