Download CLMM015 Medicines In The Radiology And Diagnostics Departments

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
MEDICINES POLICY: CODE OF PRACTICE
MEDICINES IN RADIOLOGY –INTERVENTIONAL AND DIAGNOSTIC
DEPARTMENTS
Reference
Approving Body
Date Approved
Implementation Date
Version
Summary of Changes from
Previous Version
Supersedes
Consultation Undertaken
Date of Completion of
Equality Impact Assessment
Date of Completion of We
Are Here for You
Assessment
CL/MM/015
Directors’ Group
30 June 2015
30 June 2015
4
Change in authorisation process within
Diagnostic radiology.
Medicines in the radiology and diagnostic
departments CLMM015 Version 3 April 2012
Clinical Director, Associate Clinical Director
for Diagnostics, Modality managers and
Clinical Leads for MRI, CT and Intervention,
Clinical Lead for MSK and Intervention,
Matron and Lead Nurse in Intervention.
28/4/2015
28/04/2015
28/04/2015
Date of Environmental
Impact Assessment (if
applicable)
Legal and/or Accreditation
Implications
Target Audience
28/04/2015
Review Date
May 2018
Lead Executive
Medical Director
ISAS Radiology Accreditation Ready
This policy applies to whole of the Radiology
Department in the Trust excluding Medical
Physics.
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Chief Operating Officer
Author/Lead Manager
Mo Rahman
Head of Pharmacy and Clinical Director for
Medicines Management
Ext 61199
Further Guidance/Information Jagrit Shah
Consultant Neuroradiologist and Head &
Neck Radiologist
Extension: 61949
Shashi Gupta
Specialist Pharmacist
Extension:67622
Sonia Gilmore
Medicines Management pharmacist,
professional sec to MMC
Extension 59374
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CONTENTS
Paragraph
Title
1.
2.
3.
4.
5.
6.
6.1
6.2
4
4
5
5
5
6
6
8
Appendix 1
Introduction
Executive Summary
Policy Statement
Definitions (including Glossary as needed)
Roles and Responsibilities
Policy and/or Procedural Requirements
Specialist professional groups
Prescribing and authorisation for
administration of medicines
Training, Implementation and Resources
Impact Assessments
Monitoring Matrix
Relevant Legislation, National Guidance
and Associated NUH Documents
Equality Impact Assessment
Appendix 2
Environmental Impact Assessment
16
Appendix 3
Appendix 4
Here For You Assessment
Certification Of Employee Awareness
18
20
7.
8.
9.
10.
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1.0
Introduction
1.1
This policy applies to whole of the Radiology Department in the Trust
excluding Medical Physics.
All staff that use and are responsible for medicines in these areas
must incorporate the principles of safe and secure custody and use
of medicines as defined in the Medicines Code of Practice with any
additional policy for the safe use of specific types of substances (e.g.
radioisotopes)
The Trust CL/MM/006 Prescribing policy should be followed.
However some of the processes in Radiology are different, for these
processes, local policy should be followed as described below.
2.0
Executive Summary
2.1
Radiology is split into two categories Diagnostic and Interventional
radiology sections both of which must have a system of procedures
to ensure the safety and security of medicines stored and used in
these areas.
Diagnostic sections include:




CT
MRI
Ultrasound
Plain film service
Interventional Radiology Section includes the following procedures
carried out in the Theatre setting:



Vascular intervention
Neuro intervention
General body intervention
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3.0
Policy Statement
3.1
The Trust supports the safe use (prescribing, supply, administration
and storage) of all medicinal products. The measures outlined in the
policy below must be adhered to by all staff in order that potential
harm to patients is minimised.
4.0
Definitions
4.1
Medicinal products as defined under the Medicines Act and other
legislation. This definition of medicines includes contrast media,
isotopes and other diagnostic agents which enter a patient’s body by
any route for a physical or pharmaceutical effect.
5.0
Roles and Responsibilities
5.1
Committees
5.1.1 Medicines management committee- responsible for ensuring
that this policy is in place and up to date
5.2
Individual Officers
5.2.1 The Chief Pharmacist and the Clinical Director of the Radiology
and Diagnostics Department have executive responsibility for
establishing and maintaining a system for the security of medicines.
This responsibility may be delegated to the Section Manager,
medical, nursing, professional and technical staff as appropriate.
5.2.2 The Appointed Practitioner in Charge of the Department
(Matron in Interventional Theatres, Lead Nurse in MRI and
Superintendent/Modality Manager in other diagnostic sections) at any
given time shall have the responsibility for ensuring that the system is
followed and that the security of medicines in the Department is
maintained.
The Appointed Nurse or Practitioner in Charge is responsible for
ensuring that checks of the Controlled Drug stocks and records are
made on each working day. For all details regarding Controlled Drug
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management refer to section 12 of this Medicines Code of Practice
(CLMM012)
The Appointed Practitioner in Charge and Designated Practitioner in
Charge (Nurse in charge or Superintendent Radiographer) are
responsible for:




Ordering medicines.
Receiving, checking and recording stock from Pharmacy
Ensuring the stock is stored securely.
Holding medicine cupboard (including Controlled Drug
cupboard) keys.
5.2.3 Individual practitioners must ensure they are familiar with this
policy
6.0
Policy and/or Procedural Requirements
6.1
SPECIALIST PROFESSIONAL GROUPS
6.1.1 Operating department practitioners (ODPs) working within
interventional radiology / theatres
A registered ODP must be registered with the Health and Care
Professions Council. ODPs will be included under the term
‘practitioner’ throughout this procedure.
A registered ODP who has received the appropriate training and
assessment may undertake an expanded role in drug administration
and have the same responsibilities as a registered nurse regarding
the management of medicines in theatre.
6.1.2 Radiographers
Radiographers must be registered with the Health and Care
Professions Council.
Radiographers who have received Trust approved training in IV
Cannulation and administration of diagnostic imaging specific
medicines may undertake this as an extended role under a local
agreement under indirect supervision of a Radiologist or a Doctor.
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6.1.3 Registered Nurses
Nurses must be registered with the Nursing and Midwifery Council.
Registered Nurses must undertake and maintain by updates, the
Trust training in IV Drug Administration and Sedation package prior
to being able to administer and/or assist in procedures requiring
sedation or any IV Drug administration.
6.1.4 Vascular Access Practitioners
Registered Nurse/Radiographer whom have at least 1 years post
registration experience; and hold registration with either the NMC or
HCPC.
Vascular Access Practitioners who have received Trust approved
training in IV Cannulation and administration of diagnostic imaging
specific medicines may undertake this as an extended role under a
local agreement (Administration of subcutaneous 1% Lidocaine and
Heparin Sodium (50units in 5ml) intravenous flushes for the
placement of peripherally inserted central catheter (PICC)/Mid lines in
Adults by Vascular Access Practitioners within Interventional
Radiology.)
6.1.5 Radiologists
Radiologists must be members of the Royal College of Radiologists
and are registered with the General Medical Council (GMC).
Radiologists may direct, supervise or undertake administration of
medications according to individual competencies, training and good
medical practice guidance by the GMC.
6.1.6 Anaesthetists
Anaesthetists are doctors who have completed full medical training
and must be registered with the Royal college of Anaesthetists with
specialist knowledge and training.
They hold responsibility for administration and management of
Medicines according to local and hospital procedures.
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6.2 PRESCRIBING AND AUTHORISATION FOR
ADMINISTRATION OF MEDICINES
Any medicine administration must be against a written prescription,
Local Agreement or local protocols.
Practical guidance for use of contrasts is in the standards for
intravascular contrast agent administration to adult patients by the
Royal College of Radiologists. This outlines the standard doses of
contrasts for procedures, cautions, contraindications and dose
adjustments which should be used as a guide at NUH.
6.2.1 Diagnostic radiology
A referral is authorised for a specific procedure by a Radiologist with
consideration of renal function etc. The type of contrast and dosage
range is set by local scanner protocols which can be referred to via
the intranet under Radiology Policy Documents. When the
Radiologist authorises the procedure they delegate authority to the
radiographers to administer contrast as outlined in the local scanner
protocols within the set limits. All contrasts/medications should be
double checked by two practitioners and recorded along with the
administration, name and volume of contrast and who has completed
the checks electronically on Radiology CRIS system (or on request
form which should be scanned on to CRIS). If not requested
electronically the request form should have the date and name
printed in full of the practitioner. The Radiology Report should
mention the use of contrast in the study title or the body of the report.
Other non-contrast medications e.g. hyoscine butylbromide or
lidocaine or flushes must be prescribed on the drug chart for
inpatients. For outpatients, the request should be written on CRIS to
authorise the Radiographer to administer and the details of the
medication used should be detailed on the Radiology Report as per
contrast. These reports should be ideally authorised on the day of the
procedure.
6.2.2 Intervention radiology
Contrasts should be prescribed on the pre-printed Interventional
radiology drug chart. The Radiology Report should also mention the
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use of contrast in the study title or the body of the report. Dose and
type of contrast used should be mentioned for intra-arterial
procedures and if more than the usual dose of contrast is used for
intravenous contrast.
For Non contrast medications if the medicine is to be continued post
procedure it must be prescribed on the inpatient prescription chart.
Administration of any medicines that have been given in
interventional radiology which affect the subsequent dose of the
same (or another) medicine must be documented on the inpatient
prescription chart. Any other medications e.g. local anaesthetics etc.
should all be prescribed on the interventional radiology drug chart
and this should be filed in the patient’s notes.
7.0
Training and Implementation
7.1
Training
See section 6.1.1 to 6.1.6 of this policy. Health professionals must
ensure they have received any appropriate and relevant training.
7.2
Implementation
Health professional should ensure they are familiar with this policy. It
is the responsibility of the accountable manager to monitor any
incidents arising from its use.
7.3
Resources
No additional resources are required.
8.0
Trust Impact Assessments
8.1
Equality Impact Assessment
An equality impact assessment has been undertaken on this draft
and has not indicated that any additional considerations are
necessary.
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8.2
Environmental Impact Assessment
An environmental impact assessment has been undertaken on this
draft and has not indicated that any additional considerations are
necessary.
8.3
Here For You Assessment
A Here For You assessment has been undertaken on this document
and has not indicated that any additional considerations are
necessary.
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9.0
Policy / Procedure Monitoring Matrix
Minimum
requirement
to be
monitored
Responsible
individual/
group/
committee
Process
for monitoring
e.g. audit
Review of
Scanner
protocols must
be undertaken
every 2 years,
with expiry at
3years if not
reviewed and
ratified.
Superintenden Annual
Ongoing
t/
documentation
Modality
audit.
Manger
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Frequency
of monitoring
Responsible
individual/
group/
committee for
review of
results
Clinical
Improvement
Group (CIG)
Responsible
individual/
group/
committee
for
development
of action plan
Operational
Management
team
Responsible
individual/
group/
committee
for monitoring
of action plan
CIG
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10.0
Relevant Legislation, National Guidance and Associated NUH
Documents
10.1
1. Standards for Intravenous Contrast agents for adult Patients,
Third Edition (Royal College of Radiologists) https://www.rcr.ac.uk/publication/standards-intravascularcontrast-administration-adult-patients-third-edition
2. Radiology Scanner Protocols – Link to Radiology Intranet to
be added.
3. NUH Prescribing Policy (CLMM006)
4. NUH Medicines Code of Practice (CLMM012)
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APPENDIX 1
Equality Impact Assessment (EQIA) Form (Please complete all sections)
Q1. Date of Assessment: 28.4.15
Q2. For the policy and its implementation answer the questions a – c below against each characteristic (if
relevant consider breaking the policy or implementation down into areas)
a) Using data and supporting
b) What is already in place in c) Please state any
Protected
information, what issues,
the policy or its
barriers that still need to
Characteristic
needs or barriers could the
implementation to address
be addressed and any
protected characteristic
any inequalities or barriers to proposed actions to
groups experience? i.e. are
access including under
eliminate inequality
there any known health
representation at clinics,
inequality or access issues to
screening
consider?
The area of policy or its implementation being assessed:
Race and
Ethnicity
Gender
n/a
n/a
n/a
n/a
n/a
n/a
Age
n/a
n/a
n/a
Religion
n/a
n/a
Disability
n/a
n/a
n/a
Sexuality
n/a
n/a
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n/a
n/a
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Pregnancy and
Maternity
Gender
Reassignment
Marriage and
Civil Partnership
Socio-Economic
Factors (i.e.
living in a poorer
neighbour hood
/ social
deprivation)
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Area of service/strategy/function
Q3. What consultation with protected characteristic groups inc. patient groups have you carried out?
None
Q4. What data or information did you use in support of this EQIA?
None
Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from
surveys, questionnaires, comments, concerns, complaints or compliments?
No
Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups
identified or to create confidence that the policy and its implementation is not discriminating against any
groups
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What
Q7. Review date
By Whom
By When
Resources required
May 2018
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Environmental Impact Assessment- APPENDIX 2
The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the
significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b)
implement mitigating actions.
Area of
impact
Environmental Risk/Impacts to consider
Waste and  Is the policy encouraging using more materials/supplies?
materials
 Is the policy likely to increase the waste produced?
 Does the policy fail to utilise opportunities for
introduction/replacement of materials that can be recycled?
Soil/Land  Is the policy likely to promote the use of substances
dangerous to the land if released (e.g. lubricants, liquid
chemicals)
 Does the policy fail to consider the need to provide adequate
containment for these substances? (e.g. bunded containers,
etc.)
Water
 Is the policy likely to result in an increase of water usage?
(estimate quantities)
 Is the policy likely to result in water being polluted? (e.g.
dangerous chemicals being introduced in the water)
 Does the policy fail to include a mitigating procedure? (e.g.
modify procedure to prevent water from being polluted;
polluted water containment for adequate disposal)
Air
 Is the policy likely to result in the introduction of procedures
and equipment with resulting emissions to air? (e.g. use of a
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Action Taken (where
necessary)
No
No
No
No
No
No
No
No
No
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

Energy

Nuisances

furnaces; combustion of fuels, emission or particles to the
atmosphere, etc.)
Does the policy fail to include a procedure to mitigate the
effects?
Does the policy fail to require compliance with the limits of
emission imposed by the relevant regulations?
Does the policy result in an increase in energy consumption
levels in the Trust? (estimate quantities)
Would the policy result in the creation of nuisances such as
noise or odour (for staff, patients, visitors, neighbours and
other relevant stakeholders)?
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No
No
No
no
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APPENDIX 3 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit
The We Are Here For You service standards have been developed together with more than 1,000 staff and
patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe
and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but
with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their
inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization.
Please rate each value from 1 – 3 (1 being not at all, 2 being affected and 3 being very affected)
Value
1.
Polite and Respectful
Whatever our role we are polite, welcoming and positive in the face of adversity, and are always
respectful of people’s individuality, privacy and dignity.
2.
Communicate and Listen
We take the time to listen, asking open questions, to hear what people say; and keep people
informed of what’s happening; providing smooth handovers.
3.
Helpful and Kind
All of us keep our ‘eyes open’ for (and don’t ‘avoid’) people who need help; we take ownership of
delivering the help and can be relied on.
4.
Vigilant (patients are safe)
Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates
attention to detail for a clean and tidy environment everywhere.
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Score (13)
1
1
1
1
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5.
On Stage (patients feel safe)
We imagine anywhere that patients could see or hear us as a ‘stage’. Whenever we are ‘on stage’
we look and behave professionally, acting as an ambassador for the Trust, so patients, families and
carers feel safe, and are never unduly worried.
6.
Speak Up (patients stay safe)
We are confident to speak up if colleagues don’t meet these standards, we are appreciative when
they do, and are open to ‘positive challenge’ by colleagues
7.
Informative
We involve people as partners in their own care, helping them to be clear about their condition,
choices, care plan and how they might feel. We answer their questions without jargon. We do the
same when delivering services to colleagues.
8.
Timely
We appreciate that other people’s time is valuable, and offer a responsive service, to keep waiting to
a minimum, with convenient appointments, helping patients get better quicker and spend only
appropriate time in hospital.
9.
Compassionate
We understand the important role that patients’ and family’s feelings play in helping them feel better.
We are considerate of patients’ pain, and compassionate, gentle and reassuring with patients and
colleagues.
10. Accountable
Take responsibility for our own actions and results
11. Best Use of Time and Resources
Simplify processes and eliminate waste, while improving quality
12. Improve
Our best gets better. Working in teams to innovate and to solve patient frustrations
TOTAL
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1
1
1
1
1
1
1
12
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APPENDIX
CERTIFICATION OF EMPLOYEE AWARENESS
Document Title
Medicines In Radiology- Interventional And
Diagnostic Departments
Version (number)
4
Version (date)
30 June 2015
I hereby certify that I have:
 Identified (by reference to the document control sheet of the above
policy/ procedure) the staff groups within my area of responsibility to
whom this policy / procedure applies.
 Made arrangements to ensure that such members of staff have the
opportunity to be aware of the existence of this document and have the
means to access, read and understand it.
Signature
Print name
Date
Directorate/
Department
The manager completing this certification should retain it for audit and/or other
purposes for a period of six years (even if subsequent versions of the
document are implemented). The suggested level of certification is;
 Clinical directorates - general manager
 Non clinical directorates - deputy director or equivalent.
The manager may, at their discretion, also require that subordinate levels of
their directorate / department utilize this form in a similar way, but this would
always be an additional (not replacement) action.
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