Download medicines code - Sussex Partnership NHS Foundation Trust

MEDICINES CODE
2015/16 (version 2)
(replacing policy 159/Clinical)
GUIDELINE NUMBER
GUIDELINE VERSION
RATIFYING COMMITTEE
DATE RATIFIED
DATE OF EQUALITY & HUMAN RIGHTS
IMPACT ASSESSMENT (EHRIA)
NEXT REVIEW DATE
GUIDELINE SPONSOR
GUIDELINE AUTHOR
171/Clinical
2
Professional Practice Forum
Executive Medical Director
Chief Pharmacists
This policy undergoes at least an annual review in order that the Trust
works within national compliance standards for provision of secure inpatient
services.
KEY DOCUMENT ISSUES:



To state the Trust’s position with regard to medicines management and New
Ways of Working.
To ensure safe and secure handling of medicines.
To help ensure the safe and secure prescribing and administration of medicines.
This document supercedes:
Medicines Code 20015/16 version 1 – January 2015
If you require this document in an alternative format, i.e. easy
read, large text, audio or Braille please contact the pharmacy
team on 01243 623349
Page 1 of 130
SUSSEX PARTNERSHIP NHS FOUNDATION TRUST
MEDICINES CODE
2015/16 (Version 2)
POLICIES AND PROCEDURES TO MANAGE THE
CLINICAL RISKS ASSOCIATED WITH THE USE OF
MEDICINES
Originally based on the Southern Derbyshire Mental Health NHS Trust Medicines Code
(2002). Provided and shared by kind permission of Dr. Dave Branford via the United
Kingdom, Psychiatric Pharmacists Group Website. Ratified by the Trust’s Professional
Practice Forum.
This should be read in conjunction with local polices and procedures relating to
medicines management where they are available. If there are any contradictions in
these with this Medicines Code then these should be drawn to the attention of the Chief
Pharmacist.
The document can be accessed via the medication section of the Trust’s website. Hard
copies will also be placed in the pharmacy folder provided on all inpatient units.
Archived versions are held by the medication section web editor and the Chief
Pharmacist – Strategy.
Significant changes since the last version
Please note that the changed text from the last version is printed in italics.
Chapter/section Main changes
1.0 The whole section on medicines management training has been updated to reflect
the latest standards.
1.4 The section detailing the training available relating to medicines has been updated.
3.3 The section on cultural issues now advertises the fact that there is information for
Muslims on the use of animal products in medicines, with a link to the information on the
Trust’s external website.
4.2.4 The requirement to record the patients weight and height on the drug chart hs
been removed as this should now be recorded on MEWS. This information must still be
used to monitor weight gain or loss due to the treatment or illness.
8.7.3 Further guidance on what to do with CDs in TTOs if discharge is delayed or a dose
of the CD in the TTO needs to be administered to the patient while on the ward.
9.1 Details the preferred alternatives to borrowing medication from another ward.
18.1 All controlled drugs, including schedule 4 controlled drugs, e.g. lorazepam,
zopiclone must now be destroyed in DOOP kits and the destruction witnessed by a
pharmacist.
18.1.2/18.1.3 A change in practice when disposing of controlled drugs, which must now
usually be disposed of using DOOP kits and clarification of what goes into the
medication waste bin.
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18.1.3 Clarifies that if schedule 4 controlled drugs are destroyed by a pharmacist , which
are not recorded in the controlled drug register, an entry needs to be made in the back
of the ward’s controlled drug register.
18.1.5 - New section on disposing of used tramsdermal patches that contain controlled
drugs.
21.5.2 – Add to the self-administration protocol that pharmacy staff can also undertake
spot checks of patients self-adminstration medication cabinets.
21.8.22/23 - Clarification that patients self-administering at level 3 should only use
original packs if the quantity in the pack is no greater than 30 days supply. If greater, a
maximum of 30 days should be supplied.
32.9 - Updated advice for community nurses taking unwanted patients own medicines
back to the pharmacy or dispensing doctor for destruction.
32.10 – clarification that community teams without controlled drug cupboards may store
patients’ own CDs on a ward instead in line with locally developed protocols.
34.4 – Updated the destruction of illicit substances section to reflect the introduction of
DOOP kits for disposing of CDs. These can also be used for illicit substances.
Appendix 2 – a reference to ‘ad hoc’ spot checks by nursing and pharmacy staff, of a
patient’s medication storage cabinet added to the consent form.
Appendix 10 – The list of medicines not suitable for self-adminstration has been updated
to include tramadol and lisdexamfetamine.
Appendix 11 – additional instruction on the Covert Administration Record on what to
write if the patient has no family, carer or advocate enaged with their treatment.
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1. INTRODUCTION.............................................................................................................. 6
2. DEFINITIONS RELEVANT TO THIS CODE .................................................................... 9
3. GENERAL PRINCIPLES ................................................................................................ 11
4. PRESCRIBING OF MEDICINES ................................................................................... 13
5. REMOTE PRESCRIBING (formerly VERBAL ORDERS) ............................................ 21
6. MEDICINES ADMINISTERED UNDER PROTOCOL (MAUP) ...................................... 23
7. PATIENT GROUP DIRECTIONS .................................................................................. 24
8. ORDERING AND RECEIPT OF MEDICINES ................................................................ 25
9. BORROWING OF MEDICINES ..................................................................................... 29
10. PATIENT AND CARER INFORMATION ...................................................................... 30
11. TRUST PHARMACY SERVICES ................................................................................. 30
12. PHARMACY OUT-OF-HOURS SERVICE .................................................................... 31
13. ADMINSTRATION AND PREPARATION OF MEDICINES ......................................... 32
14. TRANSPORT OF MEDICINES ..................................................................................... 41
15. STORAGE OF MEDICINES ......................................................................................... 44
16. STORAGE AND HANDLING OF FLAMMABLE LIQUIDS, GASES AND AEROSOLS 48
17. LOSSES OR DISCREPANCIES ................................................................................... 48
18. DISPOSAL OF MEDICINES NO LONGER REQUIRED .............................................. 49
19. PATIENTS’ OWN MEDICINES ..................................................................................... 51
20. DAY HOSPITALS AND RESPITE CARE ..................................................................... 54
21. SELF-ADMINISTRATION OF MEDICINES .................................................................. 55
22. CUSTODY AND SAFE-KEEPING OF MEDICINE KEYS ............................................. 67
23. CHECKING OF STOCK BALANCES ........................................................................... 69
24. USE OF COMPLEMENTARY MEDICINES AND ESSENTIAL OILS ........................... 70
25. USE OF UNLICENSED MEDICINES AND LICENSED MEDICINES OUTSIDE THEIR
LICENCE ............................................................................................................................. 71
26. CLINICAL TRIALS INVOLVING PHARMACEUTICAL PRODUCTS ............................ 71
27 MEDICINES RELATED DUTIES PERFORMED BY AUTHORIZED EMPLOYEES ...... 74
28. USING MEDICAL GASES ............................................................................................ 75
29. PHARMACEUTICAL INDUSTRY REPRESENTATIVES ............................................. 76
30. MEDICATION ERRORS AND NEAR MISSES ............................................................. 76
31. MEDICINE DEFECT REPORTING ............................................................................... 79
32. COMMUNITY BASED PRACTITIONERS .................................................................... 79
33. CONSENT TO TREATMENT ....................................................................................... 80
34. ILLICIT SUBSTANCES ................................................................................................ 82
35. COMPLIANCE AIDS (e.g. dosette boxes and monitored dosing system (MDS)) ......... 83
36. SAFE HANDLING OF MEDICINES REQUIRING COLD STORAGE ............................ 84
37. CONTROL OF FP10 (NC) PRESCRIPTION ................................................................ 86
38. COVERT ADMINISTRATION OF MEDICINES ............................................................ 89
39. ADVERSE DRUG REACTIONS ................................................................................... 94
40. DRUG ALERTS AND RECALLS.................................................................................. 94
41. NURSE DISPENSING OF LEAVE AND DISCHARGE MEDICATION ......................... 95
42. OCCUPATIONAL THERAPISTS INVOLVED WITH MEDICINES .............................. 103
43. REFERENCES ............................................................................................................ 105
44. LINKED TRUST POLICIES AND GUIDANCE ............................................................ 106
Appendix 1 ......................................................................................................................... 107
Self-administration Flowchart ......................................................................................... 107
Appendix 2 ......................................................................................................................... 108
Self-administration: Patient Agreement / Consent Form .............................................. 108
Appendix 3 ......................................................................................................................... 109
Patient Risk Assessment and Decision Form for the Self–administration of Medicines
........................................................................................................................................... 109
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Appendix 4 ......................................................................................................................... 111
Self-administration of Medicines – Patient Information Leaflet ................................... 111
Appendix 5 ......................................................................................................................... 113
Daily Self-administration Progress Record – Stages 1 & 2 .......................................... 113
Appendix 6 ......................................................................................................................... 114
Daily Self-administration Progress Record – Stage 3................................................... 114
Appendix 7 ......................................................................................................................... 115
Patient Self-administration Assistance Sheet ............................................................... 115
Appendix 8 ......................................................................................................................... 116
Patient Self-administration Aide Memoire ..................................................................... 116
Appendix 9 ......................................................................................................................... 117
Compliance Aid Assessment and Request Form ......................................................... 117
Appendix 10 ....................................................................................................................... 119
Medication Not Considered Suitable for Self-Administration ...................................... 119
Appendix 11
Appendix 11 .................................................................................... 120
Covert Administration of Medicines ............................................................................... 120
Appendix 12 ....................................................................................................................... 122
One Stop Dispensing (OSD) Risk Assessment Form ................................................... 122
Appendix 13 ....................................................................................................................... 123
Patient’s own medication checklist ................................................................................ 123
Appendix 14 ....................................................................................................................... 124
Glasgow Antipsychotic Side-effect Scale (GASS) ........................................................ 124
Appendix 15 ....................................................................................................................... 126
Nurse Dispensing Procedure for Urgent Discharge and Leave Medication in
Exceptional Circumstances ............................................................................................ 126
Appendix 16 ....................................................................................................................... 130
Checklist for Ward Managers to Assess the Competence of Care Assistants to Check
the Administration and Recording of Controlled Drugs (CDs) in the Absence of a
Second Qualified Nurse – v1 – November 2014 ............................................................. 130
The Appendices listed above may be printed off from the medication related
charts and forms section of the Trust website:
http://www.sussexpartnership.nhs.uk/charts-and-forms
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1. INTRODUCTION
1.1
New Ways of Working in Medicines Management
The Trust will embrace the principles of New Ways of Working
(www.newwaysofworking.org.uk) to improve our cost effective use of medicines for
patients, carers and staff. These principles will also be key in assisting patients to
recover.
The following principles will be applied:
1.1
Patients(and carers if appropriate) will be put at the centre of all our thinking into
how medicines are used and handled, by asking them about their concerns and
beliefs in mediciation.
1.2
A medicines management team will be developed that supports medication use
across all localities and specialties. To improve cost effectiveness the roles of
pharmacy technicians, pharmacy assistants and nurses will be explored to work
alongside pharmacists.
1.3
The clinical roles of both pharmacists and pharmacy technicians will be
recognized by the Trust. Further information can be obtained by clicking on the
link: http://www.sussexpartnership.nhs.uk/node/2237/attachment
1.1
The principle of ‘prevention is better than cure’ will be adopted with continuing
developments in medicines management related training. This will include:
 Induction training for junior medical staff.
 Online drug chart, rapid tranquilization and clinical scenario training for
all junior medical staff on appointment..
 Online drug chart training on appointment and every three years for all
trained nurses administering medicines from the Trust’s drug chart.
 Three yearly medicines management training for all qualified nurses.
 Three yearly online dosage calculation training for all qualified nurses.
 Three yearly online training rapid tranquilization training for all inpatient
nurses.
1.2
Staff will be continually encouraged to report medication errors and near misses.
Lessons learned will be fed back to staff and used to improve systems and
identify training needs. The medicines management team will work closely with
other partnership trusts in the Region to develop region-wide solutions.
1.3
Patients, carers and staff will be supported by a range of easily accessible
medication related information and guidance. This will be accessible via the
Trust’s website.
http://www.sussexpartnership.nhs.uk/medication-information
1.4
Services will be developed to provide greater access to individualized advice on
medicines for patients and carers by utilizing the Trust’s website, by running
medication education groups and providing one to one consultations with
members of the medicines management team for those patients identified as
having complex problems or concordance issues. Access to interpreter and
translator services and information in other formats is available on request.
1.5
Patients will be able to get more timely access to the medicines they need by
utilizing the options provided by the development of the role of non-medical
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prescribers and the use of patient group directions and group protocols for
homely remedies (MAUPs). Training and support will be provided non-medical
prescribers to support their role.
1.6
Greater emphasis will be put on ensuring medication is accurately reconciled, at
or soon after admission with systems in place to ensure that there is accurate and
timely medication information provided to primary care or the receiving unit at the
time of discharge or transfer.
1.7
Systems will be in place to allow appropriate inpatients to self-administer their
own medication to either stop them losing skills they already have or to provide
them with skills to aid their recovery.
Why have a Medicine Code?
The Department of Health requires that NHS Trusts establish, document and maintain
an effective system to ensure that medicines are handled in a safe and secure manner.
In order to meet this requirement, the Trust must ensure that:

Professional practices concerning the use of medicines are current and up-todate and that they remain subject to review and further development.

All healthcare practitioners dealing with medicines remain aware of current policy.

The concepts of patient focused care and patient empowerment are
acknowledged and, where possible, are built in to policy and practice.

Medicines Management is seen as a high priority within Clinical
Governance.
This Medicines Code defines the policies and procedures to be followed within the
Sussex Partnership NHS Foundation Trust for the prescribing, ordering, dispensing,
storing and administering of medicines. The Sussex Partnership NHS Foundation Trust
Medicines Code is not intended to apply to any other NHS Trust. Other legal
requirements and standards laid down by professional bodies must also be followed.
All staff working within the Sussex Partnership NHS Foundation Trust who are involved
in some way with the use of medicines, must familiarise themselves with the correct
procedures contained in the Code. Those in charge of wards and departments are
responsible for ensuring that their staff, especially new starters and locum staff, follow
procedures in the Medicines Code, which may differ from procedures elsewhere.
Copies of the Code will be available in all wards and departments and on the Trust’s
website.
If staff have any concerns about the handling and use of medication by another
healthcare professional, these concerns would usually be raised with their manager or
their manager’s manager if more appropriate. However ‘designated officer’ can be
approached instead. A copy of the Trust’s policy on raising matters of concerns
(whistleblowing) is available at the link below detailing what to do:
http://policies.sussexpartnership.nhs.uk/workforce/445-raising-matters-of-concernwhistleblowing-policy
The procedures in this Code also apply to medical staff, nursing staff and other types of
staff from other NHS trusts or from private practices, who are contracted to work in the
Sussex Partnership NHS Foundation Trust on a temporary basis. Managers who
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contract for these services must make it explicit within the written contract that these
temporary staff must follow the procedures described in this Code.

The aim of the Medicines Code is to ensure that all patients requiring medication
receive their medication correctly and that the proper procedures have been
followed. The Code assists Trust staff in complying with legal requirements and
standards laid down by their professional bodies.

The Sussex Partnership NHS Foundation Trust provides treatment to a diverse
range of individuals and this has been written to ensure that their individual
requirements are met. This Code provides a common core upon which the
procedures for specific areas or treatments can be based. It must be read,
together with any local procedures or protocols, and adhered to when carrying out
care.
In a number of instances throughout this Code specific training requirements have been
highlighted as necessary to perform certain tasks. As a principle, all training provided
will be subject to regular review and the participants will be offered refresher and update
training as necessary to ensure continued quality of care for all patients.
Implementation, Monitoring and Review of the Code

Implementing this Code is the responsibility of all staff who are involved in any
aspect of the prescribing, supplying or administrating of medicines.

Team leaders, home leaders, modern matrons and ward managers in conjunction
with the Trust’s directors, heads of service and integrated team managers have
additional responsibilities to ensure that staff, working in services for which they
have responsibility, are adhering to the standards laid down in the Code.

The code will form the basis for local and trust-wide audits or checks to monitor
implementation. As a minimum annual trust-wide audits or checks will be
undertaken of some aspect of:






Prescribing
The administration of medicines
The storage, recording and disposal of controlled drugs
Self administration
Compliance with medicines management training
The Code will be reviewed regularly, at least every year, and revised as
appropriate in consultation with all relevant staff.
Medicines Management Training

All registered nursing staff working in clinical practice should attend a
structured full-day training course on Medicines Management every three years.
This will be provided at several venues across the Trust and will cover aspects
such as the Medicines Code and the Drug chart; together with clinical updates on
medication in common use and there will be some tailoring depending on the
area of practice. All new nurses should attend a relevant course within the first 6
months of appointment (unless one for their speciality is run less frequently) and
all nurses must attend for an update every three years.

Following attendance at the Medicines Management full-day training course,
all nurses must complete the online dosage calculation course.
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
Nurses on wards all must undertake the Trust’s online rapid traquilization training
programme within three months of appointment onto their first ward and then at
least ever three years.

Nurses administering medicines using the Trust’s drug chart must undertake the
Trust’s online drug chart training programme prior to doing unsupervised drug
rounds or equivalent if in the community and then at least ever three years.

New junior medical staff must undertake the Trust’s online traing programmes for
rapid tranquilization, using the drug chart and mental health clinical scenarios.
The expectation is for new juniors to successfully complete all the specified
training prior to taking up their position with the Trust or at the latest by the end of
their first week in post.

All junior doctors are expected to attend a structured induction programme on
taking up their position with the Trust. This programme contains a module on
pharmacy services and medicines management.

For further details of training the Trust considers essential, staff should refer to
the current Trust training policy.
2. DEFINITIONS RELEVANT TO THIS CODE
2.1. Staff Definitions
Throughout this Code, certain specialist titles describe healthcare staff who have
defined responsibilities regarding the management of medicines. Only staff with
contracts (or honorary contracts) of employments to work in The Sussex Partnership
NHS Foundation Trust are recognised as having any involvement with medicines.
Throughout, the term “Practitioner” is used. This is a general term used to describe a
qualified medical practitioner, nurse, pharmacist or other authorised healthcare
employee.
Prescriber – A registered professional authorised through training registration to
prescribe medication.
Independent Prescriber – Doctor, dentist, nurse or pharmacist who has completed
the non-medical prescribing course as an independent prescriber or who qualified as
a supplementary prescriber and has undertaken the conversion course.
Supplementary Prescriber – A registered professional, other than a doctor or
dentist, who through training and registration can prescribe in accordance with a
clinical management plan agreed between the supplementary prescriber,
independent prescriber and patient
Appointed Practitioner in Charge – The senior practitioner appointed in charge of
a ward or department e.g. Ward Manager, Superintendent Physiotherapist.
The Chief Pharmacist, together with senior managers, must agree and authorise
named individuals to be given these responsibilities.
NB. In situations where the person in charge is not from a professional background
appropriate to take such responsibility (e.g. community team leader with a social
work background) another member of the team must undertake the role of Appointed
Practitioner in Charge.
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Assigned Practitioner in Charge – The senior practitioner on duty for the ward or
department, who has been rostered as the professional in charge for the shift.
Designated Practitioner (e.g. Registered Nurse) – Any registered practitioner
identified by the Appointed Practitioner in Charge as competent and appropriate to
perform a specific function. The designation as such has been communicated to and
accepted by the Designated Practitioner. If the practitioner is based in the
community the term used is Designated Community Practitioner.
Designated Complementary Therapist – Any practitioner of a complimentary
therapy (see index) who has obtained the appropriate qualification from a recognised
organisation, and is approved by The Sussex Partnership NHS Foundation Trust.
Authorized Pharmacy Staff – Any qualified pharmacist or pharmacy technician
authorised as competent and appropriate to perform a specific function by the Chief
Pharmacist of their employing trust.
Authorized Employee – (e.g. Nursing Assistant or assessed carer) – A member
of staff who following training, (which may take place locally), has been authorised by
the Appointed Practitioner in Charge to undertake specific duties in relation to
medication, (e.g. witnessing the administration of controlled drugs). Note: Any
additional unit-specific policy must be taken into consideration.
2.2. Other Definitions
Patient – A person prescribed medicines irrespective of the environment in which
they are residing.
Medicine/drug – Any substance or combination of substances presented for treating
or preventing disease. Any substance or combination of substances which may be
administered with a view to making a medical diagnosis or restoring, correcting or
modifying physiological or psychological functions.
Prescribe – To authorize in writing the supply and if appropriate administration of a
medicine.
Dispense – To prepare a clinically appropriate medicine for a patient for self
administration or administration by another. The act of dispensing includes supply
and also encompasses a number of other cognitive functions (e.g. checking the
validity of the prescription, the appropriateness of the medicine for an individual
patient, assembly of the product). Only pharmacy staff, doctors or designated
practitioners should perform these functions.
Supply/Issue – To supply a medicine to a patient/carer for administration. Only
pharmacy staff, doctors or designated practitioners should perform these functions.
Administer – To give a medicine by either introduction into the body, (e.g. orally,
inhaled or by injection) or by external application (e.g. cream, ointment or application
of a patch).
Administration
In this situation the drugs are fully
administered by staff.
Supervised Administration
In this situation patients will exercise
varying degrees of responsibility for the
administration of their own drugs short of
self administration and staff will provide
varying degrees of assistance short of full
administration.
Page 10 of 130
Self Administration
In this situation the patients manage their
own drugs with appropriate monitoring by
staff.
Drug chart – The Trust’s official Drug Prescription and Administration Chart
Patient Group Direction (PGD) - A written procedure for the supply and/or
administration of a specific medicine, including prescription only medicines, in an
identified clinical situation, to a clearly identified group of patients, by named
competent practitioners in the absence of a written prescription. It has been drawn
up within the Trust by doctors, pharmacists and other professionals and approved on
behalf for the Trust by the Medical Director.
Medicines administrated under Protocol (MAUP) - A written instruction for the
administration of named non prescription-only medicines to provide patients with
symptomatic relief in an identified clinical situation in the absence of a written
prescription. It has been drawn up within the Trust by doctors, pharmacists and
other professionals and approved by the Medical Director on behalf of the Trust.
3. GENERAL PRINCIPLES
3.1. Medicines, whether for internal or external use, will be regarded for the
purpose of the Code, as comprising the following categories:

Controlled Drugs controlled under the provisions of the Misuse of Drugs Act 1971,
with stringent requirements for supply, storage and administration.

All other medicines and medicinal products prepared for administration to patients
and which are controlled by the Medicines Act 1968. This also includes many
diagnostic agents, X-ray contrast agents and medical gases. Whilst less stringent
regulations apply than in the case of controlled drugs, they must be treated with
care.

All complementary medicines e.g. aromatherapy, herbal or homeopathic
remedies. These products are used for therapeutic purposes and require the
same safeguards as other medicines.

Other pharmaceutical preparations: Disinfectants, reagents and other
preparations not used directly to treat patients. The use of these products in
hospital is still subject to certain rules. It is important to understand that
procedures listed in this document apply to all medicines used in The Sussex
Partnership NHS Foundation Trust. These include topical lotions, applications,
intravenous infusions, medicated dressings and complementary medicines.
Full attention must also be given to the requirements of current Control of
Substances Hazardous to Health (COSHH) Regulations.
3.2. The responsibilities of the various practitioners associated with the
prescribing, ordering, storing, dispensing, issuing and administration of
medicines are as follows:

It is a requirement that all Health Authorities designate a senior pharmacist to be
responsible for the organising, monitoring and reporting of a system for assuring
the safe and secure handling of medicines. In The Sussex Partnership NHS
Foundation Trust the designated senior pharmacist is the Chief Pharmacist.
Page 11 of 130

In most situations medical staff are responsible for prescribing medicines for
patients. They and any other authorised prescriber must comply with legislation,
any agreed formulary, drug application procedures and the Medicines Code when
performing these duties.

A record showing appointment and signature of all prescribers (including locum
appointments) should be notified to the appropriate mental health pharmacist and
updated upon any change by Medical Staffing.

The Assigned Practitioner in Charge of the ward or department is responsible for
the stock of medicines held in the ward or department and for ensuring that
stocks of controlled drugs, if held, correspond with the details shown in the
register. The Appointed Practitioner in Charge is responsible for ensuring that
accurate CD records are maintained.

Pharmacists and pharmacy technicians are responsible for the stock of medicines
held in the pharmacies, their manipulation and preparation into user ready
presentations and for their supply to wards and departments. They are also
responsible for advising on the safe, effective and economic use of medicines.
These responsibilities include advising practitioners on the storage of medicines
in clinical areas. Authorised pharmacy staff will inspect the stocks of medicines
held on the ward or department at any time to ensure the medicines are in date
and stored under the proper legal and environmental conditions. This will occur
at least annually. Where units receive a regular pharmacy top-up service, this will
occur at least every four weeks.

The administration of medicines is the responsibility of the Assigned Practitioner
in Charge of the ward or department who may delegate these duties to a
Designated Practitioner, but must exercise supervision as is necessary. It is the
responsibility of the Appointed Practitioner in Charge to ensure that the
Designated Practitioner or Authorised Employee has received the relevant
training and experience before being allowed to take on responsibility for
medicine procedures.

Practitioners in training must be given every opportunity to become proficient in
medicines related activities under appropriate supervision. The supervising
practitioner has responsibility for medicine procedures at such times.

The responsibilities for medicine procedures that may be held by various grades
of practitioner are indicated in this document. Practitioners must be aware of the
tasks they may or may not perform.
3.3. Cultural issues may arise when prescribing or administering medicines,
particularly with regard to:

The use of animal products in medicines, particularly the source of gelatin in
capsules and other formulations. Information for Muslims concerned about
animal products in medicines is available on the Trust’s external website:
www.sussexpartnership.nhs.uk/node/1499/attachment

The wish to avoid taking medicines during the hours of daylight during the Muslim
religious festival of Ramadan.

The pharmacy team are available to advise on the formulation of any
psychotropic medicines being prescribed and suitable alternatives and the
implications of changing the times medication is taken during Ramadan.
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4. PRESCRIBING OF MEDICINES
4.1. Inpatient prescribing
Medicines may only be prescribed on official Trust prescription stationery.
Details that must be included on the drug chart are:

Patient’s name, including aliases on every page.

Date of birth or age

Ward or clinic name, or number, or name of department or patient’s address

Patient’s hospital number and/or NHS number.

Known allergies or sensitivities to medicines
Where more than eight medicines are prescribed regularly, a second chart may be
used, which must remain with the first. In such circumstances both drug charts must
indicate the existence of a second chart. When a patient is re-admitted, including for
respite care, a new drug chart must be used. The drug chart of patients transferred
from one trust site to another does not require to be rewritten. When patients are
transferred from other trusts, the duty doctor must rewrite the drug chart at the time
of clerking in, or at the earliest opportunity. In addition to the main drug chart there
may be other charts e.g. clozapine initiation chart, the main drug chart must make
reference to any therapy indicated on the other chart.
4.2. Initiation of Treatment

It is important to recognise that in most situations only medical staff have the
authority to prescribe medicines for hospital inpatients or for patients attending
day hospitals or clinics. However if authorised by the Trust in certain situations
non-medical prescribers may undertake this role.

Medicines must only be administered where they have been authorised by a
prescriber.

This authorisation must be in writing, in the form of a prescription in advance of
the administration of the medicine.
The recognised exceptions to this are listed as follows:

In areas where there are no resident prescribers and in cases of clinical urgency
a verbal instruction may be acceptable (see Chapter 5).

Certain medicines may be administered at the practitioner’s discretion against an
agreed PGD or MAUP. In each instance a record of the administration must be
entered on the drug chart in the appropriate section.

Specialist practitioners and clinical pharmacists involved in certain services may
be authorised to modify dose regimens and, in certain instances, to initiate or stop
medicines therapy in accordance with protocols approved by the Drugs and
Therapeutics Group or following prior agreement with individual prescribers.
Foundation 1 grade doctors are not permitted to prescribe controlled drugs or on
FP10s.
Medical students are not permitted to prescribe medicines.
Page 13 of 130
4.2.1. Range of medicines to be prescribed
Only the following medicines, including complementary and homeopathic
medicines, can be prescribed to patients:

Psychotropic medicines approved for use by the Trust’s Drugs and
Therapeutics Group.

Physical drugs approved on the local acute trust’s formulary.

Medicines prescribed prior to admission by the registered doctor, dentist,
nurse prescriber or authorised supplementary prescriber. Medicines being
taken within a formal clinical trial.

Over the counter medicines, including complementary and homeopathic
medicines following a review by medical staff. If there is any doubt about their
safety then the advice of a pharmacist should be sought.
A defined procedure must be followed in order to request a new medicine or new
indication for use within the Trust. Details of the procedure are available from the
local mental health pharmacist or the Chief Pharmacist.
4.2.2. Range of medicines not to be prescribed.

New medicines, new indications and/or unlicensed medicines unless
approved by the Trust’s Drugs and Therapeutics Group.
4.2.3. Function of the drug chart.

To provide a permanent record of the patient’s treatment with medicines.

To indicate the patients’ sensitivity to medicines.

To direct and record the administration of the medicines to the patient.
A well-written drug chart enables the rapid and accurate interpretation of the
medicines required by the patient. All prescriptions must be in black ink to
facilitate legible faxing and scanning.
4.2.4. Prescribing on the drug chart.

Prescriptions must clearly identify the patient for whom the medication is
intended and, whenever possible, be based on the patient’s choice,
awareness of the purpose of the treatment and informed consent.

The prescription must be clearly written in BLOCK LETTERS, typed or
computer-generated and be indelible.

The prescription must indicate the drug, dose, variable does (if required),
timing, frequency, route of administration, original start date, stop date,
stopped by (see later) and date.

Controlled Drugs must be written clearly and indelibly, by the prescriber, on
the in-patient prescription chart. There is no requirement for the quantity of
the controlled drugs to be written in words and figures.

For ‘drugs given as required’ additional information of max dose/24hrs and a
clear indication for use must be stated.
Page 14 of 130

Allergy status or sensitivities to medication must be recorded on the drug
chart, ideally by the prescriber when first writing up the chart. If this cannot be
ascertained at the time of first writing up the chart the prescriber must
complete the second section of the allergy box stating the allergy status ‘is not
yet ascertained’. The medical team is ultimately responsible for completing
the allergy status box as soon as possible, but another healthcare clinician
involved in the medicines management process may ascertain the status and
sign instead of the prescriber, including their designation e.g. pharmacist. (see
also 4.2.10 below).

The patient’s weight and height should be recorded on admission on MEWS
and further weights measurements should be taken as necessary.
When rewriting drug chart allergies or sensitivities, weight on admission and
start dates or ‘before admission’ must be carried forward.
When prescribing oral cancer medication, access is needed to the written
protocol and treatment plan from the hospital where treatment was initiated
and advice obtained if needed from a pharmacist with experience in cancer
treatment in that hospital.



When prescribing insulins it is imperative that the correct type of insulin is
prescribed. Patients on insulin should have been issued with an ‘insulin
passport’ or an equivalent local pateint record to help provide accurate
identification of their current insulin products. This should be used to check
the accuracy of the prescription. If the patient is admitted without an insulin
passport and there is any concerns about the product they are on, then
confirmation must be obtained from the patients GP as soon as possible.
4.2.5. Name and Form of the Medicine

A medicine may have numerous brand names but only one approved or
generic name, therefore the approved or generic name rather than brand
name/s should be written clearly in BLOCK LETTERS. However if the
medicine is a compound (with no approved name) or has a unique release
property or bioavailability, then the brand name should also be used e.g.
Priadel. Non-approved abbreviations of the name of the medicines e.g. CBZ
for carbamazepine must not be used.

When prescribing oral medicines, tablets or capsules will be supplied unless
another formulation is specified e.g. liquid. In situations where confusion may
arise e.g. creams and ointments, the form should be specified.

When a liquid preparation is required the prescriber should usually just
prescribe the dose and add the word ‘liquid’. The only exceptions should be
when the dose strength is critical e.g. methadone liquids or the liquid
formulation does not have equivalent doses to the tablet or capsule e.g.
phenytoin.
4.2.6. Dose and Route of Administration

The dose must be expressed in metric units, avoiding decimal points wherever
possible by using whole units, i.e. 125 micrograms rather than 0.125mg. The
word “micrograms” must be written in full and not abbreviated to mcg, to avoid
confusion with milligrams (mg).

The word “Unit” must be written in full rather than abbreviated to “U”, which
can frequently be confused with “the number O” and may lead to 10 times the
dose of e.g. insulin or heparin, being administered in error.
Page 15 of 130

Roman numerals (e.g. ii) are also the cause of medication errors and must not
be used.

No more than one route can be specified against an entry.
Ext
IM
Inh
IV
Neb
External use
Intramuscular
Inhalation
Intravenous
Nebulisation
O/PO
By Mouth
PR
PV
SC
SL
Top
Per Rectum
Per Vagina
Subcutaneous
Sublingual
Topical, indicating the
specific area or eye/ear.
All other routes of administration must be written out in full.
4.2.7. Times of Administration

The times of administration must be specified by the prescriber in the
appropriate column on the drug chart.

Abbreviations such as ‘bd’ ‘tds’ are only to be used for as required (PRN)
medicines and on take home/outpatient prescription charts. The following
abbreviations are standard means of indicating a dose regimen:
OD
OM
ON
BD
TDS
QDS
Mane
Nocte
PRN
Once a day
Each morning
Each night
Twice daily
Three times daily
Four times daily
Morning
At bedtime
As required (with indication and interval stated).
All other dose regimens must be written out in full.
4.2.8. Signature of Prescriber
Prescription item must be validated by the full signature of the prescriber. The
signature should be legible or the printed name of the prescriber should be written
next to the signature. If the prescriber is a non-medical prescriber then the
following letters must be written after the signature:


‘SP’ - if prescribing as a supplementary prescriber.
‘IP’ - if prescribing as an independent prescriber.
4.2.9. Date
Each prescription on the drug chart carries three dates.

The ‘original start date’ is the date the drug commenced if initiated on the
ward. If the drug was started prior to admission put ‘before admission’ in the
‘original start date’ box. This box only relates to the drug and not the dose.
This start date or before admission’ must be carried forward to any rewritten
prescription charts in the future.
Page 16 of 130

The ‘stop’ date is either specified in advance and administration will stop on
the completion of that day unless administration boxes are crossed (X) or the
‘stop’ date should be completed on discontinuation of the drug.

The ‘date’ is the date the prescription was written on that chart.
Allergies or Sensitivities
The following procedure must be followed

Ideally, allergy status should be confirmed before the first drug chart is
completed after admission.

This is not always possible and it is the responsibility of the medical team to
ensure it is completed as soon as possible, but all staff involved in the
medication management process may confirm the allergy status, recording it
in the patient’s notes and on the Drug chart. If not signed by a prescriber
when first writing the chart the signature and the designation of the person
completing the Drug chart’s allergy box should be included, e.g. ‘pharmacist’.

The medical team must take ultimate responsibility for ensuring that the drug
allergy boxes on all Drug charts are completed and signed.

If there is a known allergy, the following signed and dated entries must be
made in the patient’s notes and on all Drug charts:
-

Generic name(s) of medicine(s), unless otherwise recommended by the
BNF
Nature of reaction(s) – to ensure a true allergy is being described.
Otherwise one of the following designations must be utilised. (The use of
abbreviations is not recommended as they may be confusing);
No Known Drug Allergies – the patient/carer, case notes or GP are clear
that the patient has never experienced an allergic reaction or severe adverse
reaction to any medication.
Not Yet Ascertained – only to be used in exceptional circumstances where it
has not been possible to ascertain allergy status on admission. The reason
why must be documented in the patient’s notes by the medical team, e.g. a
new admission requiring rapid tranquillisation. Allergy status must be
confirmed as soon as possible.
Guidance Notes

If the allergy status is not documented on the Drug chart, prescribing,
administering and supplying medicines carries a significant risk.

Take particular care with “co-“named drugs, checking that the patient is not
allergic to either constituent. Also take particular care with penicillin, (e.g. coamoxiclav/Augmentin® is a penicillin).

The above principles apply equally to adverse/untoward reactions and severe
side effects – this may include previous incidence or suspicion of neuroleptic
malignant syndrome (NMS) or neutropenia associated with clozapine. Avoid
the use of any other means of documenting or highlighting allergy status.

Counsel patients on the need to inform all healthcare professional of their
allergy status.
Page 17 of 130

Newly identified allergies must be communicated to primary care by
documenting in CPA and Discharge Letter.
When predictable allergic reactions result from the prescribing and administration
of medicines, the most likely causes are:

Incomplete documentation of allergy status

Inconsistent location of documentation of allergy status

Using brand name of medicines rather than generic (approved) names

Information on allergy status not being available to relevant healthcare
professionals

Lack of clinical knowledge
4.2.10.
Alterations

Prescribers should not attempt to alter existing instructions. Any change in
medication must be written as a new entry. Correction fluid such as tip-ex
must not be used.

Incorrect prescriptions should be crossed through with a single line, signed in
the ‘stopped by’ box and dated.
4.2.11.
Cancellation of Treatment

It is important that a suitable means of cancellation of the prescription is
adopted, such as a bold line being drawn diagonally across the prescription.
The ‘stop date’ and ‘stopped by’ boxes must be completed.

When the ‘stop’ date is specified in advance and administration will stop on
the completion of that day unless administration boxes are crossed (X).
4.2.12.
Length of Treatment

Drug charts are valid for a maximum of 9 weeks and community prescriptions
for 6 months. After this period, treatment must be re-written if it is to be
continued. If the prescription is considered ambiguous at any time, the
practitioner responsible for the administration of the medicine or the
pharmacist must request the prescriber to rewrite it.

If prior agreement has been obtained from the prescriber, drug charts may be
written or re-written by designated practitioners or pharmacists. However,
overall responsibility for the prescriptions remains with the prescriber who
signs them. Nurses must not administer medicines from prescriptions,
which have not been signed by the prescriber, other than against
remotely prescribed orders (see index).
4.2.13.
Once Only Doses (Stat doses)
Medicines that are intended to be given once only must be prescribed in the ‘once
only’ section of the drug chart. This includes test doses of long acting
intramuscular injection or Depots.
Page 18 of 130
4.2.14.
“As Required” Prescriptions (PRN)

The ‘as required’ section of the drug chart must only be used for those
medicines to be given at the practitioner’s discretion according to the needs of
the patient.

An entry in the patient records should give reasons for administration and
outcomes. The reason should also be documented on the drug chart.

The minimum interval between doses and indication for administration must
be clearly specified by the prescriber. The maximum dose or frequency to be
given in a 24-hour period must also be stipulated.

Different routes must be prescribed separately on the PRN side of the chart.
If more than one route is prescribed that maximum dose should include all
routes and must state all routes. If different routes have different maximum
doses this also must be clearly stated.

Care must be taken not to duplicate medicines being taken regularly and thus
overdose the patient. Combination analgesics frequently contain
paracetamol, which may already be prescribed in the regular section of the
prescription chart. Rapid dose escalation using combinations of PRN and
regularly prescribed antipsychotic drugs is one of the most commons causes
of sudden death and neuroleptic malignant syndrome in patients suffering
from schizophrenia.

The ‘as required’ prescription must be reviewed regularly by a doctor to
determine its continuing clinical need. To prevent the accumulation of
unnecessary ‘as required’ prescriptions the following guidelines should be
observed:
o Any ‘as required’ prescription that has not been administered for 4
weeks should normally be cancelled, unless specific rules apply or
continued clinical need is established.
o No more than two ‘as required’ medicines should be prescribed
together for the same indication. If two are, then the one to be used
first line should be clearly stipulated along with information on when the
second would be used.

Medicines originally prescribed ‘as required’, but which are needed regularly
as indicated by the administration record, must be reviewed and if appropriate
rewritten in the regular prescription section.

If there is any doubt or concern, or the member of staff is unsure of the criteria
given for the administration of as required medication, then advice must be
sought from the prescriber, a senior colleague or pharmacist.

Reasons for not administering as required medication when requested by the
patient should also be recorded in the patient’s notes.
4.2.15.

Review of the drug chart
It is good practice to review medication and prescriptions must be reviewed
and re-written by the authorised prescriber at least every nine weeks in
hospital settings.
Page 19 of 130

As a minimum standard all medication must be reviewed within 12 months in
all non-hospital settings.

Older people who are on more than 4 drugs should have their medication
reviewed at least every 6 months regardless of setting.
4.2.16.
Archiving of the drug chart
 Once the Drug chart has been cancelled it must be filed into the patient’s
notes.
4.3. Outpatient prescribing
4.3.1. Prescribing using FP10 Prescriptions


Only prescribers authorizes by their consultant can old FP10 prescriptions.
On appointment a form will be provided by Medical Staffing to record the
prescriber’s signature and initials for use by the local pharmacy department. It
will also have space for the consultant to authorise the holding of a pad of
FO10s if he or she wishes.

This form must be taken or sent to the local Pharmacy Department.

If collecting a FP10 pad, the prescriber must provide proof of identity. See
index for further details on pad security.

If collection has not been agreed then a special form must be filled out and
sent to the distribution point.

The use of FP10s is restricted to prescribing for patients of the Trust.

Unless there are concerns about patient safety, the usual length of treatment
prescribed should be as agreed by the local PCT. In East Sussex and
Brighton & Hove this is 14 days and in West Sussex this is 28 days. This will
ensure the community pharmacist or dispensing doctor provides a patient
information leaflet.

Prescriptions for controlled drugs, which are subject to prescription
requirements must be indelible, and must be signed by the prescriber, be
dated, and specify the prescriber’s address. The prescription must always
state:
o The name and address of the patient
o In the case of a preparation, the form and where appropriate the strength
of the preparation
o The total quantity of the preparation, or the number of dose units, in both
words and figures
o The dose

Stationery used for requesting medicines must be kept in a secure place when
not in use. Prescription pads (i.e. FP10s), must be locked away when not in
use, the responsibility for this lies with the person to whom they are issued.

Except in the following circumstances the use of FP10s should be restricted to
initiating treatment or when a dose change has been made:
o Patients of the Substance Misuse Service
Page 20 of 130
o A hospital only medicine is being prescribed e.g. clozapine
o For a drug currently under evaluation by the Drugs and Therapeutics
Group
o During the initiation phase of a drug later prescribed by GPs under a
shared care agreement
o For exceptional patients who would otherwise disengage from all services.
4.4. Prescribing long acting antipsychotic injections in the community

The ‘Community Depot Injection Prescription Sheet’ should be used for
prescribing and recording the administration of depot injections in the
community.

The maximum validity for any one prescription sheet is 6 months.

The patient must be reviewed at least six monthly by the prescriber, using the
patient’s multidisciplinary notes.
4.5. Monitoring side effects
4.5.1.
Ideally, all patients should be given information in a suitable format, e.g. in large
print leaflets, on the possible side effects of a medication prior to it being
prescribed, to inform their choice and make them aware of the side effects they
may encounter.
4.5.2.
All patients prescribed medication must be monitored for side-effects after starting
a medication, when initiating or changing medication, including dose changes, at
least annually but more frequently if appropriate.
4.5.3.
Medication care plans must include details of how long-term side effects will be
minimized by regular monitoring e.g. regular weighing following initiation of
antipsychotics to identify rapid weight gain.
4.5.4.
The Glasgow Antipsychotic Side-effect Scale (GASS) (see appendix 14) should
normally be given to patients prescribed antipsychotics to self report side effects
after initiating or changing medication, including dose changes and at least
annually and more frequently if appropriate.
5. REMOTE PRESCRIBING (formerly VERBAL ORDERS)
5.1. It is not acceptable for a nurse to take a verbal order on its own, without followup confirmation.
5.2. In exceptional circumstances, where the medication has been previously
prescribed and the prescriber is unable to issue a new prescription but
where a change of dose or re-prescribing of a drug is considered necessary,
a remote prescription can be accepted.
Page 21 of 130
5.3. In very exceptional circumstances, a doctor (but not a non-medical
prescriber) may need to prescribe remotely for a previously unprescribed
medicine, for example, in palliative care or remote and rural areas.
5.4. The person due to receive the remote prescription must inform the
prescriber of all other medicines being taken by the patient. They should
request and receive information from the prescriber regarding contraindications and side effects of the remotely prescribed medications.
5.5. In all instances of remote prescribing the prescriber must confirm the
prescription using information technology. If the prescriber has access to
fax or email then these methods of off-site communication should be used to
transmit information between the prescriber and the inpatient unit. In
exceptional circumstances text messaging can be used.
5.6. A copy of any fax or email must be stapled to the patient’s Drug chart until
the entry in the Drug chart has been countersigned by the prescriber or their
deputy. The original must be placed in the patient’s notes. A note must
also be made in the patient’s notes detailing the prescriber’s name, date and
time and the name(s) and signature(s) of the staff receiving the remote
prescription.
5.7. If a text message has had to be used, the message should be retained on
the receiving mobile-phone until the entry in the Drug chart has been
countersigned by the prescriber or their deputy. In addition a record must
be made in the patient’s notes stating that a text message was received
along with a verbatim transcription of the text message and details of the
mobile phone that received the text. A note must also be made in the
patient’s notes detailing the prescriber’s name, date and time and the
name(s) and signature(s) of the staff receiving the remote prescription.
5.8. Only qualified nurses and pharmacists may accept remote prescriptions.
However, qualified nurses and pharmacists retain the right to refuse to
accept remote orders from prescribers if they do not feel competent to do
so, if there are communication problems so the intentions of the prescriber
are not clear, if they feel the order is inappropriate, or if they feel it is not in
the patient’s best interests.
5.9. If the medication is for an ‘as required’ medication it would usually be
prescribed remotely for one dose only and written up in the ‘once only’
section of the Drug chart. In exceptional circumstances it can be written in
the ‘as required’ section but a stop date must be written that does not
exceed the next normal working day.
5.10. If the medication is to be given regularly this must be written in the ‘regular
medication’ section of the ‘Drug chart’.
5.11. If the transmitted prescription does not match the medication discussed
verbally with the nurse or pharmacist, the prescriber must be contacted
again to clarify the remote prescription.
5.12. The remote prescription must be recorded in the appropriate section of the
Drug chart and the additional information written in the ‘additional
instructions box’.
Additional information:
Page 22 of 130

The maximum number of doses if more than one (to a maximum of 72
hours)

“This is a remote prescription by (name of doctor)”.

The name of the member of staff who has received the remote
prescription.
5.13. The entry must be countersigned by a prescriber, ideally by the originating
prescriber, on the next normal working day and no longer than 72 hours
after the remote order was given, to safeguard patient welfare and minimise
risk.
5.14. Any active remote prescription not yet signed by a prescriber must be
reported to the next shift at handover and/or recorded in the patient’s notes
or record of care.
5.15. There must never be more than one medication prescribed remotely for any
patient at any one time. If further prescriptions are required the patient must
be seen by a prescriber.
5.16. Controlled Drugs cannot be prescribed remotely except those in Schedule 4
& 5 e.g. most benzodiazepines, but not temazepam.
5.17. When a pharmacist identifies a possible medication error, any alterations
should ideally be made by the prescriber or their deputy. However, the
pharmacist may accept a verbal order from a prescriber to add a missing
item or amend a prescription, in line with the prescriber’s instructions, if not
doing so would put the patient at greater risk. Once taken the pharmacist
must:

Read the intended alteration back to the prescriber who must then
confirm it verbally.

Sign all alterations and explain in the ‘additional instructions box’ why
the alteration has been made noting the name of the prescriber
contacted.

If the patient’s clinical notes are available, make an entry (signed and
dated) detailing the alteration made, the reason for it and, the name of
the remote prescriber.
6. MEDICINES ADMINISTERED UNDER PROTOCOL (MAUP)
6.1. The contents of the Protocol must include the following information:

Details of the condition or situation to which the Protocol applies.

Details of which patients are included and excluded from treatment under
the Protocol

Characteristics of the staff authorised to take responsibility for the
administration of the medicine under the Protocol

Details of recording requirements.

The management and monitoring of the Protocol.

An expiry date before which Protocol must be reviewed.
Page 23 of 130

Details of who drew up and who signed off the Protocol.
6.2. It is the responsibility of the Appointed Practitioner in Charge of each ward,
department or area to ensure that if medicines are administered without a
written prescription then a valid and current Protocol is available to guide
practitioners in their area and that the person administering the medicine has
receive training about the protocol and is eligible to work under it.
6.3. The practitioner must assess the need for the use of medication and judge
him/her self competent, (and therefore accountable), to administer them.
6.4. Hard copies of approved Protocols must be available in each area where they
are used. Copies of all MAUPs will be available on the Trust website.
6.5. A record of this type of administration must be entered in the “Medicine
administered under protocol (MAUP)” section of the drug chart and signed by
the Designated Practitioner.
6.6. A Designated Practitioner can only administer a medicine following their own
assessment and not under the directions of another practitioner.
6.7. The Trust Drugs and Therapeutics Group is responsible for ensuring that
Protocols are reviewed every two years. New editions, revisions and deletion
of Protocols must be approved by the Trust Drugs and Therapeutics Group. A
record of the review must be on the documentation.
7. PATIENT GROUP DIRECTIONS
It is usually necessary that all medicines administered or supplied to a patient by a
practitioner be done so on the authority of an authorised prescriber. Patient Group
Directions allow named practitioners to administer and/or initiate a supply of medicines
without the authority of an authorised prescriber. Patient Group Directions must be
authorised by the Medical Director on behalf of the Trust.
7.1. The contents of a Patient Group Direction (PGD) must comply with the
requirements in Health Services Circular (2000/026, including:

Details of the condition or situation to which the PGD applies.

Details of which patients are included and excluded for the PGD and what
action to take if patients are excluded.

A description of the treatment available under the PGD including dose,
frequency and the aims of the treatment.

Characteristics of staff authorised to supply or administer treatment.

Details of records to be kept for audit purposes.

Details of practitioners responsible for drawing up the PGD.

Signatures of the lead doctor, chief pharmacist, Head of Profession(s)
eligible to work under the PGD and the Medical Director on behalf of the
Trust.
7.2. It is the responsibility of the appointed practitioner in charge of each ward,
department or area that if medicines are administered or supplied under a
Patient Group Direction that the PGD is valid, the practitioner is authorised to
work under the PGD and all appropriate documentation is completed.
Page 24 of 130
7.3. Copies of approved PGDs must be available in the areas they are to be used.
7.4. A practitioner working under a PGD cannot delegate responsibility for
administering and/or supplying a medicine under the PGD.
7.5. The Trust Drugs and Therapeutics Group is responsible for monitoring all Patient
Group Directions in use and for ensuring the Patient Group Directions are
reviewed before they expire (usually two years).
7.6. Individual practitioners are responsible for ensuring that their team manager or
Appointed Practitioner in Charge is told three months before their assessed
competency to work under a PGD is due to expire so appropriate training, if
needed, can be accessed.
8. ORDERING AND RECEIPT OF MEDICINES
Where appropriate, a list of medicines to be held for stock purposes, including
controlled drugs, will be drawn up by Pharmacy Staff in consultation with the
Appointed Practitioner in Charge. This list should be reviewed at least annually and
revised according to actual usage since the last review. Once agreed, a copy of the
stock list must be printed, signed and dated by the Appointed Practitioner in Charge
and the member of the pharmacy team involved in agreeing the stocklist. This copy
must be held on the ward in the pharmacy folder. Only nurses authorized by the
Appointed Practitioner in Charge to order drugs can do so. Before a nurse can order
any medication a sample signature must be sent to the pharmacy, countersigned by
the Appointed Practitioner in Charge.
8.1. Controlled Drugs


The responsibility for ordering, receipt, storage and recording of controlled
drugs is that of the Assigned Practitioner in Charge of the ward/department.
The ordering of stock and temporary stock controlled drugs will use the
documentation and standards of the SLA acute trust providing the pharmacy
supply service.

Some local Substance Misuse Teams may have special supply
arrangements agreed with community pharmacies. These local
arrangements must be approved by the Chief Pharmacist.

Controlled Drugs can only be ordered from the pharmacy by submitting a
requisition from the official Controlled Drugs Requisition Book. Ordering is
restricted to an Assigned Practitioner in Charge. All Assigned Practitioners
who may order controlled drugs must provide the supplying Pharmacy
Department with specimen signatures.

Unless the Controlled Drug order is for an agreed stock controlled drug, the
Controlled Drugs Requisition Book must be accompanied by the Drug Chart
(or a photocopy for off site pharmacies) to confirm the reason for the
temporary stock supply.

All controlled drugs must be delivered to wards or departments in a tamper
evident package.

o
The tamper evident package can be a locked box such that the person
delivering the box has no access to the key.
o
Or a package sealed by a tamper evident closure that has a unique
serial number recorded.
Where appropriate a porter, driver or courier may deliver controlled drugs in
a tamper evident package.
Page 25 of 130

The porter, driver or courier must sign a drugs delivery record sheet or
book. A Designated Practitioner must receive the package and sign a drugs
delivery record sheet or book. The Designated Practitioner signs for receipt
of a tamper evident pharmacy container. If the controlled drugs are to be
collected by a Designated Practitioner, the appropriate part of the Controlled
Drugs Requisition Book must be signed and the medicines transported back
to the ward in a sealed package.

A Designated Practitioner must check the contents of the package
containing controlled drugs against the requisition. Any discrepancy must
be reported to the appropriate pharmacy IMMEDIATELY. If correct, the
Designated Practitioner must sign the requisition. The Designated
Practitioner must enter the new stock into the controlled drugs register on
the appropriate page, witnessed by another Designated Practitioner,
Authorized member of the Pharmacy Staff or an Authorized Employee who
must verify the stock level and sign the register. The medicines must then
be immediately locked away.

Where sealed packs of controlled drugs are supplied with tamper evident
seals, there is no requirement to open these packs for stock checking
purposes.

Controlled Drugs must be stored in a locked medicines cupboard, approved
by pharmacy and reserved for the sole storage of controlled drugs. Access
must be limited to Designated Practitioners, Pharmacists or Authorised
Pharmacy Technicians.

Registers and Requisition Books for controlled drugs are controlled
stationary and obtainable only from the pharmacy. Requisition books must
be locked away.

Orders and records must be in permanent ink and must be retained for two
years.
8.2. All Other Stock Medicines
8.2.1. Ordering of stock medicines
A designated Practitioner or authorised member of the pharmacy staff shall be
responsible for ordering medicines from the pharmacy for the purposes of
maintaining ward stocks.
Stock medicines may be ordered by:

Supplying a written requisition from the appropriate order book, or an order
sheet signed by a Designated Practitioner.

Using a fax machine to send a copy of the above.

By means of the pharmacy top-up service.
8.3. Non-Stock Medicines
8.3.1. Ordering of non-stock medicines
Non-stock medicines for individual patients may be ordered by:
Page 26 of 130

Submitting a signed order plus the patient’s drug chart.

Using a fax machine to send a copy of a signed order and the patient’s drug
chart.

By means of the ward pharmacy service.
If a patient’s own medicines are available, they may be used with the patient’s or
their carers (if appropriate) consent, providing they comply with the standards set
out in this Medicines Code.
8.4. Medicines for Short Term Leave or Discharge
8.4.1. Short term leave or discharge medication can be ordered by:

Completing the “Short Term Leave” section of the drug chart, or completing a
discharge prescription. Depending on local arrangements, a copy of the drug
chart may also have to be submitted to the pharmacy.

Using a fax machine to send copies of the above (if agreed locally).
8.4.2. Controlled Drugs cannot be supplied to a patient until the original
prescription has been received by the Pharmacy.
8.4.3. Once the leave/discharge medicine is delivered to the ward the supplied
medication and its labeling should be carefully checked by a designated
practitioner against a copy of the drug chart or discharge prescription.
Special care must be taken to ensure any medicines not supplied by
pharmacy but already on the ward are labeled for leave or discharge e.g.
inhalers, are added to the bag of medicines. (See below).
8.4.4. When checking delivered discharge / leave medication, the designated
practitioner must:

Check the labels, including the quantity / number of doses issued, against
the prescription chart / discharge prescription.

Make a visual check of the approximate quantity of medication supplied
and compare against the expected quantity / number of doses.

Mark the ‘TTO bag’ as “checked” and add their initials and date checked.

Record receipt of the medication in the patient’s notes, including a record
of any errors and action taken to correct these.

Report any errors to the ward / unit manager and / or the Modern Matron.
8.4.5. If a problem with a discharge/leave medication is discovered after it has
already been taken from the ward/unit, this must be reported to the ward/unit
manager or Modern Matron and they must decide on what action to take.
8.4.6. All errors relating to the supply of leave or discharge medication must be
recorded in the patient’s notes and must also be reported via the Trust’s
incident reporting scheme.
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8.4.7. If the leave/discharge medicines have been supplied well in advance of the
leave/discharge then extra care must be taken to check that no prescription
changes have taken place in the interim.
8.5. Delivery of Medicines
8.5.1. All medicines must be delivered to wards/departments in a secure
container. Where appropriate, a porter, driver of courier may deliver
medicines in a tamper evident package or locked box. The porter, driver or
courier must sign a drugs delivery record sheet or book. A Designated
Practitioner or authorized employee must receive the package or box and
sign the drugs delivery record sheet or book. The Practitioner is signing for
the receipt of a tamper evident pharmacy container or locked box and not the
contents.
8.5.2. If there is a central receipt point then an authorized member of staff may
sign for it but a local audit trail needs to be established for onward distribution.
8.5.3. Medicines may be collected from Pharmacy by a Designated Practitioner
or approved messenger and transported back to the ward in a tamper evident
pharmacy package or locked box.
8.5.4. On arrival the Designated Practitioner must:

Sign for the tamper evident package or locked box in the delivery book.

Check the contents against any delivery note, signing and retaining it for a
minimum of 12 months.

Lock the medicines in the medicine cupboard, fridge or trolley
immediately.

Report any discrepancies or errors to the Pharmacy as soon as
possible.
8.6. ‘One stop’ Dispensing
Where one stop dispensing has been introduced, supplies of inpatient medicines
dispensed for the individual patient can be issued for short term leave or discharge,
provided:
 There are sufficient supplies.

The patient has been deemed suitable to receive one stop dispensing supplies
following assessment by the primary nurse and a member of the pharmacy team
using the ‘One Stop Dispensing Risk Assessment Form’. (Appendix 12). This
form should be checked prior to using one-stop supplies for short term leave or
discharge.

The decision has been recorded in the patient’s notes along with a copy of the
assessment.

The medicines stored in their individual tray(s) within the ward medicine trolley
correspond to those prescribed on the discharge or leave prescription.

The medicines have a label including the name of the medicines, the directions
for use and the name of the patient that correspond to those on the prescription,
along with the date of dispensing.
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
The Designated Practitioner checking the inpatients medicines for use has been
deemed competent to check ‘one stop’ medicines for short term leave or
discharge use.
Where the short term leave or discharge prescription differs from the medicines in
the patient’s cabinet or when there are insufficient supplies of medicines, the ward
staff must contact the Pharmacy Department to make arrangements for the required
discharged medicines to be dispensed.
The patient’s suitability or unsuitability must be reviewed if the patient’s condition or
circumstance change.
8.7. Controlled Drugs to Take Out
8.7.1 Controlled drugs to take out should be ordered on a short term leave or
discharge prescription which has been completed and signed by the prescriber in
accordance with current legal requirements. The prescription must include the
patient’s name and address, drug name, the form, the dose, the frequency, and the
total quantity (in words and figures). The original prescription must be sent to
pharmacy for dispensing.
8.7.2 Delivery and receipt of controlled drugs for short term leave or discharge TTO
purposes should be as for other medicines, but storage on the ward/department
should be in the controlled drug cupboard.
8.7.3 It is not usually necessary to enter the TTO into the Controlled Drug Register
although individual units may choose to do so if it is felt that additional administrative
safeguards are required. However, if a patient’s discharge is delayed beyond the
planned discharge date or one of the CDs supplied for discharge needs to be
administered while the patient is still on the ward, then the CDs supplied as a TTO
must be stored in the CD cupboard, entered into the CD register and booked out
when the patient is discharged or the TTOs are destroyed if not needed.
9. BORROWING OF MEDICINES
9.1
Medicines must not be borrowed from a ward or department unless a
supply cannot be obtained directly from the pharmacy during normal
working hours. If the unit has an emergency cupboard, this must be
checked first. Most wards have access to a small number of FP10
prescriptions that can be dispensed at a local community pharmacy. These
should be used in preference to borrowing when local community
pharmacies are open. Only medicines dispensed by the hospital pharmacy
service may be borrowed and usually the complete container should be
transferred to the receiving ward. If only one container is available and the
drug is needed on the original ward the full container must be taken and the
dose administered from it, and then return the container to the original ward.
9.2 Only in exceptional circumstances may medicines be transferred into
another container in order to be transferred. In these circumstances an
appropriate, clean medicines container must be used, and must be labeled
with all details of the medication including batch number and expiry date.
Where such transfer occurs, it is the responsibility of the assigned practitioner
in charge.
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9.3
A signed record of the transfer of medicines must be kept in both wards’
diaries involved in the ‘borrowing transaction’. The signatures must be those of
the Assigned Practitioners in Charge of both wards.
9.4
Controlled Drugs must not be borrowed expect in an extreme emergency.
Where this does occur, full records of the transaction must be made in both
wards’ Controlled Drugs Registers and both signed and countersigned by the
Assigned Practitioners in Charge of both wards.
9.5 If borrowing occurs, Pharmacy should be informed at the earliest opportunity so
that the stock can be replenished.
10. PATIENT AND CARER INFORMATION
10.1 It is important that the patient (or carer if appropriate) receives adequate
information about their medicines prior to discharge unless their care plan
deems it inappropriate.
10.2 The patient should know as a minimum:

The purpose of the medicine

How to take it.

For how long it is to be taken for.

What side-effects they may experience.
10.3 This is the responsibility of the prescriber who may choose to involve authorized
pharmacy staff in this process and the actions taken should be documented.
10.4 Best use should be made of any Patient Advice Leaflets supplied with the
medicines and any additional leaflets endorsed by the Trust and are available
on the Trust website.
10.5 Patient information is available on request in other formats including large print
and electronically. Interpreter and translation services are also available.
11. TRUST PHARMACY SERVICES
11.1 Medicines will be procured supplied and dispensed in accordance with the
relevant legislation, professional standards and NHS recommended practice.
11.2 So far as possible, pharmacists will monitor the use of medicines for patients
in their care, and place special emphasis on complex; potentially toxic and high
risk medicines that require higher levels of monitoring. Monitoring will include the
need for the medicine, the medicine selected, the dose regimen including the
duration of treatment, the medicine formulation and the route of administration In
addition pharmacists will monitor for medicine interactions and adverse reactions
and whether the therapy is achieving the desired therapeutic end points
Continuing medicine treatment will be reviewed as necessary.
11.3 Authorized pharmacy staff will annotate the prescription. This annotation must
ensure the approved name (where appropriate); does, route and cautions and
any additional information is included on the prescription, to guide practitioners
when they administer the medicine.
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11.4 Where an authorized pharmacy staff member wishes to make a
recommendation to change or modify a patient’s therapy and the prescribe is
not immediately available and the advice is not deemed to be urgent, he/she
will liaise directly with the assigned practitioner in charge and, where
considered appropriate, will record the recommendation in the patient’s notes
and if available the doctors’ communication book. If urgent another member
of the medical team should be contacted.
11.5 Authorized pharmacy staff will make and maintain their own record of any
significant interventions for future reference.
11.6 Inpatients (or their carers where appropriate) should be advised about their
medicines by authorized pharmacy staff during their admission stay or period of
admission unless their car plan deems it inappropriate. This should be a part of
an agreed programme for each ward. The Appointed Practitioner in Charge
should agree with the pharmacist and consultant the arrangements for advising
patients (or their carer) about their medicines.
11.7 Where practicable and appropriate, practitioners may request the authorised
pharmacy staff advise patients about their medication during the course of their
in-patient stay, attendance at clinic, outpatients or in discussion or educational
groups.
11.8 Alternative arrangements for advising patients about their medicine may be
provided if:






The nature of the hospital stay is less than one week.
There is a need for a rapid discharge
Patients are identified who may need further advise post discharge
The care plan indicates that such discussions would be inappropriate.
There is insufficient availability of suitably trained pharmacy staff.
The patient requires the information in another format or language.
Such alternative arrangements must identify the person responsible for the
provision of information and the nature of the information to be provided.
11.9 Authorized pharmacy staff must be involved in advising on security and
medicine storage conditions on the ward/unit or department.
12. PHARMACY OUT-OF-HOURS SERVICE
12.1 Only in cases of clinical urgency will the on-call pharmacist supply items. The
supply of the vast majority of medicines will not be clinically urgent and can
usually be safely left to the next time the pharmacy is open. However, when in
doubt the on-call pharmacists may be contacted and will assist ward staff to
determine the degree of urgency.
12.2 It may not always be possible to have individual medicine supplies available
from the pharmacy for the next medicine administration round.
Nursing/practitioner staff must make maximum use of patients’ own medicines
and emergency drug cupboards (where provided). If the medicines have been
ordered and have not yet been supplied by the pharmacy the Designated
Practitioner must record “N” on the medicine administration chart. Medicines
brought in by patients at the time of their admission must never be used for
other patients.
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12.3 The Pharmacy out of hours service is also available for urgent medicines
information advice and for reporting suspected significant adverse reactions to
medicines or suspected faulty medicines.
13. ADMINSTRATION AND PREPARATION OF MEDICINES
The preparation, checking or administration of medicines to a patient must only be
undertaken by the following categories of healthcare staff:

A Designated Practitioner.

A Medical Practitioner.

Authorized Pharmacy Staff.

A practitioner in training or an employee training to administer medicines, but only
under the direct supervision of a Designated Practitioner. The Designated
Practitioner remains responsible for ensuring that the correct procedure takes
place.
In addition a designated practitioner may delegate the role of assisting the patient to
ingest or apply the medicine, to an unregistered employee or carer who has been
assessed as being competent to carry out the task. The Designated Practitioner in
Charge is accountable for the assessment of this competency, which may be
delegated to another Designated Practitioner to undertake.
13.1 Preparation of Medicines
13.1.1 It is during the preparation of medicines for administration that errors
frequently occur, particularly where some form of dose calculation is
involved. In the majority of cases, medicines will be presented to ward
areas from the Pharmacy Department in a ready-to-use form, where no
further dilution or dose calculation is required.
13.1.2 Where the preparation of medicines is performed outside the Pharmacy
Department, the following points must be observed:

Read the prescription carefully; determine the name, dose, diluents, route
for administration and expiry date.

If a dose calculation is required this information must be included as part
of the prescription either by the doctor or the pharmacist so that the
Designated Practitioner administering the dose is clear about the actual
amount to administer. It is strongly recommended that the Designated
Practitioner checks all calculations with a second practitioner or
pharmacist before administration.

Where a calculation is involved and where the medicine is intended for
parental administration, a second practitioner must check all aspects of
the preparation of the medicines and sign and date the entry.

If the practitioner is unclear as to the correct medicine diluent or precise
method for medicine preparation, he/she must obtain this information from
the Summary of Product Characteristics (SPC), BNF, appropriate
Pharmacy Department or on call pharmacist before proceeding. Most
SPC can be obtained from www.medicines.org.uk.
Page 32 of 130
13.2 Administration of Medicine
13.2.1 The Assigned Practitioner in Charge is responsible for ensuring that
prescribed medicines are administered at the prescribed time. Minimum
time intervals between doses must always be checked if doses are
delayed or need to be given early. If the timing has to be significantly
exceeded or brought forward, advice should be sought from the prescriber
or authorized pharmacy staff. For patients who repeatedly request to
delay their medication the pharmacy team can provide advice that can be
incorporated into the patient’s care plan.
13.2.2 Before administration of a medicine, a practitioner must check:

Legibility and correct completion of all details on the drug chart.

Authorization and administration (Form T2 or T3) if the patient is detained
under the Mental Health Act.

All sections of the drug chart to get an overview of all the medicines being
administered to identify any prescribing or administration errors.

Extreme care is required to confirm the patient’s identity. Use a
photograph if available and verbal questioning to confirm the patient’s
identity before proceeding to administer the dose.

The record of the administration of medicines that the prescribed dose has
not already been given.

The name, form and strength, and prescribing period of the drug to be
administered against the drug chart.

The time of administration and the time the last dose was administered, if
appropriate.




The route of administration.
Any special guidance relating to the drug e.g. dilution with water, before or
after food.
The expiry date of the medicine.
Before signing the administration chart ensure that the medication has
been taken.
13.2.3 To reduce the risks of inadvertently administering an oral drug,
intravenously:

Only use labeled oral syringes that cannot be connected to intravenous
catheters or ports, to measure and administer oral medicines.

Do not use intravenous syringes to measure and administer oral liquid
medicines.

Make sure stocks of oral/enteral syringes are available in all clinical areas
that may need to measure and administer oral liquid medicines in
syringes.

When patients or carers need to administer oral liquid medicines with a
syringe, supply them with oral or enteral syringes.
Page 33 of 130
13.2.4 To reduce the risk of inadvertently administering an enteral drug,
intravenously:

Only use labeled enteral syringes that cannot be connected to intravenous
catheters or ports, to measure and administer enteral medicines.

Enteral feeding systems should not contain ports that can be connected to
intravenous syringes or that have end connectors that can be connected
to intravenous or other parenteral lines.

Enteral feeding systems should be labeled to indicate the route of
administration.

Three-way taps and syringe tip adaptors should not be used in enteral
feeding systems because connection design safeguards can be bypassed.
13.2.5 To prevent cross infection, following administration, single use medicines
pots and oral syringes must be destroyed. Non-disposable items must be
thoroughly washed in hot soapy water, rinsed in clean water and allowed
to dry. Oral syringes, even if manufactured for multiple use, must be
labeled for use by an individual patient.
Because of the inaccuracy of medicine pots the majority of oral liquid
medicines must be measured using oral syringes or medicine spoons.
Medicine pots can only be used for measuring; senna liquid, antacids,
lactulose, Gaviscon Advance® and Peptac® Liquid.
13.2.6 Prior to administering intramuscular or subcutaneous injection, if the skin is
clean, no further cleaning is necessary. Only visibly dirty skin needs to be
washed with soap and water.
In the event that alcohol or chlorhexidine swab is used to disinfect the skin
before an injection, the skin should be in contact with the swab for 30
seconds and the area allowed to dry completely for at least a further 30
seconds. Breaking the skin before the alcohol has completely dried can
affect the outcome/result and cause pain to the patient.
13.2.7 Medicines dispensed by the hospital pharmacy for an individual patient
should only be administered to that patient (supplies labeled for individual
patients must not be shared). In exceptional circumstances e.g. out of
hours individual doses can be used for another patient (see chapter 9).
Medicines brought in by patients at the time of their admission must
never be used for other patients.
13.2.8 The Practitioner who has administered or supervised the administration of
the medicine must, at the time of administration, sign with initials in
the appropriate column of the drug chart. To avoid confusion with
omission codes, the initial must consist of at least two letters.
13.2.9 The Designated Practitioner must observe the patient has taken their
medicines. Prepared medicines must never be left unsupervised.
13.2.10 If the patient is absent from the ward, or has missed a dose for some
other reason, the delayed dose can be administered at a later time
provided a doctor or pharmacist has confirmed that it is appropriate to do
so or that it is according to an agreed protocol. The actual time of
administration must be clearly recorded in the administration record by the
Designated Practitioner and appropriate entry into the patient’s record is
Page 34 of 130
made. There is a missed dose card available to highlight missed doses
on the drug chart.
13.2.11 Patients classified ‘Nil by Mouth’ prior to a diagnostic procedure or
receiving an anesthetic and undergoing ECT must have all their
prescribed oral medicines administered to them at the prescribed time
unless specifically advised otherwise by ECT staff and these omissions
must be marked on the drug chart as ‘E’. The medicines should be taken
with a small amount of water to enable the patient to swallow these
medicines. Only medicines that have been clearly marked on the
prescription sheet may be omitted. It is the responsibility of the prescriber
to provide clear written instructions to the nursing staff concerning the
omission of prescribed doses.
13.2.12 Patients receiving medication via a PEG feeding tube must only have
their drugs administered by a nurse or authorized employee who has been
formally trained by a member of a specialist team responsible for inserting
PEG feeding tubes. If a patient is admitted and no formal training has
been provided, specialist advice must be sought. Advice should be also be
sought from the pharmacy team if any doubts exists with regard to
administration of any medication via this system.
13.2.13 To reduce the risks of spreading or prolonging an eye infection due to
contaminated eye drops the following steps must be taken when a patient
is diagnosed with an eye infection:

If the patient is already on regular eye drops (e.g. for glaucoma) or ‘as
required’ eye drops (e.g. artificial tears) these must be replaced
immediately with a fresh supply, a separate bottle for each eye (if used in
both eyes), until the infection has been treated. The drops must be given
an expiry date of just one week once opened until the infection is
successfully treated, instead of the usual 28 days.

If the infection is in both eyes, a separate bottle of antibacterial/antiviral
eye drops should be dispensed for each eye and each bottle given an
expiry date of one week until the infection is treated.
13.2.14 If when administering or supervising the administration of insulin you are
unsure of the type of insulin that has been prescribed, every patient should
have in their possession an ‘insulin passport’ or equivalent local patient
record to help provide accurate identification of their current insulin products.
This should be used to check the accuracy of the prescription and if there are
any concerns the medical team should be contacted to clarify the prescription.
13.2.15 The self-administration of insulin by competent patients should be
actively encouraged, to help themmaintain their skills during an admission.
13.2.16 If a medicine is omitted (see also 13.8 below), covert administartion is
occuring or a patient is self-administering the following codes must be
entered on the administration record.



‘A’ must be recorded for absence without leave.
‘C’ must be recorded for covert administration along with the initial of the
practitioner administering the medicine.
‘E’ must be recorded for omitted prior to ECT.
Page 35 of 130

‘L’ must be recorded for on leave.

‘N’ must be recorded if there is no stock.

‘P’ must be recorded if the patient is managing their own medicines*

‘R’ must be recorded if the patient refuses.

‘S’ must be recorded when a patient is sleeping.

‘SA’ must be recorded for supervised self administration along with the
initial of the practitioner supervising the administration.

‘X’ must be recorded for a prescribed omission (e.g. alternate days
dosing).

‘O’ must be recorded if a medicine is omitted for any other reason, which
must be recorded in the patient’s notes.
* Assuming the nurse supervising self administration is confident that the
prescribed medication has been self-administered either the administration code
‘P’ (patient managing own medicines) can be written in the appropriate
administration box or other suitable wording written across over the appropriate
administration boxes on the drug chart to indicate self-administration is taking
place e.g. ‘patient self-administering’.
13.2.17 Refusal of medication by any route or of their aspects of care (e.g. blood
tests or physical observation) may have a serious detrimental effect and
should be reported to the senior nurse or doctor.
Failure to record the administration of a medicine or an omission code
constitutes a medication error and must be reported. The scrutiny of such
records will be the subject of regular audit.
13.3 Two person checking procedure
13.3.1 All designated practitioners are authorized to administer medicines without
involving a second practitioner. However, it is recognized that certain
circumstances exist where involving a second person in the process may
enhance safety e.g. when instructing a student or where the patient’s
condition or conditions on the ward indicate that a greater staff presence at
the point of administration is required.
13.3.2 Except in extreme emergency, two practitioners must check the following
(including calculations and measured doses)


All medicines given by continuous administration, e.g. IV infusion, syringe
drivers. There should be a record of the individual practitioner setting up
and replenishing each intravenous infusion.
All bolus injections, IV additives and injections via drip tubing.

All injections taken from multi-dose vials, including insulin pens. When a
patient has proven competent to self-administer the medicine (e.g. insulin)
the checking of administration need only involve one practitioner with the
patient.

All medicines administered to a child less than 12 years of age.
Page 36 of 130
13.3.3 Where a two person administration takes place, the following roles and
responsibilities will be assumed:

The administering practitioner takes sole responsibility for the safe
administration of the medication (unless that practitioner is a student or
trainee).

The administering practitioner will read the prescription, prepare and
administer the medication, and sign the administration record. This role
should not be shared.

The second person will ensure that medication pots etc. are clean, dry and
ready for use and that water is available for patients.

The second person will assist in the identification of patients unknown to
the administering practitioner.

The second person may offer a checking role to the administering
practitioner where any uncertainty occurs, but must do so if the
administering practitioner is a student or trainee or the two person
checking criteria above apply.

The second person will deflect any possible disruption, which may occur
during the administration process, to allow the administering practitioner to
fully concentrate on the task of administration.
13.4 Controlled Drugs
13.4.1 In in-patient areas a registered nurse must administer controlled drugs
and all aspects of administration must be checked by a second authorized
person, including authorized employees, doctors and pharmacists. This
second authorized person may also be a student nurse assessed as
competent by the Assigned Practitioner in Charge, to undertake this role
safely. A checklist is available for assigned practitioners in charge to help
them assess the competency of care assistants to witness the
administration of controlled drugs (appendix 16) and be designated
authorized employees for this role. In other settings local protocols will
apply.
13.4.2 In the community controlled drugs can be administered and checked by
one registered nurse.
13.4.3 The administration will be noted on the patient medication record and
signed by the administering nurse.
13.4.4 On inpatients units an entry must also be made in the ward or department
Controlled Drugs register, including:

Date and time of administration.

Name of patient.

Dose administered.

Full signature of both authorized persons.

Remaining stock balance must be checked (this must be physically
checked other than for liquids – see below)
On completion of the register any discrepancies must be dealt with
immediately (see the Losses and Discrepancies chapter).
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13.4.5 Any medicine prepared and not used, or only partly used must be
destroyed by the designated practitioner in the presence of an authorized
employee. An entry must be made in the Controlled Drug register and
signed by both persons.
13.5 Special Provision for liquid controlled drugs
13.5.1 This special provision addresses the need to avoid any excessive
decanting of liquid medication, (in order to check stock balance), as this
can lead to discrepancies in the balance due to loss during measurement.
13.5.2 Liquid CD preparations include:

Concentrated morphine sulphate solutions (Oramorph® and
Oramorph® concentrated).

Diamorphine solution and linctus.

Methadone solution and linctus.
13.5.3 Whenever possible the measurement of doses of oral liquid medication
should be by oral syringe, rather than by spoon (which can easily be spilt)
or for larger volumes calibrated measures provided by pharmacy, and not
by plastic medicine pot. (Such pots are readily available and are in
common use but are not accurate).
13.5.4 Before the preparation of each dose the persons responsible for the
procedure must make a visual check and estimate of the stock balance
held. Only if they consider the balance appears inaccurate do they need to
physically measure the stock in order to accurately confirm its quantity.
13.5.5 The record of stock balance in the CD register must be made routinely.
During normal use it will be based simply on the calculation of balance
remaining after removal of the dose.
13.5.6 The Appointed Practitioner in Charge remains responsible for balancing
the stocks of all controlled drugs at least weekly. Provided no
discrepancies have occurred in the preceding period, and particularly
where use of a drug has been limited, this again may be carried out by
visual estimate. However, weekly balance by measurement should be
considered where usage is heavy.
13.5.7 An accurate measurement of stock balance, preferably using a calibrated
glass measure, must be made whenever a discrepancy occurs, is
suspected or a bottle is finished. If significant loss is detected, greater
than 5ml per 100ml (e.g. less than 25ml per 500ml bottle), this must
immediately be brought to the attention of the unit manager and the unit
pharmacists.
13.5.8 If the discrepancy is less than 5ml per 100ml then the actual stock balance
should be recorded in the controlled book and endorsed “stock adjustment”
signed and dated by the designated practitioner in charge and a second
nurse or an authorized employee. If the adjustment is due to an overage,
which is normally the case, the additional quantity of controlled drug added
to the stock balance should also be written in the left hand section of the
register as a an additional supply. Instead of writing in the requisition
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number , put the word ‘Overage‘ instead. These small adjustments do not
need reporting as an incident.
13.5.9 Accurate measurement of stock balance may also be carried out by the
unit pharmacist at their discretion.
13.6 The administration of medicines by authorized pharmacy staff and by
designated practitioners other than nurses and medical officers.
13.6.1 Authorized pharmacy staff may carry out medicine administration
procedures only with the prior approval of the medical team.
13.6.2 Authorized employees other than nurses and medical officers, may only
carry out medicine preparation and medicine administration procedures
with the full approval of the medical team and only after a written
procedure has been approved by the Drugs and Therapeutics Group and
the appropriate intergrated governance team.
13.7 Medication to be given as required
13.7.1 The administration of the medicine must be recorded on the drug chart to
include time, date, dose and the initials of the member of staff
administering the medicine.
13.7.2 The reason for administration should be recorded on the drug chart and
the patient’s record.
13.7.3 If there is any doubt or concern, or the member of staff is unsure of the
criteria given for the administration of as required medication, then advice
must be sought from the patient’s doctor, a senior colleague or pharmacist.
13.7.4 There should be a review procedure in place, which ensures that frequent
or regular use if highlighted and brought to the attention of the patient’s
doctor.
13.7.5 Reasons for not administering as required medication when requested by
the patient should also be recorded in the patient’s notes.
13.8 Reducing harm from omitted and delayed medicines in hospital
13.8.1 Medicine doses may be omitted or delayed in hospital for a variety of
reasons, eg:
 Medication not available
 Administration overlooked
 In-patient chart lost or unavailable
13.8.2 Whilst occasionally these events may not seem serious, for some critical
medicines or conditions delays or omissions can cause serious harm or
death.
13.8.3 It is therefore important that nursing staff seek advice from pharmacy
and/or medical staff and follow Trust policies and procedures when any
drug is going to be omitted or delayed for whatever reason, or if it is
discovered that a dose or several doses of a drug have already
inadvertently been omitted.
13.8.4 The senior nurse on duty should decide whether the clinical risks warrant
getting advice during the night or whether this can wait until the following
morning.
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13.8.5 The following table gives examples of the consequences of omitting some
of the medication seen in an inpatient setting; these include psychotropic
drugs and physical drugs. The severity of the consequences may depend
on the length of delay, half-life of the drug, etc.
Medication
(This is not a comprehensive list)
Analgesics
Anticoagulants
Anticonvulsants / mood stabilisers
Antidepressants
Anti-infectives / antibiotics
Benzodiazepines (alcohol detox)
Regular benzodiazepines (shortacting)
Buprenorphine
Clozapine
Immunosuppressants
Insulin
Lithium
Lofexidine
Methadone
Oral contraceptives (especially
progestogen only)
Parkinson’s disease medication
Procyclidine
Resus / emergency medication
Possible consequence of omission or
delay
Loss of pain control
INR reduced, resulting in increased
blood clotting and the possibility of DVT
or PE
Loss of seizure control / loss of
symptom control
Withdrawal symptoms (especially with
paroxetine and venlafaxine)
Treatment failure and / or development
of resistance
Alcohol withdrawal symptoms e.g. risk
of convulsions
Withdrawal symptoms, agitation /
insomnia
Withdrawal symptoms
Loss of symptom control; if omitted for
more than 48 hours dose must be retitrated from 12.5mg to avoid serious
adverse effects e.g. hypotension,
seizures.
Rejection of organ transplant
Hyperglycaemia
Loss of symptom control, invalid test
results
Opioid withdrawal symptoms increased
Withdrawal symptoms
Unwanted pregnancy, exposure of
foetus to teratogenic medication
Loss of symptom control
Antipsychotic side effects exposed
Increased mortality
13.8.6 Omission or delay of medicines, for inpatients or on discharge from
hospital, are patient safety incidents and should be reported.
13.9 Administration of medication to members of staff
13.9.1 On duty staff occasionally requesting paracetamol tablets for mild pain
relief may be supplied with one dose, (one to two 500mg tablets), from
ward/unit stock at the time of their request, and up to a maximum of two
doses may be supplied within the working shift. The current edition of the
BNF should be referred to for information on dosage, precautions,
interactions etc
13.9.2 The Assigned Practitioner in Charge must respond to a request for
paracetamol and must not recommend it.
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13.9.3 A record must be kept on the ward/unit in a note book especially kept for
the purpose and must include:





Date and time of the paracetamol supply
Name of staff member requesting medication
Number of tablets supplied
Reason for the paracetamol supply
Name and signature of designated practitioner undertaking supply
13.9.4 The Assigned Practitioner in Charge is responsible for supply and must
ensure, so far as is possible, that it will not result in the individual taking
more than 8 paracetamol tablets within a 24 hour period, and that at least
4 hours have elapsed since any previous dose. Consideration should be
given to the possibility of the staff member already taking other medication,
either prescribed or purchased, which may contain paracetamol.
13.9.5 Where the Assigned Practitioner in Charge requests paracetamol for
him/herself, another designated practitioner must take responsibility for the
supply and record.
13.9.6 The Appointed Practitioner in charge must monitor the record book
regularly for any evidence of excessive use or misuse.
13.8.7 This does not allow the discretionary supply of any other medication to
staff. Nor does it allow the provision of prescribed medication where staff
may have forgotten to take or bring in their own supply.
14. TRANSPORT OF MEDICINES
The transport of medicines by community practitioners is covered in the ‘Community
Based Practitioner’ chapter.
14.1 When transferring patients
14.1.1 Medicines needing transfer

All medicines already labeled for the transferring patient must be
transferred with them. This includes controlled drugs.

If controlled drugs are included in the medicines being transferred they
should booked out of the discharging ward’s CD register and a descriptive
statement added, e.g. ‘Transferred by taxi to ward B’. The receiving ward
must be called and given specific details of the CD being transferred and
how many doses to expect. On arrival of the transferred patient the
receiving ward must ring the discharging ward to confirm safe arrival of the
CD. If there are any concerns about them going missing the pharmacy
team or on-call pharmacist should be called for advice. On receipt, the
receiving ward must immediately record the delivery in the CD register
putting something like ‘Transferred from ward A by taxi’, before storing the
controlled drug in the CD cupboard.

If a controlled drug is being transferred in the a taxi or in the possession of
a carer, the sealed bag with the controlled drug in must not indicate the
bag contains contolled drugs.

If some or all of the medicines for the transferring patient were being
administered from stock the receiving unit must be contacted to check
whether these stock drugs are held by them. If not:
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
During normal pharmacy hours advice should be obtained about arranging
appropriate supplies.

Outside normal pharmacy hours the principles for borrowing medicines
(Chapter 9) should be followed.
14.1.2 Transfers within hospitals



Authorized members of staff must transport medicines within hospitals and
must not delegate to patients or carers.
Medicines must not be left unattended at any time during transport.
When medicines are received at their final destination they must not be
left unattended or unsecured. They should be handed to a Designated
Practitioner and locked away in medicine cupboards, drug trolley or fridge
at the earliest opportunity.
 If controlled drugs are included in the medicines being transferred they
should booked out of the discharging ward’s CD register and a descriptive
statement added, e.g. ‘Transferred to ward B’. On receipt, the receiving
ward immediately book them into their CD register and store the CDs in
the CD cupboard.
14.1.3 Transport of medicines between health services premises

Medicines accompanying a patient and being transferred from one
hospital to another may be transported between hospitals with the patient
in an ambulance or by authorized hospital transport, or taxi in a sealed
bag. It is important that medicines are packaged securely and are labeled
with the final destination. The packaging must not indicate the contents of
the sealed package.

If the patient is being escorted by ward staff or transferred by ambulance
the medicines must remain in the possession of the ward staff or the
ambulance crew and dealt with as though transferring a patient within a
hospital.

If a relative or taxi driver is ever given responsibility to escort a patient
between units, unless there are concerns about security, medicines and
documents can be transported by them in a sealed package clearly
marked with the addressee’s name and address but not indicating what is
inside the package. The addressee must be asked to confirm by phone if
the medication/documentation has arrived safely within an agreed
deadline.
14.2 Transport of medicines from the pharmacy department
14.2.1 Transportation using hospital transport

All medicines must be transported in locked boxes or tamper evident
containers.

Controlled drugs must be transported in locked boxes or tamper evident
containers with uniquely numbered tamper evident seals with the number
recorded in the CD requisition book and the top copy kept in pharmacy.
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
Containers shall be kept securely or under surveillance whilst awaiting
collection from or on receipt at the designated areas.

On arrival on the wards/departments/clinics, containers should be placed
in a designated area. Once delivered to the ward/department/clinic the
responsibility for the security of the medicines rests with the Assigned
Practitioner in Charge who will arrange that the contents be unpacked,
checked against any delivery note and put away securely as soon as
possible. The delivery note must be signed and stored for a minimum of
12 months. Report any discrepancies or errors to the Pharmacy as soon
as possible.

The driver shall carry a record book stating the destination and the
number of containers for each destination with any unique seal numbers
recorded if appropriate. The authorized person accepting the delivery
must sign the record book.
Where the medicines are delivered to a central distribution point local
audit trails need to be established. The containers must be securely
stored while waiting to be distributed to the wards/departments/clinics.


The responsibility for the security rests with those transporting the
medicines until the delivery is completed and the necessary signatures
obtained.
14.2.2 Transportation from pharmacies by Taxis

All items should be transported in locked boxes or tamper evident
containers. Containers with controlled drugs in them must not have any
special marks to indicate controlled drugs.

If tamper evident seals are used. The seal number of the container must
be recorded in the transport book.

A suitable record must be completed and a copy must be retained in the
pharmacy department or on the ward. The driver takes two copies.

The taxi driver should be asked for an approximate time of arrival at his or
her destination. The ward, department or clinic due to receive the delivery
must be telephoned to forewarn them of the delivery and be given a time
after which they should chase the delivery if it has not arrived. This will
either be via the pharmacy, or the pharmacist on-call if out of hours.

Only hospital contract taxis with drivers able to produce identification
bearing a photograph shall be used.

Items must be collected from the pharmacy or an agreed designated
manned area, e.g. A & E, and delivered to the addresses or an agreed
designated manned area, e.g. ward reception.

If items are not delivered directly to the addressee the responsibility for
security rest with those receiving the container until delivery is completed
and documentation countersigned.

On arrival the driver must obtain a signature from addressee or agreed
representative.
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
After obtaining a signature for receipt of the medicines, one copy is kept
by the driver. The ward, department or clinic must retain their copy for 2
years.
14.3 Transport of medicines to individual patients at home
14.3.1 Patients who have left the hospital before all their medicines have been
dispensed must be instructed to return to the hospital later to collect their
medicines unless other approved arrangements have been made.
14.3.2 Medicines may be delivered by a member of the community team to the
patient’s home.
14.3.3 In exceptional circumstances medicines may be delivered to a GP
practice, health care clinic or community pharmacy by authorized hospital
transport, taxi or by post, for collection by the patient. Arrangements must
be agreed with the receiving premises and the Assigned Practitioner in
Charge of the ward needs to authorize it. It is important that medicines are
packaged securely and are labeled with the final destination.
14.4 Collection of medicines by voluntary drivers, relatives or representative
of the patient
14.4.1 Voluntary drivers, relatives or representatives of the patient may collect
medicines from a hospital pharmacy on behalf of a patient provided the
appropriate pharmacy has received prior notification of their impending
arrival by the ward, day unit or department and the person collecting the
medicine has proof of identity e.g. driving licence.
14.4.2 Voluntary drivers who receive medicines on behalf of a patient must deliver
the medicines to the patient and not pass the medicines to another
voluntary driver.
14.4.3 Voluntary drivers must carry identification of their role.
15. STORAGE OF MEDICINES (see also chapter 22 – Custody and safe keeping of
medicine keys)
 The appointed Practitioner in Charge is responsible at all times for the
safekeeping of all medicines on their ward or department.
 The design and location of all ward or department medicine storage cupboards
must be approved by Authorized Pharmacy Staff and regularly monitored.
 All internal and external medicines, disinfectants, and reagents must be stored
in locked rooms, cupboards, trolleys or other secure cabinets – all reserved
solely for medicinal products. The only exceptions to this requirement are
medicines for clinical emergencies. Intravenous fluids, sterile topical fluids and
nutritional products and some bulky medicated dressings, which because of
their bulk are stored in a clean area (as agreed between the Appointed
Practitioners in Charge and an Authorized member of the Pharmacy staff).
 Internal medicines must be stored separately from other medicines. Under no
circumstance must medicines be transferred form one container to another,
nor must they be taken out of their container and left loose.
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 Medicines should be arranged in a way to ensure clear identification and
efficient stock control. A nominated person should perform regular checks to
identify medicines that are approaching their expiry date.
15.1
Positioning of cupboards and trolleys
Cupboards and trolleys must be sited where most convenient for staff, allowing
adequate space and permitting surveillance to afford maximum security against
unauthorized entry. Medicine cupboards must generally be sited in a clean clinic
room to which patients and visitors do not have access. Cupboards must not be
sited where they may be subjected to higher than average humidity or temperatures
greater than 25°C. Reagent cabinets may be sited in areas where testing is carried
out.
15.2
Review of storage of Medicines
The authorized Pharmacy Staff and Appointed Practitioner in Charge will regularly
review the quantities, range and storage of medicines to be stocked.
15.3
Controlled Drugs
No ward or department will store controlled drugs unless there is an Appointed
Practitioner in Charge responsible for their storage and use.
15.4
Sample Medicines or dressings
Medicines or dressings samples must not be left on or accepted by wards, clinics or
departments, including pharmacy or with any member of staff.
Representatives of commercial companies wishing to leave samples must be told
that the Trust will purchase the product should it wish to use it.
15.5
Storage Accommodation
Clinical areas may have some or all of the following medicine storage units.
 Controlled Drug Cupboards – reserved solely for the storage of controlled
drugs and other high risk medicines following specific agreements with
authorized pharmacy staff. These cupboards must be made of metal and may
be separate from others or be inside other locked metal medicines cupboards
used to store internal medicines. These cupboards must be secured to the
wall. The lock must not be the same as any other lock in the hospital or unit.
controlled drugs must not be stored in trolleys.
 Internal Medicine Cupboard(s) – for the storage of tablets, liquid medicines,
injections, patches etc. and must be made of metal.
 External Medicine Cupboard(s) – for the storage of creams, lotions etc (May
also be used for the storage of reagents and tests).
 Medicine Refrigerator – medicines are not to be stored together with food or
pathological specimens, but in a separate locked fridge. Medicines requiring
storage below room temperature will be marked “Store between 2°C and 8°C,
in a refrigerator.” All medicines fridges will be fitted with a digital thermometer
(maximum/minimum type) and an audible alarm. The assigned practitioner in
charge is responsible for ensuring that max/min temperatures are monitored
and recorded daily. Pharmacy should be informed if these temperatures are
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outside the range. See Chapter 36 for more extensive guidance on handling
medicines requiring cold storage.
 Reagent Cupboard(s) – situated in the area where urine testing is carried out.
Some wards may not require a separate cupboard if urine testing is only very
rarely carried out but in such circumstance there should be a ward agreement
about where such testing is to take place.
 A Clean Storage Room – for intravenous fluids and sterile topical fluids, if no
suitable cupboard is available.
 Medicine Trolley – for storage of medicines in current use on the medicine
administration round. When not being used the medicine trolley must be
locked and secured to the wall. The trolley must not be left unattended during
the medicine round. If the Designated Practitioner leaves the trolley, it must
be locked immediately.
 Medicines for Resuscitation – these must only be held where an acute trust
crash team is available or in an ECT suite for use by the anaesthetist. They
must be in a position to afford supervision to prevent unauthorized access.
These must be held in a tamper evident box and must not be in a locked
cupboard. Once opened the box must be returned to the appropriate
pharmacy for replacement. (See Sussex Partnership NHS Foundation Trust
resuscitation and anaphylaxis policy).
 Individual Patient Medicine Cupboards – medicines dispensed for individuals
(together with the patient’s own medicines) can be stored in an individual
locked medicine cupboard at the side of the patient’s bed. These cabinets
must be kept locked when not in use and the keys held by a Designated
Practitioner. Where self-medication takes place, the individual patient may
also keep keys to this cupboard. (See self administration policy).
15.6
Closure of a Ward or Department

If a ward or department is due to close, the controlled drugs must be handed
over by an Assigned Practitioner in Charge to an Authorized member of the
Pharmacy Staff who will sign the appropriate section of the register and return
the controlled drugs to the pharmacy. All other medicines must be returned to
the appropriate pharmacy in a locked box that has been sealed and the seal
signed by assigned practitioner in charge on the day the ward or department
closes. Items requiring refrigeration must be stored separately in an
appropriately sealed tamper evident container.

If the closure is only for a short period, (e.g. just one or two days), all
medicines may stay on the ward (other than controlled drugs) provided there
is adequate security to prevent unauthorized access to the cupboards.
15,7
Medicines Requiring Additional Security
15.7.1 The Trust has identified a list of non-CD medicines with greater
abuse potential that may be at greater risk of diversion. To avoid
diversion additional pharmacy monitoring will take place and, where a
specific need is identified, some wards / units may introduce additional
storage safeguards. The medicines covered are:
 Alprazolam
 Codeine
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












Diazepam
Dihydrocodeine
Flurazepam
Ketamine
Loprazolam
Lorazepam
Lormetazepam
Midazolam
Nitrazepam
Oxazepam
Zapelon
Zolpidem
Zopiclone
15.7.2 Any request to add one of these medicines to a ward/home stock list must
be supported by a written request on a special proforma available from the
pharmacy team. The Appointed Practitioner in Charge must complete it
and give it to the clinical pharmacist who will need to support the request.
This request will need to be approved by the Chief Pharmacist.
15.7.3 Stock medicines on this list should be reviewed regularly and removed
from stock if use is low and it is not needed for emergency use.
15.7.4 Pharmacy staff checking ward stocks will pay particular attention to the
usage patterns of these medicines, reconciling usage with administration
records if there are any concerns. Pharmacy staff will record in the ward
diary when these checks have taken place.
15.7.5 When any of these listed medicines are returned to pharmacy, either as
stock medicines, named patient supplies or patients own medicines, a
record must be made in the ward diary detailing the medicine and the total
number of doses removed and the patient’s name if not a stock supply.
This record must be signed and dated by the member of pharmacy staff
and the nurse witnessing the removal.
15.8
Breach of Security

Any suspected incident must be reported immediately and investigated by
the Appointed Practitioner in Charge together with an Authorized member
of the Pharmacy Staff. If a breach of security is confirmed the Chief
Pharmacist (or in his absence the most senior pharmacist on duty at the
local acute trust) and the Trust Head of Security (or his deputy) must be
contacted and a decision made on whether to call the police.

In the case of an obvious break in or theft then the police must be called
immediately.

Following a breach of security the Appointed Practitioner in Charge may
agree with the local clinical pharmacist heightened monitoring and
increased security measures for a limited or extended period.
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16. STORAGE AND HANDLING OF FLAMMABLE LIQUIDS, GASES AND
AEROSOLS
Very small quantities of these may be kept in the external medicines cupboard. Where
larger quantities are held, advice must be obtained from the Trust Fire Safety Officer.
16.1 Medical Gases
16.1.1 Oxygen cylinders should be stored in a dry, clean and well-ventilated area
and secured in a safe position where they cannot fall over. Cylinders must
never be used or stored where there are naked flames or high
temperatures. Where necessary, the Fire Officer should be consulted on
the safe sue and storage of oxygen cylinders ‘No Smoking’ signs should
be displayed where oxygen is in use or being stored near areas where
smoking is allowed.
16.1.2 Where cylinders are held they should be in specifically designed trolleys or
wall racks to prevent them from falling over. Their storage position on the
ward should be agreed with the Trust Fire Safety Officer.
16.1.3 Staff involved in the use of oxygen should receive approved and
documented training regarding the safe use of equipment including
checking, maintenance and storage of oxygen cylinders.
16.1.4 When not in use the cylinders should be closed at the cylinder head (with
the appropriate spanner) as well as at the flow meter.
16.1.5 Flow meters seals (‘O’ rings) must be replaced every 2 years to prevent
leakage which is a fire risk.
16.1.6 When changing cylinders hands must be clean as the mixture of oil or
grease e.g. butter with oxygen is combustible.
16.1.7 More details on the storage and use of medical gas cylinders, and the
issues associated with medical gases together with Health and Safety
information will be found in the guidance set out in Health Technical
Manual, HTM2022.
16.1.8 A local written procedure should be available which details the ordering,
receipt, handling, storage, issue and use of medical gases.
17. LOSSES OR DISCREPANCIES
In the case of an obvious break in or theft then the police must be called
immediately.
17.1 Controlled Drugs
17.1.1 In the event of a discrepancy between the stock balance and register for
controlled drugs, the Appointed Practitioner in Charge must immediately
and thoroughly investigate the loss. A missing or incorrect entry or
arithmetical error must be investigated first and if found corrected. When
correcting the error in the register no crossing out or Tippex® must be
used on previous entries. A full explanation should be recorded in the
register. Any recording must be signed and dated by the Appointed
Practitioner in charge and authorized witness.
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17.1.2 If this investigation is unsuccessful the discrepancy must be reported
immediately to the senior manager responsible for the ward or department
and the local mental health pharmacist to investigate further.
17.1.3 If after further investigation a breach of security cannot be ruled out the
Chief Pharmacist (or in his absence the most senior pharmacist on duty in
the local acute trust) and the Trust Head of Security (or deputy) must be
contacted and a decision made whether to call the police.
17.1.4 In all cases of a confirmed discrepancy involving controlled drugs, an
incident report form must be completed.
17.2 Other Medicines
Any loss of other medicines must be reported to the senior manager responsible for
the ward or department (via the Appointed Practitioner in Charge) and the local
mental health pharmacist who can then decide on a further course of action.
18. DISPOSAL OF MEDICINES NO LONGER REQUIRED
18.1 Controlled Drugs
Important Note – for the purposes of destruction all controlled drugs in schedule
4 are included, which includes all benzodiazepines and the ‘Z’ drug hypnotics.
These are not usually subject to other restrictions, e.g. special ordering and
storage.
18.1.1 In date controlled drugs
Controlled drugs no longer required by a ward or department must only be
removed or destroyed by a pharmacist. The pharmacist must be authorized to
remove or destroy controlled drugs on behalf of the Sussex Partnership Trust.
Those pharmacists authorized will carry an authorization letter, signed by the
Trust’s Accountable Officer for Controlled drugs.
Upon removal of the controlled drugs, pharmacist will enter the appropriate stock
balance and sign the Controlled Drugs Register. The transaction should be
witnessed by a designated practitioner who will also sign the register. The drugs
must remain securely stored in the CD cupboard prior to their removal.
Any controlled drug removed from the ward or department by a pharmacist must
be returned to the pharmacy department where an appropriate entry will be made
in the pharmacy’s Controlled Drug Register.
If the quantity or value of in date controlled drug stock is minimal a decision can
be made by the pharmacist to destroy it on site instead of returning it. If a
decision is made to destroy the controlled drug on site the procedure laid down
for out-of date controlled drugs below, must be followed.
18.1.2 Partly used or opened controlled drug
Any dose of a controlled drug that is prepared or opened but not administered,
including partly used syringes used in syringe driver pumps, or ampoules and odd
doses spat out by the patient must be destroyed on the ward or department
immediately. Though CDs are usually destroyed in a DOOP kit, these single
doses or part used doses can be disposed of in the general medicines waste bin.
Solid dosage forms should be wetted in a small amount of soapy water before
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tipping everything into the general medicines waste bin. Once emptied, any
syringe or ampoule can then be disposed of in the sharps bin. The destruction of
the controlled drug must be in the presence of a second designated practitioner
or if not available, an authorized employee. The appropriate entry must be made
in the Controlled Drug Register (see 18.1.3 for schedule 4 CDs), which includes
the signatures of the two individuals involved in the destruction.
18.1.3 Out of date controlled drugs
Any dose of a controlled drug that is out of date must be destroyed where
appropriate. The destruction of the controlled drug must be in the presence of a
pharmacist and the Assigned Practitioner in charge using a DOOP kit (except for
patches) and the DOOP kit can then be disposed of in the medication waste bin.
DOOP kits can be ordered on the stores catalogue. The pharmacist must be
authorized to destroy controlled drugs on behalf of the Sussex Partnership Trust.
Those pharmacists authorized will carry an authorization letter, signed by the
Trust’s Accountable Officer for controlled drugs. The appropriate entry must be
made in the Controlled Drug Register, which includes the signatures of the two
individuals involved in the destruction. If the controlled drug is from schedule 4,
e.g. lorazepam or zolpidem, then an entry must be made in the back of the
Controlled Drugs Register (drug name, formulation, dose and number of dose
units destroyed), indicating that the stock was destroyed on the ward and the
entry signed and dated by both the pharmacist and nurse involved. If the
controlled drug is a transdermal patch e.g. fentanyl patch, these should be folded
over onto themselves to that the drug layer is sealed with the outer film skin and
disposed of according to local procedure. The method of destruction needs
recording in the Controlled Drugs Register.
18.1.4 Patient’s own controlled drugs
Controlled drugs brought in to the hospital by a patient may be:


Used by the ward staff for administration to the patient (see Patient’s Own
Medicines section).
Stored for subsequent destruction on the ward as in 18.1.3 above.
In both of the above the controlled drug must be stored in the controlled drug
cupboard, and entered in the Controlled Drug Register on a new page specifically
allocated for that patient’s own medicine.
Patient’s own controlled drugs can be returned to the patient on discharge if
appropriate. If the controlled drugs are no longer required they should ideally be
destroyed on the ward rather than returned to the patient or carer. If they require
destruction they must be dealt with in the same way as out of date controlled
drugs (see 18.1.3 above).
On the death of a patient on the ward:

Patient’s owns must never be returned to a relative or carer and must be
kept on the ward in quarantine in the Controlled Drugs Cupboard for two
weeks in case they are requested by the coroner.

While on the ward they must be put in a sealed bag and labelled with the
patient’s name and the date after which they can be destroyed.

If the relatives or carer insist on collecting the medicines after the two
weeks, advice should be sought from the Chief Pharmacist.
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18.1.5 Used transdermal patches containing controlled drugs
If the controlled drug is a used transdermal patch e.g. fentanyl patch, these
should be folded over onto themselves to that the drug layer is sealed with the
outer film skin and disposed of in the medication waste bin. No record need be
made in the Controlled Drugs register
18.1.6 Auditing correct destruction of controlled drugs
During their six monthly controlled drug stock checks, pharmacists will audit the
destruction of controlled drugs in the Controlled Drugs register to ensure
compliance with this guidance.
18.2 Other Medicines
All stock medicines, other than controlled drugsthat are no longer required by the
ward or department must be returned to the appropriate pharmacy either by
Authorized Pharmacy Staff or in a locked box.
All patient labelled medicines, including Patient’s Own Medicines (see chapter 19),
that are no longer required must be put in the medication waste bin on the ward.
Any odd dose that is spat out, prepared or opened but not administered, including
partly used syringes used in syringe driver pumps, or ampoules, must be destroyed
on the ward or department usually by placing the medicine in the medication waste
bin. Once emptied syringes or ampoules can then be disposed of in the sharps box.
Failure to dispose of the excess drug before placing the syringe or ampoule into the
sharps box will render the sharps box ‘medication waste’ requiring disposal and
additional costs. For used transdermal patches, these should be folded over onto
themselves to that the drug layer is sealed with the outer film skin. They may then
be disposed of in the medication waste bin.
19. PATIENTS’ OWN MEDICINES
19.1 All medicines brought into the hospital by patients remain their own property
and must not therefore be destroyed or otherwise disposed of without their
agreement or, if this is not possible, their relatives’ agreement. A best interest
decision may have to be made. In all cases the decision should be recorded in
the patient’s notes.
19.2 Medicines brought into hospital by patients must be reviewed by the admitting
doctor who may or may not wish to prescribe them.
19.3 Patient’s own medicines brought into the hospital may, with the patient’s
permission, continue to be used provide:
19.3.1 The admitting doctor wishes the medication to continue and has prescribed
the medication on Trust Drug chart.
19.3.2 The ward has a procedure to routinely use ‘patients’ own medicines.
19.3.3 The medication is examined by the Trust doctor, authorized pharmacy
staff, or a designated practitioner and is considered suitable for use.
19.4 If ‘patient own medicines’ are not routinely used they may still be used if:
19.4.1 Alternative supplies are not available (e.g. because of night time, weekend,
or bank holiday admission).
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19.4.2 Ward stock or named patient supplies remain unavailable for the supplying
pharmacy.
19.5 In the case of a patient maintained on a medicine not approved by the Trust the
following options can be considered:
19.5.1 The patient’s prescription can be modified to the nearest equivalent
approved medicines.
19.5.2 The patient can agree that their own medicines can be used including
supplies kept at home.
19.6 In no circumstances should Trust staff contact an inpatient’s general
practitioner to receive a further supply of a medicine. These items may be
supplied on FP10 (NC) by special arrangement with the local mental health
pharmacy team. The FP10 (NC) must be provided by the team wishing to
prescribe it.
19.7 Inpatients are not eligible to pay prescription charges, but dispensing an FP10
(NC) in a community pharmacy will incur a dispensing fee unless the patient
would have been exempt from prescription charges in the community, e.g. over
60. If a fee is applicable this must be paid to the community pharmacy out of
the ward’s petty cash. This prescription charge will eventually be credited back
to the Trust.
19.8 A Designated Practitioner or Authorized Pharmacy Staff member must check
any patient’s own medicines, including controlled drugs, before they can be
used in the hospital. A ‘Patient’s own medication checklist’ (appendix 13) must
be completed by nursing staff for each medicine used before the pharmacy
team have had a chance to check them. The following criteria must be used:
19.8.1 There is confirmation that the medicines have been stored appropriately,
e.g. items that require refrigeration, such as insulin, have been stored in a
refrigerator.
19.8.2 The overall appearance of the bottle, label and medicine is acceptable e.g.
the container must be intact and clean. The medicine must be without
visible sign of deterioration.
19.8.3 The medicine in the container is all of the same type. If the appearance of
the medicine is not uniform it must not be used. Loose solid dosage forms
in bottles should be tipped out onto a tablet counting triangle for inspection
to avoid the need for handling. The triangle should be washed and dried
after use and between patients, if admitting more than one patient at the
same time, to avoid the risk of triggering an allergic reaction with cross
contamination.
19.8.4 Medicines such as glyceryl trinitrate and eye drops, which have a short
shelf life once opened, must not be used unless the date that the medicine
container was opened is clear and within the accepted expiry date.
19.8.5 Liquid medication should not be used unless presented in an unopened,
sealed bottle as contamination may not be apparent.
19.8.6 Items that require refrigeration should not normally be used unless
previous correct storage conditions can be confirmed by the patient or
carer. Please note insulin retains potency for at least one month at normal
room temperature within its overall expiry date.
19.8.7 The medicine must be clearly labeled with:
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




The name of the patient.
Name and strength of the medicine.
Method and frequency of administration.
Date dispensed (do not use if dispensed more than 6 months ago).
Name and address of supplier.
19.9 If the medicine has no dispensing label, it must not be used unless:
It is clearly identifiable in the manufacturer’s original container and it is within it expiry
date.
19.9.1. Controlled Drugs must be stored in the CD cupboard and recorded as
detailed in the procedure for making entries onto the Register. (Wherever
possible, a separate register should be maintained for patient’s own
drugs).
19.9.2. If the patient’s own medicines are in a compliance aid they must not be
used to administer the medicines to the patient. The compliance aid must
be stored on the ward/unit until a full assessment is carried out by a
member of the pharmacy team. Patients admitted on compliance aids
must be drawn to the attention of the pharmacy team.
19.9.3. When the brand name is the only name appearing on the label and
generic name appears on the prescription the pharmacist must annotate
the inpatient prescription sheet with brand name used on the label.
19.9.4. If the use of patient’s own medicines is the agreed policy of the ward the
medicines should be stored in an individual section of the medicine trolley
or if fully self-medicating in the patients locked medicine cabinet on the
ward.
19.9.5. If patient’s own medicines are received but not used, they must be kept in
a sealed bag in a separate section of the medicines cupboard, or in a
separate locked cupboard. Such medicines must not be stored in the
medicines trolley.
19.9.6 Where medicines are labeled for an individual’s use it is the responsibility
of the Designated Practitioner to ensure that if a patient is moved to a new
location all of their medicines move with them.
19.10 The patient’s own medicine if not required can be disposed of in one of several
ways:
19.10.1 If a medicine is no longer required, then with the patient’s or their
relatives’ consent or a best interest decision, the medicines must be
disposed of safely in a medication waste bin and the consent or best
interest decision recorded in the patient’s notes.
19.10.2 If the patient insists, the medicines may be returned home. The patient
and/agent shall be advised if the medicines are not safe for use.
19.10.3 The designated practitioner may still make a best interest decision not
to return them if they feel it would be dangerous to do so. This decision
must be recorded in the patient’s notes and reported immediately to the
Trust prescriber and to the assigned person in charge.
19.11 In the event of a death of a patient while on the ward:
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19.11.1 Patient’s own medicines must never be returned to a relative or carer
and must be kept on the ward in quarantine for two weeks in case they are
requested by the coroner.
19.11.2 The patient’s own medication, including any CDs, must be placed in a
sealable bag with the patient’s name on it.. A list of these medicines, along
with their quantities, must be made in the ward diary and the entry dated,
witnessed and signed by two nurses or a nurse and a member of the
pharmacy team. The bag should then be sealed and the two people
involved in witnessing the sealing should sign across the seal along with
the date. The bag should then be stored in the drug cupboard or if it
contains CDs, in the CD cupboard. (However, as any CDs will have been
booked out of the CD register they do not need checking when the weekly
CD check is done).
19.11.3 If any of the patient’s own medicines are controlled drugs, these must be
booked out of the CD register and an entry made stating ‘Patient
deceased and their medication has been put into quarantine’. This should
be witnessed and dated by either two nurses or a nurse and an authorized
member of the pharmacy team.
19.11.4 If the Coroner asks for the medicines they can be released to his or her
approved representative. The wording ‘Handed over to the Coroner’ along
with the date handed over should be written against original entry in the
ward diary and this should be signed by the coroner’s representative
removing them and by a nurse who must witness the removal.
19.11.5 If after two weeks the Coroner has not asked for the medicines they can
be disposed of in a medicines waste bin. The wording ‘Medicines
disposed of.’, along with the date disposed, should be written against the
original entry in the ward diary and this should be signed by by the two
nurses who witnessed the disposal.
19.11.6If the relatives or carer insist on collecting the medicines after the two
weeks, advice should be sought from the Chief Pharmacist.
19.12 Guidance on the handming of patients’ own medicines in community teams
is available in Chapter 32.
20. DAY HOSPITALS AND RESPITE CARE
A variety of arrangements may be in place to prescribe and provide medicines for
patients who attend day hospitals or who receive respite care. Special arrangements are
in place for Learning Disability Services (see Learning Disability Services –
Administration of Medication Policy).
Good liaison is vital to ensure that at all times both Primary and Secondary Care are
aware of all the medicines to be received by the patient and, who is responsible for the
prescription, the supply and the administration of each medicines.
Day hospitals
20.1 The prescribing of medicines for patients who attend day care is usually the
responsibility of the general practitioner. In exceptional situations a hospital
prescriber may wish to take responsibility for part or all of the prescribing.
These situations include:
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 If the hospital prescriber wishes to start a new medicine an stabilize the patient
on that medicines before requesting the general practitioner to take over the
responsibility.
 If the patient remains on a hospital only drug, e.g. clozapine.
 If arrangements to continue supervision of the prescribing of medicines still
remains with the hospital prescriber.
 If the prescription is subject to continual change.
 If there is no other reliable method of ensuring that the patient receives the
medicine.
20.2 There may be occasions were someone may need to receive medicines whilst
attending the day hospital. In such circumstances it is preferable that the
hospital prescriber prescribes the medicines on the Trust’s ‘Drug prescription
chart’. It can also be used to provide a record of medicines administration.
Respite care
20.3 For patients admitted for respite care, it is usual for the patient or home carers
to provide the medicines from the patient’s own supply. The Designated
Practitioner must:
20.3.1 Confirm with the carers, prior to admission, that the necessary medicines
to span the period of respite care will be provided by the carer.
20.3.2 Confirm with the patient’s general practitioner, prior to admission, the
medicines to be prescribed for the patient.
20.3.3 Confirm with the hospital prescriber that the patient’s own supply agrees
with the details provided by the carer and the general practitioner. Once
the confirmation has taken place the medicines will be prescribed using a
hospital prescription sheet.
20.3.4 If all attempts to receive a supply from the carer fail or the supply of
medicines is thought unsuitable to use, arrangements must be made to
receive further supplies from the GP and/or the community pharmacy,
Alternatively, (and temporarily), ward stock may be used, or named
patient medicines obtained from the supplying pharmacy.
21. SELF-ADMINISTRATION OF MEDICINES
21.1
Philosophy and Aims
21.1.1 The Trust is committed to the safe administration of medicines through the
provision of a service, which is effective and responsive to the needs, and
wishes of individual patients, in a variety of care settings throughout the
Trust.
21.1.2The practice of self-administration is an opportunity that allows for the
continuation or promotion of patient independence, responsibility and
autonomy during their in-patient stay. Patient involvement in care regimes
not only assists in the rehabilitative aspects of care but is also believed to
promote patient satisfaction and compliance through improved knowledge
and understanding of their treatment.
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21.1.3 The aims of a self-administration scheme should include:

Establishing a standardised approach for determining the ability of
patients to take their own medication reliably.

Promoting and maintaining a patient’s independence and autonomy.

Improving adherence through education and personal involvement to help
improve outcomes and reduce hospital re-admissions.

Assessing the patient’s long-term adherence with their medication
regimen by:
o Reviewing their adherence formally when on the ward.
o Reviewing their adherence with carers and relatives if appropriate,
while on leave.
o Exploring their level of insight and attitude to their medication.

21.2
Preparing patients with the skills and knowledge to be independent and
responsible in the safe and effective self-administration of medication after
their discharge.
Scope
21.2.1 Self-administration will not be appropriate for all patients. Participation
must therefore be based upon assessment of suitability, safe systems of
practice and informed choice and consent of the patient (See the Trust’s
Consent Policy).
21.2.2 Self-administration requires agreement and commitment by medical,
nursing and pharmacy staff.
21.2.3 Each unit should look at the feasibility of implementing self-administration
from their different care perspectives. Each care environment must have
safety measures in place, to allow safe practice of self-administration to be
carried out. These will include a clear understanding of roles and
responsibilities, the assessment of patient suitability, education, monitoring
and supervision and assessing risk factors, including the risk that other
service users may pressurise the patient to hand over their medication.
21.2.4 Some degree of modification may be considered in order to adapt these
guidelines to local specific conditions. Under no circumstance must these
adjustments result in a reduction in the security of the processes relating to
medicines safety.
21.2.5 Clear documentation, safe storage of medication and lines of
communication within the multidisciplinary team (MDT) and with the
individual patient must also be carefully considered.
21.2.6 Patients must agree and consent to participation in self-administration
before any self-administration takes place. The patient must sign a consent
form (appendix 2). The completed form must be kept in the clinical notes.
21.2.7 Patients must be informed that they may withdraw consent at any time and
choose not to self-administer without their care being affected.
21.2.8
It is important to remember that a patient’s participation in selfadministration does not mean that all responsibility for medication
administration has been transferred from the nurse to the patient.
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21.2.9
The Self-administration of Medicines patient leaflet (appendix 4) should
be given to all patients for information purposes.
21.2.10 All self-administration programmes must be subject to monitoring,
supervision and review by registered nursing staff and the findings
reviewed with the MDT on a regular basis. This must include exploring
their levels of insight and attitude to their medication and if self
administering while on leave, feedback if available from carers and
relatives. Increases in side effects or worsening of symptoms may be a
sign of non-compliance; therefore this must be investigated before
considering changes in treatment. Summaries of any reviews and
decisions made must be recorded in the patient’s notes.
21.2.11 Any decision to move a patient from one level of responsibility to another,
must be made by the MDT taking into account feedback on their
adherence, insight and attitude. An updated risk assessment should be
completed if the proposed change does not concur with a previously
documented plan.
21.2.12 When patients are at early stages of the self-administration programme
(stages 1 & 2), each dose administered must be signed for on the Drug
chart, by the supervising nurse. A Daily Self-administration Progress
Record Form - Stages 1 & 2 must also be completed (appendix 5).
21.2.13 All medicines must be prescribed by a doctor or appropriate non-medical
prescriber, on a current Drug chart, in the normal manner.
21.2.14 At all stages of self-administration the recording section of the Drug chart
must be clearly annotated to show that the patient self-administers
medication (see section 8 for codes/wording).
21.2.15 A lockable medicine locker or drawer must be made available to each
self-administering patient at levels 2 & 3 for storing his or her own
medicines. Either a key-lock or a keypad-lock is acceptable. Where keys
are used, a duplicate key must be available to nursing and pharmacy staff
but this should not be used routinely. The patient’s key may be removed if
nursing staff consider it necessary in the interests of safety to the patient
and/or others. Where key-pads are used the lock code must be changed
after a patient stops using the cupboard or locker or if there are any
concerns that an unauthorized person has become aware of the lock
code.
21.2.16 It is not acceptable to rely on a locked patient’s room for the safekeeping
of medicines. A lockable cupboard or locker must be provided.
21.2.17 In the absence of lockable cupboards or lockers then the selfadministration process cannot progress beyond stage 1.
21.2.18 Where quantities of medication are given to the patient for their own
safekeeping and administration (stages 2 & 3), patients should be
encouraged to keep their own record of self-administration (appendix 7).
21.2.19 In the latter stages of self-administration, if the patient goes on leave they
may take their “One Stop Dispensed” supply of medication with them, thus
preventing the need to obtain leave prescriptions.
21.2.20 If at any point it is felt that the patient’s mental state has deteriorated,
there are concerns about their insight or attitude to medication or they are
no longer capable of self-administering at a particular level, the patient
must drop to a lower level or cease self-administration. Nurses may take
this decision autonomously.
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21.2.21 The continuous monitoring of the patient’s mental state, their insight and
attitude to medication and ward dynamics are paramount for the safety
and success of the self-administration programme.
21.3 Patient recruitment for self-administration
21.3.1 The decision to accept a patient into a self-administration of medication
programme is a highly responsible one, which requires an assessment of
risk to be taken into account. The clinical condition, along with the
behavioural reliability of the patient must always be considered. Account
must also be taken of other patients on the unit and their ability to
influence the individual; this will need to be reviewed as and when new
patients are admitted to the unit. It is considered ‘best practice’ for these
considerations to be discussed within the multi disciplinary clinical review
meeting.
Inclusion
21.3.2 It is suggested that the patient needs to meet both of the following
criteria:

Patients who will be expected to assume responsibility for taking their
medication at home, including those patients who may have some level of
support from a carer.

Patients who are expected to remain on the ward for a period long enough
to complete at least one stage of the process.
Exclusion
21.3.3 If any of the following apply, then self-administration may not be feasible or
reasonable, though the decision should be reviewed if circumstances
change:

The patient is confused or has an unstable mental state.

The patients insight and attitude to medication causes concern.


The patient has a history of alcohol/drug abuse – although it may be
possible for them to undertake stages 1 and 2 subject to agreement of the
multidisciplinary team.
The patient does not consent to take part in the programme.

After discharge the patient will definitely be going to an environment where
their medication will be administered to them by a carer.

When the ward dynamics and or environment are not appropriate or
conducive to safe self-administration practices stage 3 may not be
possible; including the influence other patients may exert.
21.3.4 The following drugs SHOULD NOT be self-administered:

Those prescribed in variable dosages (e.g. detox regimens).

Once only (‘STAT’) doses, with the exception of pessaries and
suppositories.

Injectable drugs (except when these will be self-administered at home
following discharge, e.g. insulin).
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21.3.5 The following drugs SHOULD NOT be self-administered unless approval
as been given by the Trust's Controlled Drugs Accountable Officer
(currently Chief Pharmacist - Strategy) and special monitoring agreed for
the individual's situation.

21.4.
Schedule 2 and Schedule 3 controlled drugs (as defined by the Misuse of
Drugs Act 1971), with the exception of phenobarbital and temazepam.
(See Appendix 11).
Definitions of the roles
Medical Staff
21.4.1 To record in the notes the MDT’s agreement that the patient is suitable for
self- administration.
21.4.2 To initially sign the Patient Risk Assessment and Decision Form for the Selfadministration of Medicines (appendix 3) on behalf of the MDT. This form
must also be countersigned for subsequent decisions to move up a stage.
21.4.3
To offer education or information as indicated in the initial assessment,
either independently or in collaboration with pharmacy or nursing staff as
appropriate.
21.4.4 To involve patients in decisions to change their medication.
21.4.5 To inform nursing staff of any prescription changes.
21.4.6
To review the patient’s status on a regular basis; acute wards minimum
weekly, non-acute wards minimum monthly.
Pharmacy Staff
21.4.7
21.4.8
To review the medication and dosage schedule prior to starting the
self-administration process, and whenever possible assist in simplifying
the medication regimen.
To provide patient information leaflets.
21.4.9 To ensure that the patient is supplied with the required medication.
21.4.10 If necessary:
 To produce medication reminder charts, large font labels or other aide
memoire as appropriate in suitable formats for certain patients.
 To provide examples of compliance aids that may be suitable for use for
certain patients.
21.4.11To provide medicine education for patients, either in group sessions run in
conjunction with nursing staff or on an individual basis, utilizing information
in other formats and translation services when appropriate.
Nursing Staff
21.4.12 To undertake an assessment of the patient’s readiness to start/progress
in the programme, noting day to day attendance/attitude/insight and
knowledge of the medication regimen, notifying the MDT of findings to
inform the decision to commence and to move the patient through the
different stages of the self-administration programme.
21.4.13 To discuss the process with the patient using appropriate formats
following the MDT decision to commence the programme, addressing any
queries or concerns about the programme, offering an explanation of the
stages and ensuring consent is fully informed.
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21.4.14 To ensure the Patient Risk Assessment and Decision Form for the Selfadministration of Medicines (appendix 3) is completed and agreement
reached on what stage of self-administration to start the patient. The
completed form (and any subsequent updates) must be kept in the clinical
notes and also attached to the Drug chart.
21.4.15 To offer education or information in suitable formats, e.g. large font print,
as indicated at the initial assessment, either independently or in
collaboration with pharmacy or medical staff as appropriate.
21.4.16 To monitor, supervise, and record the patient’s progress on the
programme, reporting back to the MDT at least weekly.
21.4.17 To liaise with the pharmacy team regarding the patient’s movement
through the stages, ensuring medication requests reflect the current and
to ensure continuous supplies of medication.
21.4.18 To check and to document their findings in the Daily Self-administration
Progress Record Form – Stage 3 (appendix 6) that patients at stage 3
have self-administered their medicines correctly and completed their Selfadministration Aide Memoire (appendix 8 - this can be provided in another
format if appropriate, e.g. larger print or if appropriate another recording
system can be agreed e.g. audio recording). If there are any concerns
about the patients attitude or insight these must also be discussed with the
MDT and a record made in the patient’s notes of those concerns and any
action agreed.
21.4.19 To continually monitor the environmental risks, particularly when new
patients are admitted to the unit, with respect to the risks of them
pressurizing the patient to divert their medication.
21.4.20 It is the responsibility of the ward manager to ensure that those
doctors looking after patients on their ward are aware of the procedure
and their responsibilities as above.
21.5
Storage of medication
21.5.1 The maintenance of a safe storage system is essential. If full selfadministration is a treatment goal, the provision of an individual lockable
storage area in the patients’ rooms (either a drawer or cupboard) is
essential to prevent access by unauthorised individuals, such as other
patients or visitors. Apart from the individual patient – only nursing or
pharmacy staff should have access to a key or the key-code.
21.5.2 Consent must be gained at the beginning of the process and it must be
made explicitly clear to the patient that nursing and pharmacy staff will be
undertaking ‘spot checks’ (along with regular checks) of the medication to
ensure that safe self-administration is being undertaken. It is best practice
to do these checks in the presence of the patient, but should this not be
possible, two nurses or one nurse and one member of the pharmacy team
should then carry this out.
21.6
Patient information, teaching and supervision
21.6.1 The information given and the period of supervision should be tailored to the
individual patient’s needs and should be provided in a suitable format,
including large print or another community language. Interpreting services are
available to that effect. The following information should be provided to
patients before commencing self-administration:
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
The name and reason why the drug has been prescribed.

The dose, frequency and potential side effects.

A Patient Self-medication Assistance Sheet (appendix 7) completed by
a registered nurse or a qualified member of the pharmacy team in
conjunction with the relevant medication information leaflets. If a nurse
has completed the Patient Self-medication Assistance Sheet (appendix
7), a qualified member of the pharmacy team must check the card and
initial it at the earliest opportunity.
21.6.2 The level of retained knowledge relating to the individual patient’s medicines
should be regularly checked as part of the monitoring process and reinforced
as necessary by the patient’s primary nurse or a qualified member of the
pharmacy team.
21.6.3 Any alterations to therapy must be discussed with the patient (see doctor’s
role), altered on the Drug chart and on the Patient Self-medication Assistance
Sheet (appendix 7), then initialled and dated. The Patient Self-medication
Assistance Sheet (appendix 7) should be kept by the patient and should be
taken into the community on discharge.
21.6.4 Assessment of the patient’s understanding, insight and attitude to their current
medication regimen should be undertaken by the primary nurse, another
designated nurse or a qualified member of the pharmacy team on a regular
basis to inform any MDT review. Education/information provided needs to be
recorded in the patient’s notes along with any special communication
requirements. A programme of information provision can be devised by the
primary nurse in conjunction with a qualified member of the pharmacy team,
which will be noted in the patient’s care plan.
21.6.5 Information leaflets or links to information leaflets can be found on the Sussex
Partnership website: www.sussexpartnership.nhs.uk/medication-information
The site includes links to some medication leaflets in other European
languages, in ‘easy read’ format and access to formats suitable for patients
with impaired sight.
21.7
Suggested Stepped Approach to Self-administration
21.7.1 Multi-stage self-administration programmes are well tried and tested in many
different care settings and have been shown to be effective, whilst also being
considerate of risk. The following is a suggested programme, although MDTs
must remain aware that considerable flexibility of approach will be required
according to each patient’s abilities and capacity. Variation from this
suggested programme is therefore permitted but teams must ensure that
appropriate risk assessments are carried out and that the safety of the selfadministering patient (and that of others) is never compromised.
21.7.2 The MDT may identify a patient as potentially appropriate for selfadministration and discussion and risk assessment will then take place. If
agreed as appropriate, a record will be made in the care plan and written
consent from the patient will be sought (appendix 2).
21.7.3 The consultant must sign the Patient Risk Assessment and Decision Form for
the Self-administration of Medicines (appendix 3) on behalf of the MDT.
Stage 1 must be successfully completed before any decision is made to move
to stage 2 (with the exception of patients who have been “fast tracked” to
stage 2).
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21.7.4 When considered appropriate by the MDT (see exclusions – section 3 above)
and in order to minimise the risk of patient’s skills being lost, patients admitted
to the ward on stable treatment who were responsible for their medication prior
to admission and compliance was not an issue may be “fast tracked” onto selfadministration stage 2.
21.7.5 Stage 2 must be successfully completed before any decision is made to move
to stage 3. This decision must be documented in the patient’s notes and in the
Patient Risk Assessment and Decision Form for the Self-administration of
Medicines (appendix 3). The form must also be countersigned by the
consultant on behalf of the MDT.
21.7.6 The patient should then be issued with the form Patient Self-medication
Assistance Sheet (appendix 7) and a nurse or a member of the pharmacy
team should explain the reasons why and the benefits derived from their
inclusion in the self-administration scheme. Consideration must be given to
providing forms or information in other formats, including using the services of
an interpreter. Consideration should be given on how best to obtain consent if
written consent cannot be obtained.
21.7.7 If the patient agrees to proceed with self administration, the patient must sign
the Self-administration: Patient Agreement / Consent Form (appendix 2). This
should be also recorded in the patient’s notes. If consent is not given, the
patient cannot be entered into the programme, but information regarding their
medicines and what to do after discharge should still be provided. Their
decision not to consent should also be recorded in the patient’s notes.
21.7.8 All consenting patients should be entered into stage 1 of the programme and
the prescription chart annotated accordingly (unless it is considered
appropriate by the MDT to “fast track” the patient to stage 2).
21.8
Self-administration Stages
Stage 1 – Supervised administration
21.8.1 Patients who are suitable for inclusion in the programme should usually be
entered into stage 1. When considered appropriate by the MDT (see
exclusions – section 3 above) and in order to minimise the risk of patient’s
skills being lost, patients admitted to the ward on stable treatment who were
responsible for their medication prior to admission and compliance was not an
issue, may be “fast tracked” onto self-administration stage 2. In all other
circumstances the progress to stage 2 will be dependent on the patient’s
ability to self-medicate successfully at stage 1.
21.8.2
The decision to progress up to the next level should be made by the MDT
and should be recorded and signed by the Consultant in the patient’s notes
and the Patient Risk Assessment and Decision Form for the Selfadministration of Medicines (appendix 3), which should be kept in the patient’s
notes and also a copy attached to the patient’s Drug chart.
21.8.3 Where necessary, and where possible, rationalisation of the patient’s
treatment regimen should be carried out at this stage to minimise the
frequency of dosing and to help with adherence.
21.8.4 Assessment of the patient’s ability to read medicine labels and manage child
resistant tops (click locks) must be carried out by a member of the team, (e.g.
an OT or a member of the pharmacy team) (appendix 9). Ordinary screw-tops
are available where necessary, as well as other compliance aids. The
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pharmacy team will also be able to offer further advice and information at this
stage.
21.8.5 Individual supplies of medication will be dispensed by the pharmacy in TTO
format (‘One stop’ dispensing), with each bottle, box or blister pack, labelled
with the patient’s name and full directions on how to take the product. The
medication will be retained in the medicine trolley, which will be securely
stored in the clinic room.
21.8.6 Patients will be expected to ask nurses for access to their medication at the
prescribed times. The nurse will place the patient’s drug tray on top of the
trolley and allow the patient to self-medicate. Nursing staff or a qualified
pharmacy technician should closely monitor the medication and dosage taken
from the container by the patient, and must intervene or prompt as necessary
to ensure medication is taken as prescribed. Daily Self-administration
Progress Record Form - Stages 1 & 2 (Appendix 5) must be used to record
progress and the Drug chart must be endorsed with ‘SA’ (for supervised
administration) and initialled by the nurse or pharmacy technician once the
medication has been taken.
21.8.7 In an informal manner during the process, nurses or pharmacy technicians
should establish a conversation regarding medication in order to assess the
patient’s insight, attitude to and understanding of the prescribed drugs and to
ascertain whether the patient may be suffering from side effects due to the
prescribed treatment.
21.8.8 This stage should continue for as long as is felt necessary for each individual.
Information gathered during monitoring, will indicate each patients readiness
to move to stage 2 or suitability to remain on the programme. Before moving
on to stage 2, there should be good evidence of ‘unprompted’ attendance for
medication.
21.8.9 If the patient is having difficulty with stage 1, the difficulties must be recorded
and reported back to the MDT and a decision made on whether continued
work at stage 1 is appropriate.
21.8.10 Patients can be maintained on stage 1 until discharge if the ward
environment is not suitable for further progress.
21.8.11 The MDT should discuss the progress at stage 1 and if appropriate a
decision made to move the patient to stage 2. Patient Risk Assessment and
Decision Form for the Self-administration of Medicines (appendix 3) must be
signed again by the consultant on behalf of the multidisciplinary team to allow
proceeding to stage 2.
Stage 2 – The patient is supplied with original packs of medication and is
responsible for its storage and administration. Keys remain under
nurse’s control
21.8.12 The patient is supplied with medication dispensed by the supplying pharmacy
with full administration instructions. Under no circumstance may stock drugs
be used.
21.8.13 Drugs (see exclusions – section 3) will be stored in a locked medicine cabinet
in the patient’s room and the key (or lock code) will be held by a nurse or kept
in a safe place.
21.8.14 Whenever possible, medication should be taken at times that will suit the
patient’s home routine and the Drug chart should take account of this. These
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administration times have to be recorded on the Patient Self -medication
Assistance Sheet (appendix 7), prescription chart and care plan.
21.8.15 The patient will be given written and verbal instructions in a suitable format
on how and when to take medication (see appendix 7).
21.8.16 At administration times, it is the patient’s responsibility to ask nurses for
access to their medication at the appropriate time. Nurses will observe the
patient selecting and taking medication, any progress or if the patient requires
prompting, this should be recorded in the Daily Self-administration Progress
Record Form - Stages 1 & 2 (appendix 5).
21.8.17 In an informal manner during the process, nurses or pharmacy technicians
should establish a conversation regarding medication in order to assess
patient’s insight, attitude to and understanding of the prescribed drugs and to
ascertain whether the patient may be suffering from side effects due to the
prescribed treatment.
21.8.18 Once the medication has been self-administered the nurse or pharmacy
technician must annotate in the drug chart’s administration box ‘SA’ (for
supervised administration) and add their initial.
21.8.19 This stage should continue for as long as is felt necessary for each
individual. Information gathered during monitoring, will indicate each patients
readiness to move to stage 3. Before moving on to stage 3, there should be
good evidence of ‘unprompted’ regular and accurate self-administration.
21.8.20 If the patient is having difficulty with stage 2, the difficulties must be recorded
and reported back to the MDT and a decision made on whether continued
work at stage 2 is appropriate.
21.8.21 Patients can be maintained on stage 2 until discharge if the ward
environment is not suitable for further progress.
21.8.22 The MDT should discuss the progress at stage 2 and if appropriate a
decision made to move the patient to stage 3. Patient Risk Assessment and
Decision Form for the Self-administration of Medicines (appendix 3) must be
signed again by the consultant on behalf of the multidisciplinary team to allow
proceeding to stage 3.
Stage 3 – The patient is supplied with original packs of medication (unless the
original pack contains more than 30 days supply, when a maximum of 30
days should be supplied) and is responsible for its storage and
administration. Patient keeps the keys.
21.8.23 The aim of this stage is to promote full patient responsibility for their
medication.
21.8.24 Medication (see exclusions – section 3) will be stored in a locked medicine
cabinet or locker in the patient’s room and the patient will hold a key or be
given a lock code. The importance of keeping the cabinet locked and the key
or lock code safe must be stressed to the patient. Nurses will also hold a key
or the lock code for the cabinet. If a lock code is used this must be changed
every time a patient stops using the cabinet or locker, or if there are any
concerns that an unauthorized person has got hold of the lock code.
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21.8.25 At all times the ward situation should be assessed paying special attention to
other inpatients who may be liable to coerce the patient into handing over
medication.
21.8.26 The patient must be given written and verbal instructions in an appropriate
format on how and when to take their medication. See Patient Self-medication
Assistance Sheet (appendix 7)
21.8.27 Nurses should try to ensure that the patient is not interrupted while selfmedicating.
21.8.28 The patient will be also given the Self-administration Aide Memoire (appendix
8 - this can be provided in another format if appropriate, e.g. larger print or if
appropriate another recording system can be agreed e.g. audio recording) for
the recording of their self-administered medication.
21.8.29 The Drug chart must be endorsed in the special consideration box at the front
of the chart with the words “self-administration stage 3”. Nurses do not need
to initial the prescription chart at the time the patient self-administers.
Assuming the nurse checking is confident that the prescribed medication has
been self-administered either the administration code ‘P’ (patient managing
own medicines) can be written in the appropriate administration box when the
daily checks are performed by nursing staff or other suitable wording written
across over the appropriate administration boxes on the drug chart to indicate
self-administration is taking place e.g. ‘patient self-administering’.
21.8.30 A daily check to ensure that the cabinet or locker is secure and that the
medication has been taken as prescribed must be performed and documented
on the progress chart. If it is discovered that the cabinet is being left
open/unlocked or the medication has not being taken as prescribed then the
patient must drop back to stage 2.
21.8.31 At this stage the patient will also be expected to request fresh supplies of
their medication at the appropriate times, either via nursing staff or, (where it
can be arranged), direct from the supplying pharmacy.
21.8.32 Daily Self-administration Progress Record Form – Stage 3 (appendix 6)
should be used to annotate any comments on the patient’s progress regarding
any of the aspects of the self administration scheme, including any changes to
their insight or attitude to their medication. This should be discussed weekly
at the MDT meeting and a record made in the notes.
Self-administring while on leave
21.8.33 If the patient is self-administring while on leave, then where possible,
feedback should be obtained from carers and relatives on how well they are
coping as well as getting feedback from the patient themself.
NOTE: Patients may drop to a lower stage of self-administration if continuation
or further advancement proves problematic for any reason, including a change
in the risk environment involving another patient. Nurses may take this decision
autonomously. Further assessment and monitoring will then continue but need not
necessarily result in a return to a higher stage.
It is very important that staff have a flexible approach to the self-administration
process, but safety must never be compromised.
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21.9
Recording Procedures for Trust Staff
21.9.1 This applies to the 3-stage programme described above.
21.9.2 If the patient is assessed as suitable for the scheme and asked to take part but
withholds consent then the appropriate section of the Self-administration:
Patient Agreement/Consent Form (appendix 2) must be signed. This form
must be filed in the patient’s notes.
21.9.3 Stage 1

A Patient Risk Assessment and Decision Form for Self-administration of
Medicines (appendix 3) must be completed prior to self-medication; it should
be presented in the multidisciplinary team meeting and signed by the
Consultant. This form should be attached to the prescription chart.

Patients should be given the Self-administration of Medicines (appendix 4)
document when included in the self-administration scheme.

At each administration the Drug chart has to be annotated in the appropriate
administration box with the code ‘SA’ (for supervised administration) and
initialled by the supervising nurse or pharmacy technician.

Daily Self-administration Progress Record Form - Stages 1 & 2 (appendix 5)
should be attached to the Drug chart. Nurses, pharmacists or pharmacy
technicians will record on this form any comments on the patients insight and
attitude to their medication and any problems arising during the selfadministration process. This form should inform any MDT review.

Doctors must sign The Patient Risk Assessment and Decision Form for the
Self Administration of Medicines (appendix 3) when the patient is to move
from stage 1 to stage 2.
21.9.4 Stage 2

The prescriber will write ‘Self-administration’ or use a sticker produced for the
purpose, in the additional instructions box on the front of the Drug chart and
add their signature and date.

"Supervised Self-administration" will be written in the ‘additional instructions’
box of the Drug chart for each medication to be selected by the patient and a
note will be made in the patient's care plan.

On each successful self-administration, the nurse or pharmacy technician will
enter the code ‘SA’ as well as her initials (underneath) in the normal manner.
Where self-administration is not successful and nurse administration takes
place, or where no administration takes place, the nurse will complete the
chart in the normal manner.
 Adequate recording must be maintained (see appendix 5).
21.9.5 Stage 3

The prescriber will write "Self-administration" or use a sticker produced for the
purpose, in the additional instructions box on the front of the drug chart and
add their signature and date.

The number of days supply of medication held by the patient will be written in
the appropriate column’s of the drug chart and a note will be made in the
patient's care plan.
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
If at the daily check the nurse is confident that self-administration has taken
place, the nurse can either enter the administration code ‘P’ (patient managing
own medicines) can be written in the appropriate administration box or use
other suitable locally agreed wording written across over the appropriate
administration boxes on the drug chart to indicate self-administration is taking
place e.g. ‘patient self-administering.
 Adequate daily records must be maintained (see appendix 6).
21.10 Responsibility
It is the responsibility of the clinical team manager to ensure that where selfadministration is indicated, that safe, professional, risk-assessed procedures are
implemented.
21.11 Summary
The decision to accept a patient into a self-administration scheme is a highly
responsible one, which requires a comprehensive assessment of risk. The
clinical condition of the patient, their insight and attitude to medication, their
behavioural reliability and the ward dynamics must be considered at all times.
The views of the MDT must be obtained and all members should be in agreement
before proceeding.
21.12 Cross-reference
21.12.1 These guidelines must be read and implemented alongside the standards of
practice described in:
 The Trust’s Medicines Code (other chapters)
 The Trust’s Consent Policy.
21.12.2 In addition, nurses must remain aware of the Medicines Management
Standards (April 2010) published by the Nursing and Midwifery Council. In
particular, in relation to self-administration, these state:
“As a registrant you are responsible for the initial and continued assessment of patients
who are self-administering and have continuing responsibility for recognising and acting
upon changes in a patient’s condition with regards to safety of the patient and others.”
22. CUSTODY AND SAFE-KEEPING OF MEDICINE KEYS
Overall responsibility for controlled drugs throughout the Trust lies with the Designated
Accountable Officer (the Chief Pharmacist - Strategy).
22.1
Keys for controlled drug cupboards must be kept on a separate key ring
that can be readily identified. If there are nos being stored on the ward, these
keys can be kept with the other drug cupboard keys but must be separated
again once any controlled drugs start being stored.
22.1.1 The key must be kept on the person of the Assigned Practitioner in Charge or
Designated Practitioner nominated by them. Responsibility remains with the
Assigned Practitioner in Charge. There is no restriction on the Assigned
Practitioner in Charge or the Desunated Practitiioner nominated by them
holding both the controlled drug keys and the general medication keys at the
same time.
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22.1.2 No practitioner can have access to the Controlled Drug Cupboard except in
the presence of the Practitioner officially holding the key. The key must not be
handed over to medical staff or non-medical prescribers.
22.1.3 In the event of the person in charge being inappropriately qualified, the key
must be handed to an Assigned Practitioner in Charge of a ward or department
in the near vicinity. This information must be made known to the staff in the
ward or department and to the manager in charge of that section.
22.2
Keys for Medicine Cupboards, Medicine Trolleys and Refrigerators
22.2.1 The keys for the external cupboard, internal medicine cupboard, medicine
trolley, medicine refrigerator and pharmacy transport box must be kept
together on one key ring reserved solely for these keys. The keys must be
clearly identified.
22.2.2 Unless in a learning disability residential home, the keys must be kept on the
person of a Designated Practitioner. In the event of no Designated Practitioner
being on duty in a ward or department, the keys shall be handed to Designated
Practitioner on a ward or department in the near vicinity. This information must
be made known to the staff on both wards or departments and the manager in
charge of that section. In a learning disability residential home the keys may
be held by an Authorized Employee competent to administer medicines.
22.2.3 At Community Team bases where a number of Designated Practitioners may
require access to the medicine cupboards at different times a digitally
accessed key cupboard must be provided for storage of the medicine
cupboard keys. Alternatively a drug cupboard with a digital lock may be used.
Only staff authorized to access medications may have the combination.
22.3
Keys to individual patient’s medicine cupboards
22.3.1 The master key for individual patients’ medicine cupboards will open all such
cupboards on the ward. The master key must be kept on the ward medicine
cupboard key ring at all times and must never be issued to a patient.
22.3.2 Keys that open individual patient medicine cupboards must be individually
numbered and stored in a locked cupboard on the ward when not in use.
22.3.3 If a patient is to fully self-medicate the appropriate numbered key may be
issued to the patient who signs for receipt of this key. The key that is issued to
an individual patient must only open their designated medicine cupboard and
must be kept securely by the patient. On discharge or when the patient is no
longer self-administering their own medicines, the key must be returned to
safekeeping and a record made.
22.4
Loss of a Medicine Cupboard Key
22.4.1 If theft of the keys is suspected then the on-call manager and the police
should be called. The supplying pharmacy department must also be notified
when the department is next open.
22.4.2 In the event of a lost key every effort must be made to find the key or retrieve
it from off duty staff. Should access to the medicine cupboard be required
before the keys are retrieved the duty manager must be informed and
duplicate key may be obtained. A local policy must exist for securely
accessing duplicate keys. The keys must be clearly identified and easily
accessible to the duty manager.
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22.4.3 If there is no duplicate key and access to the cupboard is needed
immediately, the duty manager will arrange for the cupboard to be broken
open and a new lock fitted.
22.4.4 If the cupboard keys are not located before the end of the shift on which they
were found to be missing, a new lock must be fitted to the cupboard. Any loss
of keys resulting in new locks must be recorded as an incident.
23. CHECKING OF STOCK BALANCES
23.1
Controlled Drugs
23.1.1 It is good practice to check stock balances of all controlled drugs with every
shift change involving a change of Assigned Practitioner in Charge
23.1.2 However, the audit minimum and Trust standard is that the stock balance of
all controlled drugs entered in the Register, including patients’ own controlled
drugs, must be checked at least once a week against the actual stock held in
the ward/department.
23.1.3 There is no need to open packs with intact tamper evident seals for stock
checking purposes. It is also good practice to carry out occasional verification
of entries in the register against entries made on individual inpatient
prescriptions.
23.1.4 Two Designated Practitioners, or one Designated Practitioner and one
Authorized Employee must perform the check.
23.1.5 A record indicating this check has been carried out must be made to confirm
the stock, including patients’ own controlled drugs, is correct. This record may
be a single entry at the back of the register or an individual entry made on each
page in use in the register. If local practice dictates more frequent stock checks
than weekly additional checks can be recorded in a separate book kept
specifically with the register for the purpose but a weekly stock check must still
be recorded in the CD register. The record must be dated and signed by both
Practitioners or a Practitioner and an Authorized Employee. The Appointed
Practitioner in Charge must ensure that these checks are carried out.
23.1.6 The Appointed Practitioner in Charge must undertake a random check of at
least one drug in their controlled drug cupboard at least once a month and
record the check in the ward Controlled Drug register on the relevant page or at
the back of the register on a page set aside for the purpose. Where possible
this random check must reconcile recorded administrations with the appropriate
drug charts, if available. Particular attention must be taken of liquid medicines
and any stock adjustments made when bottles are emptied and controlled
drugs stocked but not in current use.
23.1.7 Stock balances of individual preparations must be checked after every
administration with the exception of liquids (see below).
23.1.8 Liquid medicine stock balances must be undertaken whenever a bottle is
finished. Due to filing inaccuracies small discrepancies occur with liquid
medicines. Stock record adjustments for small discrepancies of less than 5ml
per 100ml (e.g. less than 25ml in 500ml bottles) must be made when a bottle is
emptied (see Administration and Preparation of Medicines chapter).
23.1.9 In the event of a discrepancy between the stock balance and register for
controlled drugs, the Appointed Practitioner in Charge must immediately and
thoroughly investigate it. The possibility of a missing or incorrect entry or
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arithmetical error must be investigated first and if found corrected. When
correcting the error in the register no crossing out or Tippex® must be used on
previous entries. A full explanation should be recorded in the register. Any
recording must be signed and dated by the Appointed Practitioner in charge
and authorized witness (see Losses and Discrepancies chapter).
23.1.10 Any need for more frequent checks will be decided by the Appointed
Practitioner in Charge in liaison with the Chief Pharmacist.
23.1.11 A designated member of pharmacy staff must check the controlled drugs
balance and all register pages used since the last pharmacy check, at a
minimum of six monthly and when overall responsibility for the medicines
change e.g. change of appointment of the Appointed Practitioner in Charge
including:
23.2

A record must be made on every page with a stock balance or where a
stock has reduced to zero.

Where possible there should be verification of entries in the register
against entries made on individual inpatient prescriptions.

That all appropriate weekly and appointed Practitioner in Charge stock
checks have been done.

At least one supply from pharmacy has been selected and checked against
the CD register.

Assuming there are no unresolved discrepancies, once the stock is
checked as correct by the designated member of pharmacy staff they must
annotate each relevant page below the last entry with the statement,
‘Pharmacy stock check done’, along with the date, time and their signature.
The designated practitioner in charge must also confirm the stock is correct
by countersigning this entry as a witness.
Other Medicines
Local agreements to check other medicines may apply. Any need for checking stock
balances of other medicines must be left to the discretion of the Appointed Practitioner in
Charge. If, however, there is suspicion of abuse of medicines this must be reported to
the integrated team manager and the Chief Pharmacist. In such cases it is advised that
a stock balance must be recorded and regular checking introduced. If this shows
discrepancies the medicine must be made subject to similar procedures as Controlled
Drugs register entries must be made whenever the medicine is administered. It may
subsequently be reported to the Service Manager and the Trust’s Security Adviser, and
systems introduced (either openly or covertly), to identify further losses etc.
24. USE OF COMPLEMENTARY MEDICINES AND ESSENTIAL OILS
The patient may receive complementary therapies that may be used in conjunction with
orthodox medical, nursing and paramedical treatments to enhance patient wellbeing, quality
of life and symptomatic relief.
24.1
Patient’s own complementary medicines or essential oils brought onto an
inpatient unit
24.1.1 Complementary medicines or essential oils must be brought to the attention
of the patient’s doctor, this is particularly important with herbal medicines,
which can in some circumstances produce marked physiological and
psychological effects.
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24.1.2 Before allowing the patient to use complementary medicines or essential oils
the safety of the product and the risk of interactions, should be assessed by
pharmacy.
24.1.3 Ideally those complementary medicines then deemed not to be harmful to the
patient should be written up inside the Drug chart with a note in the ‘Additional
Information’ box that the product has been checked by pharmacy and the
patient has requested to take it.
24.1.4 Complementary medicines or essential oils are not generally available from
hospital pharmacies and therefore patient’s own should be used. If necessary
the patient may have to purchase their own supply.
24.2 New treatments initiated by the Trust
24.2.1 The Drugs and Therapeutics Group must approve any complementary
medicines or essential oils before they can be initiated by Trust staff.
24.2.2 Even when the complementary medicines or essential oil is approved it can
only be used within the guidance of any Trust complementary therapy code.
24.3 Consent
24.3.1 The patient must usually give informed consent for the initiation of treatment
including essential oils or complementary medicines. If an adult is unable to
give informed consent the relatives or carers should be involved in the
decision and a best interest decision made and recorded in the patient’s
notes.
24.3.2 Information in suitable formats must be available for patients, and relatives
and carers if appropriate.
25. USE OF UNLICENSED MEDICINES AND LICENSED MEDICINES OUTSIDE THEIR
LICENCE
(see separate policy and the Trust’s Formulary)
26. CLINICAL TRIALS INVOLVING PHARMACEUTICAL PRODUCTS
26.1
Liability issues relating to clinical trial medicines
26.1.1 When a prescriber takes part in a clinical trial initiated by a pharmaceutical
company, it is the responsibility of the company to obtain a Clinical Trials
Certificate or Clinical Trials Exemption.
26.1.2 When a prescriber initiates a clinical trial using an unlicensed medicine he or
she must notify the Licensing Authority giving details of the trial and the
method of supply of the medicines to be used. The Licensing Authority has
21 days to raise objections, although the Authority may extend this to up to 63
days if required. If no objections are forthcoming the trial can start.
26.1.3 Before starting a trial, and only when the study has been approved by the
Local Research and Ethics Committee and the Trust Research and
Development Committee, prescribers must seek no fault compensation cover
from the Trust for the research subject, ensure that their medical defence
organization membership permits the proposed activity, and if the study is
sponsored by a pharmaceutical company, that it will comply with the ABPI’s
guidelines on compensation.
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26.1.4 At the end of a study a prescriber may wish to continue to prescribe the trial
medicines for those patients who have benefited, but such a provision must
be included in the original protocol and have been supported by the Drugs
and Therapeutics Group. If there is no agreement to allow continued
prescribing of the trial medicines, patients must be made fully aware of this
fact in the patient information sheet when they are recruited.
26.2 Responsibilities for the Supply of Medication
The legal and indemnity issues surrounding supply of clinical trial materials are complex.
Before a medicines trial has received Local Research and Ethics Committee and Trust
Research and Development Committee approval, the Trust Commercial Trials Facilitator,
or the local trial coordinator, must ensure that appropriate arrangements are in place
regarding the management and supply of trial medication.
26.2.1 – The Default Position – Use of a Hospital Pharmacy Dept.
Unless specific, alternative arrangements have been agreed with the Trust Chief
Pharmacist (Governance & Professional Practice), the Senior Pharmacy Manager of the
local acute trust must be approached and agreement sought for his/her department to
facilitate the management of clinical trial materials and for supplies of trial medication to
be made from that department. The acute trust Senior Pharmacy Manager will then be
responsible for ensuring that all legal, indemnity and professional issues relating to
medicines management are adequately addressed before agreeing to the trial
proceeding.
26.2.2 – Use of a Community Pharmacy
If, for whatever reason, the local acute trust pharmacy department does not agree to
facilitate the management of medication for a particular clinical trial, or if that pharmacy’s
location is not convenient for a significant number of the trial participants, a local
community pharmacy may be approached to fulfil the role. The Trust Commercial Trials
Facilitator will be able to provide the principle investigator and sponsor of the trial with a
list of community pharmacies in the local area that have expressed an interest in
providing this service for the Trust and the Trust Chief Pharmacist (Governance &
Professional Practice) will act as a liaison point between the Trust and the community
pharmacy if this is required. Where a community pharmacy is used, the responsibility for
legal, indemnity and professional issues relating to medicines management will rest with
the manager or superintendent of the community pharmacy.
26.2.3 – Management of Clinical Trial Material on Trust Premises
Other than in exceptional circumstances, this may only take place in Trust bases that
regularly undertake clinical trial activity and that have been inspected and approved for
such activity by the Chief Pharmacist (Governance & Professional Practice) or another
member of the pharmacy team with delegated responsibility.

Bases that are considered as regularly undertaking clinical trials activity will be
agreed by the Chief Pharmacist (Governance & Professional Practice), the Trust’s
Medical Lead for Research & Development, and the Commercial Trials Facilitator.
Premises and operating procedures for medicines management (for each
commercial trial) will be assessed (and approved) by the Chief Pharmacist
(Governance & Professional Practice). A member of the pharmacy team will
inspect these premises at least annually in order to ensure that storage facilities
and conditions are suitable and sufficient and to ensure that operating procedures
relating to medicines management are being fully adhered to.
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
Other Trust bases may not be used for the storage and management of clinical
trial materials other than in exceptional, individual circumstances, and only in
cases where attempts to recruit an acute trust pharmacy department or a
community pharmacy to facilitate the trial have failed. Where this is the case, and
before the trial commences or any trial materials are delivered, the Trust premises
must first be inspected by a member of the pharmacy team and the Commercial
Trials Facilitator to assess the suitability of the facilities for the storage and
management of trial materials. Whenever possible, this assessment visit should
also include the trial sponsor and the trial’s principal investigator. In addition,
operating procedures relating to medicines management must be approved by the
Chief Pharmacist (Governance & Professional Practice). Only when this
inspection has taken place and when facilities and procedures have been
assessed as being satisfactory, (in relation to the specific trial in question), will the
trial be confirmed and agreed. Beyond the baseline approval of facilities and
operating procedures, the trial premises will be subject to on-going inspections
during the course of the trial, (usually quarterly, or at 6-month intervals as a
minimum).

Further to the points above, medical staff must ensure that specific authorization
for the management of clinical trials materials on Trust premises has been given,
before they issue (or oversee the issue of) any such materials to patients. Trust
indemnity arrangements may not extend to this practice if such authorization has
not been given.
26.3 – Responsibilities of Research Nurses & Other Nursing Staff

Before working with clinical trial materials, nursing staff must ensure that the Trust
fully supports and indemnifies them for this area of practice. This must be
confirmed by the Commercial Trials Facilitator, where necessary in liaison with the
Executive Director of Nursing.

All nursing staff working with clinical trial materials must work in accordance with a
trial-specific protocol or trial-specific operating instructions.

Trust nursing staff may only issue clinical trial materials to patients in their original
container as provided by the trial sponsor and such containers must be fully
labelled and clearly coded in accordance with the trial protocol before delivery to
the Trust premises. Where agreed with trial sponsors, nursing staff may add the
trial participant’s name, the date of issue and the name and address of the trial
centre to the trial material before issue to the trial participant. However, nursing
staff may not undertake any formulation, secondary dispensing or additional
labelling of trial materials (beyond that listed above) as the Trust would not
indemnify them for these activities.

Other than in exceptional circumstances, and in addition to the points above, the
receipt, selection, issue and recording of trial materials must involve two members
of the nursing team who will then have joint responsibility for the management of
materials. All records and logs should include two signatures.

All nursing staff involved in the handling and management of clinical trial materials
must be individually named within site-specific operating procedures or a sitespecific protocol for the trial. Nursing staff that are not individually specified and
authorised may not be covered by Trust indemnity.
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26.4 – Storage of Clinical Trial Materials

The high level of medicines management employed by the Trust for its prescribed
medication and its stock medication must also be applied to clinical trial materials.

When trial materials are stored on Trust premises, they must be stored in a locked
room or locked metal cupboard that is reserved solely for the storage of trial
materials.

Facilities must be sufficient in size to allow tidy, uncluttered storage that allows
materials to be easily identified. Wherever possible, materials for each trial must
be clearly segregated and labelled in order to assist in accurate identification and
selection.

Wherever possible, trial materials should be stored separately to any associated
items such as syringes, lancets and blood tubes etc.

Access to trial material storage areas must be restricted to practitioners who are
directly involved with the trial. Access to room / cupboard keys must also be
similarly restricted.

The temperature of trial material storage areas must be constantly monitored via a
digital maximum / minimum thermometer or data device. A daily record of
temperatures must be maintained and be available for inspection by members of
the pharmacy team and by trial sponsors.
27 MEDICINES RELATED DUTIES PERFORMED BY AUTHORIZED EMPLOYEES
27.1 Authorized employees who have successfully completed certain assessments e.g.
NVQ in care; may be authorized by the Trust to assist a Designated Practitioner to
perform the following:
27.1.1 Check the medicine label with the prescription sheet as a second check. (This
does not apply to injectable medicines.
27.1.2 Administer oral and topical medicines (including inhaler, eye and ear drops) to
a patient once prepared and checked by a Designated Practitioner.
27.1.3 Check controlled drugs with a Designated Practitioner.
27.1.4 Check the patient’s name and hospital number against the prescription sheet
with a Designated Practitioner.
27.1.5 Check discharge medicines with a Designated Practitioner against a discharge
prescription.
27.1.6 Check ward-supplied leave/discharge medicines with a designated practitioner
against the patient’s drug chart.
27.1.7 Witness the self administration of medicines either in a ward or in a patient’s
home following patient specific assessment and training.
27.2 Authorized employees may be authorized by the Trust to perform the following
duties independently.

Administer medicines to a particular patient following training and successful
assessment.
27.3 Authorized employees may hand out medication, collected by service users from
community units if:
27.3.1 The medication is in a sealed bag with the name and address of the service
user.
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27.3.2 The service user or agreed deputy is expected.
27.3.3 The authorized employee asks the service user or agreed deputy the address
of the service user and they must know it without any prompting.
27.3.4 Where communications problems are envisaged e.g. English is not spoken,
alternative arrangements to confirm the identity of the patient or their
representative must be agreed in advance.
27.3.5 The authorized employee will not be put at risk by the service user or agreed
deputy should they decline to hand over the medicines.
27.4 Authorized employees may deliver medication to service users in the community
without delay, detour or temporary storage if:
27.4.1 The medication is in a sealed bag with the name and address of the service
user that has been checked by a qualified nurse or pharmacy staff member.
27.4.2 The service user or agreed deputy is expecting the delivery.
27.4.3 Unless the service user or agreed deputy is known to the authorized
employee they must be asked for proof of identity.
27.4.4 It has been made clear to the service user or agreed deputy that the person
handing over the medicine cannot answer any clinical questions and is not
authorized to make any alteration to the contents of the bag.
27.4.5 The authorized employee has the right to refuse to undertake this task if they
have concerns about a service user or agreed deputy.
27.5 If the medication handed out or delivered to a service user is new to them the
authorized employee must ensure that:

There is a patient information leaflet provided with the medication

The service user is advised that further information can be obtained on the
medication from their care co-ordinator
27.6 Duties that cannot usually be performed by authorized employees:

Preparation and supply of medicines.

Administration of medicines by injection, vaginally or rectally.

Administration of controlled drugs.

Supply of discharge medicines from a ward.

Delivery of new medication to patients with significant communication
problems, e.g. does not speak English.
NB. The development of future training courses may provide opportunities for Trust
approved changes to some of the above.
28. USING MEDICAL GASES
All medical gases used in the Trust are Licensed Medicines and as such are subject to the
Medicines Act and must be treated in the same way as any other medicines. See also the
chapter – Storage and Handling of Flammable Liquids, Gases and Aerosols.
28.1 Under normal circumstances written authority from a prescriber must be obtained
before a medical gas is administered to a patient. This authority must include the
name, and concentration of the medical gas (where appropriate), the method of
administration and the rate of flow. This must be recorded on the patient’s
prescription record. This can be achieved by:
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
An inpatient prescription for an individual patient

A Medicine Administered Under Protocol (MAUP) for oxygen in an emergency.
29. PHARMACEUTICAL INDUSTRY REPRESENTATIVES
This section should be read in conjunction with the Trust and Employee Relationships with
Commercial Organizations Policy and the Working Formally with Commercial Organizations
Policy.
29.1 Representatives of the Pharmaceutical Industry must not be allowed to visit patient
areas unless agreement has been given by the relevant manager.
29.2 Casual visits to wards, clinics or other patient units are unacceptable and
appointments should be made with the relevant manager, head of department or
consultant.
29.3 Visits should be limited to the delivery of significant product information.
Information relating to price, pack-size, or similar, does not normally warrant a visit
and should be dealt with by post.
29.4 Details of new product launches must be discussed with the Trust’s Chief
Pharmacist before discussion takes place with other clinical staff.
29.5 The introduction of new drugs must only take place in line with the Trust’s New
Drug Policy.
29.6 Medicine samples must not be accepted. Representatives wishing to supply them
should be referred to the Chief Pharmacist.
29.7 Only the Chief Pharmacist may give a Trust commitment to purchase a medicinal
product. No other member of staff is authorized to give such commitments, or to
give any indication of the potential budget for any further purchase, and /or
competitors prices.
30. MEDICATION ERRORS AND NEAR MISSES
30.1
Definition
A medication error or near miss is a preventable incident associated with the use of
medicines, which has or may have put a patient at risk. Such incidents may be related to
any of the steps of the medicine use process. This includes prescribing, dispensing and
administration of the medicines and the transfer of information and may result in the
patient receiving an incorrect dose of their prescribed medicines, a dose of their
medicine being incorrectly omitted or delayed, or their receiving medication which they
have not been prescribed.
30.2
Management
Successful management of a medication error will include the following:

A review of the well-being of the patient and the minimization of further risk. (This is
of primary importance).

Reassurance for the patient, and where appropriate, their relatives or carers.

A full review of the incident and a full record, (using the Trust incident reporting
procedure), of the identified cause, the outcome and the measures to be taken to
prevent reoccurrence.

Where appropriate, counseling for staff involved.
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
Where deemed necessary, further assessment and re-training of staff involved.

Avoidance of formal complaints or litigation.

Rapid response to any formal complaints received.
30.3
Clinical Management
30.3.1 Where medication is incorrectly omitted or significantly delayed, the assigned
practitioner in charge must be informed. He/she should then obtain advice
from the patient’s doctor or from the unit pharmacist regarding further action to
be taken. Any action taken must be recorded in the patient’s notes and the
nursing record.
30.3.2 Where medication is administered in error, the assigned practitioner in charge
must be informed. He/she should then obtain advice from the patient’s doctor
regarding further action to be taken. Any action must be recorded in the
patient’s notes and the nursing record.
30.4
Informing the Patient/Carer
30.4.1 Under normal circumstances the patient should be immediately informed that
an error has been made, either by their doctor, their key nurse/worker, or by
another member of healthcare staff directly involved with their care. Whilst
there is no obligation to inform relatives or carers of the incident, consideration
should be given to doing so.
30.4.2 Where the patient is suffering from a condition which impairs their cognitive
or intellectual function, the decision to inform them, and /or their relatives or
carers, will rest with their doctor.
30.4.3 If the patients, relative or carer is subsequently unhappy with the outcome of
the incident or the action taken in response, the Trust Complaints Procedure
should be followed. A senior manager should be called to see the patient, or
their relative or carer, without delay.
30.5
Reporting/Recording the Incident
The Trust operates a reporting policy and actively encourages staff to openly report
incidents without fear of retribution. The purpose of reporting and recording a drug
error is to ensure that processes are reviewed in order to prevent or minimize any
change of reoccurrence.
30.5.1 Whenever possible, review should be followed by the implementation of
remedial action and subsequent further review/audit.
30.5.2 Any drug error incident or near miss which gives cause for concern should be
reported, and may be reported by any member of staff. Such incidents and
near misses should be reported using the Trust incident reporting procedure.
30.5.3 The Trust incident reporting procedure must be undertaken as soon as
possible following the incident and the form completed fully and in as much
detail as needed to properly describe the incident. The form should be
completed in liaison with the assigned practitioner in charge or the unit/line
manager as appropriate.
30.5.4 The completed, signed incident report form is sent to the Risk Manager who
in the case of incidents relating to medicines will copy the form to the Chief
Pharmacist. The Chief Pharmacist will decide if any further action needs to be
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taken and what lessons can be learnt. Where appropriate lessons learnt will
be shared in the Report and Learn Bulletin and the Drugs and Therapeutics
Newsletter.
30.5.5 Where an incident occurs which identifies a significant flaw or failure in
current procedures and systems, the Chief Pharmacist will liaise with the
appropriate professional lead to review what if any changes need to be made.
30.6
Anonymous reporting
If despite the Trust’s reporting policy a member of staff observes an incident which they
feel should be reported, but feels unable to report it to their manager, or otherwise in
accordance with Trust policy, they may report the incident by telephone, or in writing,
direct to the Executive Director of Nursing, the Chief Pharmacist or the Executive
Medical Director. Anonymity and confidentiality will be maintained and the incident will
receive investigation and review in the normal manner.
30.7
Disciplinary action
Introduction
To minimize the risks associated with the use of medicines it is essential that lessons
are learnt when errors are made. For this to occur a reporting system is needed that
encourages staff to record and report significant medication errors or near misses.
To help achieve this, staff must feel confident that reporting an error will not
automatically lead to someone being disciplined.
However there will be a small number of occasions when instigating disciplinary
action or the Capability Policy is considered appropriate and necessary. Managers
have asked for clarification in this area, both to encourage a more open culture and to
achieve a more consistent approach to handling medication errors.
30.7.1 The default position is that staff will not be disciplined if they are involved in a
medication error or ‘near miss’.

Disciplinary action will be considered in the following circumstances:
o An attempt has been made to ‘cover up’ a medication error or ‘near
miss’.
o The behaviour of the practitioner(s) is deemed to be reckless.
Action under the Trust’s Capability Policy may also be considered for practitioners
making repeated mistakes that are not due to reckless behaviour.
30.7.2 Definition of ‘Reckless’
Behaviour will usually be regarded as reckless when the practitioner has:


Knowingly gone against a policy or a procedure and/or
Made a decision knowing that they needed further information.
Examples of reckless behaviour are:

A pharmacist is asked to check and issue a dispensed clozapine prescription
without checking that an appropriate blood result has been received.

A doctor is given a path lab report saying a patient’s infection is sensitive to
amoxicillin and is prescribed it without checking the allergy status of the
patient.
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
A new nurse covering a continuing care unit is not absolutely sure of the
identity of a resident and relies on the resident confirming their name.
It is recognized that here may be occasions when a policy or procedure is ignored in
the best interests of the patient. However it must be assessed as to whether a
significant body of other practitioners would have considered it reasonable to do so
had they been faced with a similar situation.
30.8
Review of Medication Errors
The Trends and Lessons Group will meet four times a year to review the clinical incident
reports, including medication errors, to establish trends and to propose actions needed
to prevent such errors. Action may involve system redesign and improvement and/or
education, training and competency assessment of employees on any aspect of
medicine related incidents.
31. MEDICINE DEFECT REPORTING
The following procedure applies when a defect is found or is suspected in any medicine or if
the defect is in the device administering the medicine, e.g. syringe driver. Refer to the
Medical Devices Policy.
During the manufacture, storage or distribution of a medicinal product, an error or incident
may occur which alters the specification of that product and which may result in its reduced
performance or efficacy. Where the reduced quality of a pharmaceutical product is identified
it is important that the product be immediately withdrawn from use.
Inform the appropriate pharmacy who will advise on all reporting, recording and investigating
on the defect. Out of pharmacy opening hours, if a serious problem has been identified
which is considered to present an immediate hazard to patients, staff or the public, the oncall pharmacist must be contacted.
31.1 Retain any remaining product and/or the device and any associated products or
equipment (e.g. administration sets, infusion devices etc). Put these into secure
quarantine until collected by pharmacy or a nominated responsible person.
31.2 Record the details of the device and product (including batch number if
appropriate).
31.3 If the defective product has been administered to a patient or the faulty device has
administered too much or too little medication, inform the doctor responsible for the
patient and record the details in the patient’s notes.
32. COMMUNITY BASED PRACTITIONERS
For each community team base where medicines are stored, a suitably qualified practitioner
must be designated as the Appointed Practitioner in Charge. This Appointed Practitioner in
Charge is ultimately accountable for the stock of all medicines held, ensuring that Medicine
Code procedures are followed correctly and that the security and safe handling of medicines
is maintained. This chapter must also be read in conjunction with the Trust’s Core Standards
for Medication Handling by Assertive Outreach, Crisis, Home Treatment and other
Community Teams with Complex Medication Handling Needs.
32.1 Designated Community Practitioners must possess a properly authenticated letter
stating the right to carry stock medicines. The range of medicines will be specified
in the letter which will be signed by the Director Nursing, the Chief Pharmacist and
their local manager. A valid staff identification badge must support the letter.
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32.2 All other medicines carried by the Community Practitioner must be prescribed as a
specified dose for a named patient by a prescriber.
32.3 All stored medicines must be kept in a separate locked medicine cupboard to which
only Designated Community Practitioners have access. Medicines may be kept for
patients that have been prescribed for them by their GP and dispensed.
32.4 It is the responsibility of the appointed practitioner in charge of a community clinic,
(e.g. a depot medication clinic), to ensure that a record is kept which details all
medicines received from the supplying pharmacy, and all community practitioner
transactions. The record should be sub-divided according to product and should
show a “stock balance” at each entry. A full stock check should be carried out each
month to ensure that stock is correctly rotated according to shelf-life and that stock
levels are appropriate and concur with those recorded.
32.5 The Designated Community Practitioner must keep the medicine:


Secure when visiting a patient.
Secure and out of sight, e.g. within the locked boot of a car, when traveling
between visits.
32.6 Whenever practicable, unused medicines should be returned to the medicine
cupboard at the team base for overnight and weekend storage. Where this is not
possible, they may be securely stored but not for longer than 72 hours.
32.7 Medicines must not be left in practitioners’ cars overnight
32.8 Return any patient’s own medicines no longer required to a local community
pharmacy or the dispensing doctor who originally dispensed it. Community
pharmacies are obliged to take patient’s unwanted medicines from domestic
enviroments, including residential homes under their NHS contract.
32.9 When taking unwanted patient medicines to a pharmacy or dispensing doctor to be
destroyed on behalf of the patient, there is no obligation to make a record of what
has been taken. However individuals may wish to make a record to avoid
accusations of theft or misappropriation, particularly if the medicine is a controlled
drug or another medicine liable to be abused, e.g. diazepam. A list of medicines
that fall into this category are listed in Chapter 15 – section 7. Any record made
should be countersigned by the person in the pharmacy or dispensing practice
receiving the listed medicines. It may also be prudent to get a signature from the
patient/carer to confirm they agreed for them to be disposed of.
32.10 Community teams holding patients’ own drugs on behalf of clients with poor
compliance must have a local procedure to ensure medicines are booked into and
out of the staff base, though special arrangements may be made to store patients’
own controlled drugs on a suitable ward if no CD cupboard is available in the base.
Whenever practicable these medicines should be stored in the medicine cupboard
at the team base. Where this is not possible, they may be securely stored at the
practitioner’s home but not for longer than 72 hours.
33. CONSENT TO TREATMENT
This section should be read in conjunction with the trust policy and the appropriate sections
of current version of the Mental Health Act and Mental Capacity Act.
33.1 Wherever possible the medicines proposed to treat a patient should be discussed
with the patient. The discussion must be carried out in such a way that the patient
is able to contribute and express agreement or disagreement with the proposed
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treatment. If English is not spoken fluently then appropriate steps should be taken
to access the services of an interpreter.
33.2 "Consent" is the voluntary and continuing permission of the patient to receive a
particular treatment, based on an adequate knowledge of the purpose, nature,
likely effects and risks of the treatment including the likelihood of its success and
any alternative to it. Permission given under any unfair or undue pressure is
not consent (Mental Health Act 1983 Code of Practice).
33.3 It is the duty of everyone proposing to give treatment to use reasonable care and
skill, not only in giving information prior to seeking a patient's consent, but also in
meeting the continuing obligation to provide the patient with adequate information
about the proposed treatment and alternatives to it. This information must be
provided in an appropriate format and the services of translators and interpreters
used if appropriate.
33.4 Discussions about the drug treatment and consent to treatment should ideally be
when treatment is initiated or, in the case of anticipated emergency situations e.g.
rapid tranquillisation, in advance. The nature and outcome of the discussion
together with an assessment of the capacity of the patient to consent must be
recorded in the patient notes. If the patient is too ill at the time of the initiation of
prescribing the prescriber must seek further consent when the patient is well.
33.5 Information given by pharmacists or other practitioners about the treatment should
be provided in addition to that provided by the prescriber, rather than as an
alternative. A record should be made in the patient’s notes of any significant
interventions and the use of alternative communications formats to those usually
employed.
33.6 Treatment of those without capacity to consent
When a patient is incapable of consenting, medicines can be prescribed for them in
their best interests under the common law doctrine of necessity. The treatment must
be:

Necessary to save life, or prevent a deterioration of, or ensure an improvement
in the patient’s physical or mental health.

Be in accordance with the practice accepted at the time by a reasonable body
of medical opinion skilled in the particular form of treatment in question.
33.7 Reviewing treatment of those without capacity to consent
Practitioners should remain aware that capacity to consent may be subject to
fluctuation. Reassessment of the patient's capacity to consent should be carried out as
often as considered appropriate.
33.8 Treatment of those detained under the Mental Health Act
The Mental Health Act provides the prescriber with a three month period to develop a
treatment programme to meet the patient's needs. Even though the Act allows
treatment without consent the prescriber should observe the same principles of seeking
consent described above. The three month period starts on the occasion when
medicines for mental disorder were first administered to the patient under detention.
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33.8.1 Medicines after three months
A system should be in place to remind the approved clinician in charge of the
treatment at least four weeks before the expiry of the three month period. The
approved clinician must:
Seek the patient's consent to continuing medication.

Record the discussion on the form for medication from the Part 4 and Part 4A
MHA procedure including an assessment of the patient's ability to consent.

Complete a form T2+ If the patient consents to continued treatment.

Request a second opinion doctor (SOAD) visit from the Mental Health Act
Commission if the patient refuses consent or is deemed unable to provide a
reliable consent. If the SOAD agrees with the approved clinician that treatment is
necessary and can be given, the SOAD will complete a Form T3.
Practitioners must not administer medicines to patients detained under the
Mental Health Act 1983 after the 3 month period without first ensuring that a
valid Form T2 or Form T3 has indicated that the treatment can be given under
individual BNF sub-groups.
33.8.2 Pharmacy staff will report any errors relating to Form T2 or Form T3 to local
mental health act administrator using an approved form.
34. ILLICIT SUBSTANCES
Sussex Partnership Trust is an illicit substance free zone. This includes all substances,
drugs and medicines of any category, other than those specifically prescribed or approved
for the patient.
34.1 A separate policy and procedure exists for dealing with the discovery of suspected
illicit substances. This advice will also apply to ‘legal highs’ that the Trust has
deemed to have the potential to do harm before a decision has been made by the
Government on its legal status.
34.2 The procedure for disposing of any substance thought to be of an illicit nature is as
follows:
34.2.1 The substance must be sealed in an envelope.
34.2.2 On the envelope there must be a description of the substance, together with
where and when it was found. Both the Assigned Practitioner in Charge and a
second Designated Practitioner must sign the package across the seal.
34.2.3 An entry must be made at the back of the Controlled Drug Register describing
the substance, together with where and when it was found. Both the
Assigned Practitioner in Charge and a second Designated Practitioner must
sign the entry.
34.2.4 If the quantity of the substance has been deemed to be sufficient to indicate
dealing or is a class A drug the local police must be notified.
34.2.5 In other circumstances the local pharmacy department can be asked to
witness destruction on the ward.
34.2.6 The substance must be stored in the Controlled Drug Cupboard until collected
by the police or destroyed in the presence of a pharmacist.
34.2.7 In the absence of a Controlled Drug Cupboard and Register the substance
must be stored in the units locked drug cupboard and a similar entry made in
the unit diary.
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34.3 The Assigned Practitioner in Charge must NOT:

Send the substance to the pharmacy.

Return the substance to the patient or relative.

Attempt to analyse the substance
34.4 Witnessed Destruction
Witnessed destruction must only take place in the presence of the Assigned Practitioner
in charge and a pharmacist.

The sealed envelope must not be opened until both are present.

The contents must be disposed of in a DOOP kit after ‘wetting’ any light material
with washing up liquid.

A record of the destruction must be made in the Controlled Drug Register or unit
diary (if no Controlled Drug Register) against the original entry and countersigned
and dated by the Assigned Practitioner in charge and the Pharmacist.
35. COMPLIANCE AIDS (e.g. dosette boxes and monitored dosing system (MDS))
35.1 Non-compliance with medicines is a major cause of relapse and admission to
hospital. There are many factors that can lead to non-compliance with medicines.
These include:






A poor understanding of the need for medicines.
A poor understanding of how to take the medicines.
Forgetfulness.
Inability to open the containers.
Visual impairment.
A complicated regime of medicines.
For some people a compliance aid may assist a person to continue self-medication
and remain out of hospital.
35.2 Before there is any agreement to provide medicines in a compliance aid, a full
assessment of the reason for non-compliance must take place. It may be that the
provision of a compliance aid may not be of benefit and other strategies may prove
successfully, e.g. larger print labels. This assessment should normally be carried
out by the multi-disciplinary team in liaison with Pharmacy staff.
35.3 Compliance aids vary but most require weekly replenishment. Before compliance
aids are issued and the patient trained to use them arrangements must be made for
their regular replenishment.
35.4 The act of filling a compliance aid involves re-dispensing and re-labeling. Where it
is not carried out by authorized pharmacy staff this should only be carried out by a
designated practitioner following an agreed procedure. This procedure must include
a check by another designated practitioner or an authorized employee who has
been assessed as competent to undertake this role.
35.5 Alternatively, designated practitioners who are deemed competent to fill compliance
aids may:


Assist patients to fill their own compliance aids.
Train patients to fill and use a compliance aid as part of a training scheme.
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35.6 All compliance aids supplied by the Sussex Partnership NHS Foundation Trust or
filled by Trust staff must allow the identification of contents and be fully labeled.
36. SAFE HANDLING OF MEDICINES REQUIRING COLD STORAGE
36.1 General information
Unless specific advice states otherwise medicines requiring cold storage that have not
been properly distributed and stored should NOT be used.
The manufacturer’s storage requirements for medicines requiring cold storage (usually 2
to 8C) must be maintained to ensure that the administered medicine is effective.
Medicines requiring cold storage will deteriorate and become ineffective if stored outside
manufacturer’s recommendations. Medicines should also be protected against light.
36.1.1 Each Clinic/Ward is required to have: A named, trained individual with overall responsibility for cold stored
medicines, including vaccines, with named deputies.
 A lockable medical refrigerator.
 A maximum/minimum thermometer with an audible alarm with a remote probe
or a refrigerator with an integral maximum/minimum thermometer with an
audible alarm.
36.1.2 The designated person must: Have a good knowledge of this chapter of the Medicines Code.
 Be able to read the maximum/minimum thermometer and record the
temperatures daily.
 Ensure that medicines requiring cold storage are stored at the correct
temperature.
 Ensure medicines requiring cold storage are not packed too closely in the
refrigerator, nor stored against the freezer section or in the door.
 Ensure that food and drinks are not stored in a medicine refrigerator.
 Label the power point to the refrigerator to avoid accidental switching off.
 Have nominated deputies to cover in his/her absence.
 Monitor medicine stocks to avoid over-ordering, stockpiling or wastage.
36.2
Receipt of medicines requiring cold storage in clinics and wards
All staff likely to receive delivery of medicines requiring cold storage must be aware of
this section of the chapter.
36.2.1 A designated member of staff should have overall responsibility for the receipt
and storage of medicines requiring cold storage. Named deputies should also
be identified.
36.2.2 Place the medicines requiring cold storage immediately into the designated
refrigerator. Medicines requiring cold storage must not be left at room
temperature.
36.2.3 The refrigerator should be locked with access to it by authorized staff only.
36.2.4 Store the medicines requiring cold storage in the correct rotational/date order.
36.3
Storage of medicines requiring cold storage
For specific information on storage refer to manufacturer’s data sheet
36.3.1 Store the medicines under controlled conditions. Any deviation from these
may reduce the efficacy of the medicines. Medical refrigerators are generally
of a higher specification than domestic varieties and may incorporate an
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integral fan, maximum/minimum thermometer and an alarm. They must be
lockable.
36.3.2 Use medicines with the earliest expiry date first. Check expiry dates regularly
and remove time-expired medicines and destroy according to local procedure.
36.3.3 Medicines should not be packed too closely within the refrigerator - allow for
the circulation of cold air.
36.3.4 Store medicines in the main body of the refrigerator. They must not be stored
against the freezer compartment or in the door or bottom drawer.
36.3.5 Store all vaccines at a temperature between 2C and 8C.
36.3.6 No medicines must be frozen.
36.3.7 Store medicines in original packaging to protect from light and temperature
change.
36.3.8 Reconstituted medicines may not remain stable and will have an expiry period
following reconstitution - refer to manufacturer’s summary of product
characteristics for reconstituted expiry dates.
36.3.9 Cautionary notices should be placed on power plugs or sockets or tape the
power point of the refrigerator, to avoid accidental switching off, or use a
switchless socket.
36.3.10 No food or drink or clinical specimens should be stored in the medicines
refrigerator.
36.3.11 Unless a frost-free model, defrost the refrigerator regularly to prevent buildup of ice. Ideally, this should be done when the refrigerator is empty. If this is
not possible temporarily store the medicines in another refrigerator on another
ward.
36.3.12 Opening the refrigerator door should be kept to a minimum
36.3.13 The refrigerator should not be situated near a radiator or heat source and
should be appropriately ventilated.
36.3.14 Patients taking medicines home should be given written storage instructions.
36.4
Temperature control
36.4.1 The temperature of the medicine refrigerator must be continually monitored
with a maximum and minimum thermometer with an audible alarm. Digital
thermometers are recommended. Reset and replace according to
manufacturers guidelines, including the batteries.
36.4.2 Calibration of thermometers should be checked annually to ensure correct
working. Records should be kept for audit in the temperature log book.
36.4.3 Check and record the maximum/minimum refrigerator temperatures daily
when the refrigerator is in use (Monday to Friday in clinics). Record the results
in the refrigerator’s temperature log book.
36.4.4 If the temperature is not maintained within the correct range or if a refrigerator
is turned off for any length of time, local mental health pharmacy team should
be contacted to ascertain the action to be taken. Alternatively telephone the
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medicine’s manufacturer for advice. If out of hours, contact the local on-call
pharmacist for advice.
36.4.5 Ensure a repair engineer can be readily contacted in case of a breakdown.
Keep the appropriate number in the front of the temperature log book.
36.5
Ordering and monitoring of stock
Medicine stock should be monitored by the designated person to avoid over-ordering or
stockpiling
36.6
Advice on medicines following problems with the cold storage chain
Where there are queries as to the efficacy of a medicine due to problems with the cold
storage chain, the local mental health pharmacy team can usually supply advice on the
stability of medicines or contact the medicine manufacturer.
36.7
Equipment list
36.7.1 Refrigerators
Specialised refrigerators are available for storage of pharmaceutical products and
must be used for medicines requiring cold storage and diluents. Ordinary domestic
refrigerators must not be used.
They MUST be lockable.
It would be a sensible precaution to validate any refrigerator intended for medical use
by means of a thermometer or temperature probes, and also to maintain regular
ongoing checks on the temperature to assess suitability for use. The mains electrical
lead should ideally be fitted in a spur point, which should be fused but not switched.
Contingency plans should be made for defrosting activities.
36.7.2 Maximum and Minimum Thermometers
A digital maximum/minimum thermometer with a remote probe and audible alarm
should be used. It is advisable to request a certificate of calibration.
If a suitable probe is not provided with the refrigerator a separate thermometer can be
obtained.
Results should be recorded in the refrigerator monitoring book.
36.8
Health and safety
A C.O.S.H.H. data sheet is available in case of spillage or contamination by vaccines on
the Trust Intranet.
37. CONTROL OF FP10 (NC) PRESCRIPTION
37.1 Prescription Types
37.1.1 FP10 (NC) prescriptions are used by clinical teams. Each team will have
printed uniquely coded prescription pads identified for costing purposes
against their team. These should normally only be used for that team’s
patients except in exceptional circumstances when covering on call.
37.1.2 Substance Misuse Services can use PH10MDAss or FP10MDAss
prescriptions for repeat prescribing of methadone, buprenorphine and
diazepam and FP10(NC) or FP10ss for all other prescribing.
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37.2
Ordering of FP10 Prescriptions by the pharmacy Departments
37.2.1

Designated approved staff will be responsible for ordering sufficient quantities of
all FP10 prescriptions. These will be ordered by pharmacy staff wherever
practical but designated team administrators may take on this role in special
circumstances, e.g. SMS services and Hampshire CAMHS.

FP10 (NC) prescriptions will be ordered directly from the printers, by email or fax,
utilising the unique team codes by designated approved staff registered with NHS
Forms by the Chief Pharmacist – Strategy.
37.3 Ordering of FP10 Prescriptions by Authorised Prescribers
37.3.1 Only authorised prescribers who have a completed their locality’s ‘Pharmacy
Signature Form and FP10(NC) Authority’, signed by their consultant, will be
eligible to collect and use team prescription pads from the pharmacy or
designated collection point. Medical staffing will usually issue this form on
appointment, but additional blank forms will be held by the pharmacy or
designated collection points for completion.
37.3.2 Ideally the prescriber should collect their own prescriptions from the
appropriate pharmacy or designated collection points. These collection points
have a responsibility for ensuring the pads are kept in a locked cupboard or
filing cabinet with access limited to essential personnel. To save time a phone
call in advance should be made to ensure availability on arrival. If the
prescriber is unable to attend in person, he/she should forewarn the pharmacy
or designated collection point that his or her nominated deputy will be
collecting prescriptions on their behalf. In all cases the person collecting the
prescriptions must have with them proof of identity in the form of Trust security
badge or be known personally to the staff involved in issuing the prescriptions.
37.3.3 All issues must be recorded by the pharmacy or designated collection points.
The record must have the following data as a minimum:






The unique numbers of the prescriptions released.
The team code on the prescriptions.
The date released.
The name of the prescriber to whom the pad is being allocated.
The signature and printed name of the person collecting the prescriptions.
The signature of the person issuing the prescriptions.
37.3.4 Because some junior doctors move rapidly through teams, it is acceptable for
the team administrator to set up a system in which partly used pads are
collected in when a junior leaves andare later reissued to their successor on
arrival using the process described above. Subsequently when a new pad is
required this will need to be ordered/collected by the junior from the local
pharmacy or designated collection point as in 37.3.2.
The record must have the following data as a minimum:





The unique numbers of the prescriptions returned/released*.
The team code on the prescriptions.
The date returned/released.
The name of the prescriber returning/issued the prescriptions.
The signature and printed name of the doctor returning/collecting the
prescriptions.
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
The signature of the administrator receiving/issuing the prescriptions.
*If the final digit on the prescription number is ignored, the prescription
numbers run sequentially.
37.3.5 These records should be kept for a minimum of five years.
37.4
Security of Pads in Community Teams
37.4.1 It is the responsibility of each individual issued with a pad to keep it secure at
all times. Loss of a pad will lead to significant inconvenience to the team,
possible misuse and additional costs to the Trust. In substance misuse teams
where blank prescriptions are provided for printing, responsibility for secure
storage rests with the team manager.
37.4.2 In the event of a pad being stolen or, misplaced and not found within a
reasonable time, the following steps must be taken:

Contact the local police station and provide the following details:

The number of prescriptions missing.

The serial number of the prescriptions missing.

The team name, address and the Trust identification number (unless
substance misuse, this starts with RX2) as printed on the prescription.

If there is some uncertainty about the serial numbers involved or the Trust
identification number, contact the department supplying the pads at the
earliest opportunity.

Full details of the circumstance ie location, time last seen, evidence of a
break in, etc.

Obtain a crime or incident number.

At the earliest opportunity contact the Chief Pharmacist, or in his absence,
the local mental health pharmacist to agree a change in ink colour for any
prescriptions written by the team and the period the change will cover
(usually at least a month).

The Chief Pharmacist, or in his absence, the local mental health
pharmacist, will contact the Shared Service Agency on 01903 708668,
West Sussex, or 01273 403707 in Brighton and East Sussex to activate
the stolen FP10 protocol with local community pharmacies and they will
also inform the NHS Counter Fraud Services, who then inform the
Prescription Pricing Authority.

At the earliest opportunity inform the locality manager and complete a
Trust Incident Form.
37.4.3 It is essential that pads are not left on view, pre-signed or stored unlocked in
public building when not in the possession of the prescriber.
37.5
Return of FP10 Prescriptions on termination of employment
37.5.1 On termination of employment or a change of team all prescribers have a
responsibility to return any unused prescriptions to their local supply point.
This department must record, against the original issue record, the number of
individual prescriptions returned along with their unique number and the date
they were returned.
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37.5.2 In the unlikely event that a prescriber only discovers they have some
prescriptions in their possession after leaving the area they must phone the
appropriate department to notify them of the prescriptions they have and then
destroy them. The department must make a record of the phone call and
record, the number of individual prescriptions that will be destroyed along with
their unique number and the date the department was notified.
37.6
Use of FP10 Prescriptions
37.6.1 Normal out-patient prescription forms are coded FP10(NC), and are coloured
green so that they can be easily identified by dispensing pharmacists and by
the NHS Prescription Pricing Authority. Those used by the Community Drugs
Teams for instalment prescribing are coded PH10MDAss or FP10MDA, and
are coloured blue.
37.6.2 Prescriptions must be written legibly in ink, or otherwise so as to be indelible,
should state the full name and address of the patient, the name of the
prescriber (in block letters), and be signed and dated.
37.6.3 It is strongly recommended that the patient’s age and date of birth be recorded
on the prescription form. For patients under 12 years it is a legal requirement
that their age be stated.
37.6.4 The name of the drugs and preparations prescribed should be written clearly,
using approved names whenever possible, and should not be abbreviated.
37.6.5 Drug strengths and dosages should be written clearly and unambiguously.
Great care must be taken if abbreviations of measurements are used and any
unnecessary use of decimal point should be avoided, e.g. 3mg not 3.0mg
Doses under 1mg should be written in micrograms, which should not be
abbreviated.
If doses of less than 1 unit are prescribed, decimal points should be protected
by a preceding zero, e.g. 0.5units not .5units.
37.6.6 When writing prescriptions for controlled drugs, the total quantity of the
preparation, or the total number of dose units, must be written in both words
and figures.
37.6.7 The cost of the medication, together with the dispensing pharmacist’s fees are
re-charged to the Trust
37.6.8 Prescribers may not write prescriptions for themselves or for members of their
family. If this should occur, the Trust reserves the right to recover these costs,
plus an administration fee, from the prescriber and ultimately may consider
criminal proceedings if fraudulent use is suspected.
38. COVERT ADMINISTRATION OF MEDICINES
38.1
Introduction
38.1.1 This guidance relates to the administration of medicines to adult inpatients
who are detained under the Mental Health Act under section 58 or others in all
care settings who are unable to give informed consent to treatment and who
subsequently refuse to take oral medication when openly offered to them, and
for whom medicines are then administered in a flavoured drink, jam, or other
foodstuffs.
38.1.2 Consideration should be given to the application of the Mental Health Act for
appropriate patients.
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38.1.3 The Nursing and Midwifery Council (NMC) position statement on the covert
administration of medicines (2006) states:
“Disguising medication in the absence of informed consent may be regarded
as deception. However, a clear distinction should always be made between
those patients or clients who have a capacity to refuse medication and
whose refusal should be respected, and those who lack this capacity.
Among those who lack this capacity, a further distinction should be made
between those for whom no disguising is necessary because they are
unaware that they are receiving medication, and others who would be aware
if they were not deceived into thinking otherwise.”
38.1.4 The disguising of medication in food and drink cannot be encouraged as it
exposes the patient to risk. Every effort must be made to obtain the patient’s
consent to be administered prescribed medicines in the normal way.
However, it is recognised that in exceptional circumstances, covert
administration may be justified as being in the best interests of the patient.
38.1.5 In circumstances where a consenting patient has difficulty in swallowing
medication or they find it unpalatable, the medication may be given in food or
drink with their knowledge, as a last resort, provided alternative dosage
forms such as liquids or dispersible tablets have also been found unsuitable.
The ward/unit pharmacist should be asked to advice on alternative
preparations, and it may be appropriate to refer the patient to a speech and
language therapist for further assessment. In these circumstances, the food
or drink is acting as an aid to administration with the patient’s consent. This
is not covert administration.
38.2
Professional Conduct
38.2.1
All practitioners must reflect on the treatment aims of disguising medication
and be absolutely confident that they are acting in the best interests of the
patient. The treatment must be considered necessary in order to save life,
prevent deterioration in health, or ensure an improvement in the patient’s
physical or mental health status.
38.2.2
Registered nurses involved in covert administration of medicines must be
fully aware of the aims, intent and implications of such treatment. If an
authorised employee is involved in covert administration, it is the
responsibility of the appointed practitioner in charge to ensure that they are
fully aware of their own responsibilities arising from this practice. The
administration of covert medication can also present practical problems in
that a patient may not fully ingest the substance that carries the medication.
This fact is acknowledged in this guidance to recognize the difficulty that
nursing staff may encounter using this method of administration. In the event
of the patient not fully ingesting the substance containing the medication for
a variety of reasons, then the nursing staff should make medical and
pharmacy colleagues aware and a note made in the patient’s clinical notes.
38.2.3
Disguising medicines in order to save life, prevent deterioration, or ensure
an improvement in the person’s health, cannot be taken in isolation from the
recognition of the rights of the person not to give consent. It may, in such
circumstances, be necessary to administer medicines covertly. However, it
may be that in some cases this should be included in a deprivation of liberty
safeguards (DOLS) authorization if one is in place or to apply for DOLS
authorization or seek the permission of the Court to covertly administer. In
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such circumstances the Service Manager or the patient’s consultant should
consider obtaining further advice from the Trust solicitor.
38.2.4
If a patient is lawfully detained under a section of the Mental Health Act,
some forms of forced or disguised medication are recognised in law.
However, it must be recognised that such administration under the Act will
only apply to treatment for psychiatric conditions and not for physical
health problems. See Section 38.6 of the Medicines Code for more advice
on covert administration under Section 58 of the Mental Health Act.
38.2.5
In deciding what treatment may be reasonably considered as being in the
best interests of a patient who lacks capacity to consent, the General
Medical Council recommends that the following be taken into account:
 Options for treatment which are clinically indicated
 Evidence of the patient’s previously expressed preferences, including any
advance statements or directives (see Consent below).
 Knowledge of the patient’s background, including their cultural and
religious beliefs.
 Third party views about the patient’s preferences given by those
who may have other knowledge of the patient, e.g., partner, relative,
carer or advocate.
 Where more than one option (including non treatment) seems reasonable
and in the patient’s best interest, consideration should be given to that
which least restricts the patient’s choice.
38.3
Consent
38.3.1 Every adult must be presumed to have the mental capacity to consent or to
refuse treatment, including medication, unless he or she:
Is unable to take in and retain information about their treatment and given by
the treating staff, in particular with regard to the consequences of refusal or
non-treatment.

Or is unable to understand the information.

Or is unable to properly consider the information before making a
decision.
38.3.2 Assessing this capacity must be undertaken using an mental capacity
decision making checklist, e.g. FACE and is primarily a matter for the
responsible clinician and the MDT with input from carers if available, but other
practitioners, clinicians and authorised employees may all usefully contribute
to discussions about this assessment.
38.3.3 When patients are capable of giving or withholding consent, no medication
may be given without their agreement. If withholding consent, staff must
ensure that the patient has been given sufficient information in a suitable
format about the nature, purpose, associated risks and alternatives to the
proposed medication.
38.3.4 A competent adult has the right to refuse treatment, even if refusal will
adversely affect their health or shorten their life. Registered nurses and
authorised employees must respect a competent adult’s refusal in the same
way as their consent.
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38.3.5 Patients who lack capacity may have indicated consent or refusal at some
previous time whilst competent, in the form of an advance statement, advance
directive or living will. Where these wishes are known, all staff must respect
them, provided these advance decisions are still clearly applicable to the
patient’s present circumstances and there is no reason to believe that the
patient has changed their mind.
38.3.6 The ultimate decision to administer medicines covertly must be fully informed
and agreed by the multi-disciplinary team caring for the patient.
38.3.7 No one, not even a spouse or parent can lawfully give consent on behalf of
another adult. However, the views of relatives, carers, advocates and close
friends may be helpful in clarifying the wishes of the patient and establishing
what action is in their best interest.
38.3.8 In patients who lack the capacity to consent and who are physically unaware
that they are taking medication (e.g. unconscious patients), the administration
of medication will not need to be carried out covertly. However, if these
patients recover awareness their consent must be sought at the earliest
opportunity.
38.3.9 It is important to recognise that mental illness might often cause temporary or
fluctuating incapacity. In such cases, regular assessment (and record) of
capacity will be required.
38.4
Covert Administration of Medicines
38.4.1 Covert administration is only likely to be necessary or appropriate when
patients actively refuse medication and are judged not to have the capacity to
understand the consequences of their refusal.
38.4.2 There are certain exceptional circumstances in which covert administration
may be considered acceptable in order to prevent a patient from missing
essential treatment. In these circumstances and in the absence of informed
consent, the following must apply:

The best interests of the patient are considered at all times and the
medication is considered essential for the patient’s health and well-being,
(or for the safety of others).

All alternative means of administration have been explored and similarly
refused.

The decision to administer a medicine covertly must not be considered
routine but should be considered a contingency or emergency measure.
Any such decision must be reached after assessing the care needs of the
patient specifically and individually in order to avoid the ritualised
administration of medication in this way.

There should be broad and open discussion among the multi- disciplinary
team and if enageged, the patient’s relatives or carers, and agreement
reached that this approach is required in the specific circumstances.
Family and/or carer involvement in the care process should always be
encouraged when the initial decision is made and at full reviews.

The actual method of covert administration must be agreed with full and
mini reviews of the decision must be undertaken regularly and recorded on
a ‘Covert administration of medicines form’ (Appendix 11) On acute wards
full reviews should be undertaken at least every two months and mini
reviews at least every fortnight and in other areas mini reviews at least
three monthly and full reviews at least annually.
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38.5

Ward/team pharmacist and all staff made aware that if medicinal products
are to be crushed, dissolved or otherwise administered in a way in which
they were not intended, then such administration will be considered “off
licence”. Registered nursing staff must remain aware of the NMC guidance
on the administration of unlicensed and off-licence medication.

On the ward the drug chart should be annotated to indicate that medication
is being covertly administered to the patient. Following covert
administration the administration record should be annotated with the letter
‘C’ alongside the initial of the practitioner administering the medicine.

In the community suitable arrangements should be agreed to indicate to
everyone involved in administration that a decision has been made to
covertly administer the medication and which medicines these are.

The decision and action taken, including the names of all parties concerned
with that process, should be documented in the care plan and reviewed at
appropriate, agreed intervals.

A decision on whether regular attempts will be made to encourage the
patient to take their medication openly must be documented in the care
plan. If the decision is to make regular attempts, this might best be
achieved by giving regular information, explanation, and encouragement,
preferably via a team member with whom the patient has a good rapport.

If the administration is going to be undertaken for the long-term and/or is in
the context of any other measures which may be deemed to deprive the
person of their liberty, an application to the depravation of liberty
safeguards (DOLS) for an authorisation should be sought.
Review & Audit
38.5.1 A “Covert administration of medication care plan” (see appendix 11) must be
completed for each patient and reviewed at least every two months on acute
wards and annually on other wards.
38.5.2 Mini reviews should take place at least fortnightly on acute wards and three
monthly on other wards (see appendix 11).
38.5.3 This policy and guidance will be subject to audit and review at least biannually or in advance of the review date in response to changes in legislation
or national professional guidance. This will form part of the trustwide clinical
audit programme.
38.6
Mental Health Act (MHA), Sections 58 and 63
38.6.1 Before covert treatment for mental disorder is administered under ss 58 or 63
MHA the Responsible Clinician (RC) should consider:
 Why it is not practicable to seek the patient’s consent.
 Whether the giving of covert medication is a proportionate response to
the aim of improving the patient’s health or reducing the risk posed by
the patient.
38.6.2 Although it would be lawful to administer medication provided under s63 or
s58(b) forcibly (if clinically possible), the RC might consider that the covert
administration of the medication would be less invasive of the patient’s
physical integrity and therefore would be deemed a proportionate response.
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38.6.3 The issues considered and the reasoning behind any decision must be
recorded in the patient’s notes. This will help protect from a challenge under
the Human Rights Act (see paragraphs 23.37 – 23.41, Mental Health Act
Code of Practice 2008).
38.6.4 If covert medication is being proposed under s58 then it is imperative that this
is discussed and made clear to the SOAD so that this can be recorded on the
statutory form completed by the SOAD to authorise the treatment. SOADs will
look for evidence that the clinical team is aware of the RCPsych and related
guidance, that alternatives to covert routes have been thoroughly considered,
and that the clinical team have discussed the matter thoroughly between
themselves and with any appropriate relatives, carers and advocates.
38.6.5 Where a clinical team decide to resort to covert administration of medication
that is authorised on an extant Form T3 (i.e. where that extant Form relates to
a treatment plan that did not specify covert routes of administration), it is
expected that a further Second Opinion to reconsider the authorisation is
sought.
39. ADVERSE DRUG REACTIONS
Any medicine has the potential to cause unwanted or unexpected adverse reactions. It is
very important that such reactions are identified, reported and recorded.
39.1 The incident must first be reported to the assigned practitioner in charge, or
member of healthcare staff in charge of the unit.
39.2 Depending on the severity of the reaction and the health of the patient,
consideration must then be given to informing the patient's doctor.
39.3 A record of the incident must be made in the patient's notes and consideration
given to making a report to the Committee on Safety of Medicines (CSM) using the
"yellow card" scheme.

Report all adverse reactions for black triangle medicines and only serious
adverse reactions for other medicines. A report to the CSM may be made by
the doctor, the nurse, or the unit pharmacist.

Reports can be made electronically via www.yellowcard.gov.uk or on the yellow
cards found at the back of BNFs.
39.4 Where the reaction is fatal, life-threatening, disabling or incapacitating, it must also
be reported as a "clinical incident" following the Trust's incident reporting
procedure.
40. DRUG ALERTS AND RECALLS
40.1 The Medicines and Healthcare Products Regulatory Agency (MHRA) are
responsible for notifying trusts of defective medicines.
40.2 The supplying pharmacy has a responsibility to notify wards and units of any
defective medicines they may have been supplied with via the pharmacy.
40.3 If a ward or unit receives notification of a defective medicine, it must be
immediately brought to the attention of the assigned practitioner in charge.
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40.4 The assigned practitioner in charge must follow the instructions received regarding
the identification and withdrawal of the defective product and the local pharmacy
informed if medicines are withdrawn at the earliest opportunity.
40.5 The withdrawn medicines must be quarantined in a locked medicines cupboard,
sealed in an envelope clearly warning staff that the contents are quarantined and
are awaiting collection by the pharmacy team.
40.6 In the event that all the stocks of a particular medicine are being quarantined a
discussion needs to take place with the pharmacy team or on call pharmacist to
ensure alternative arrangements are made to ensure patients do not miss doses.
40.7 A record of any action taken must be made in the ward/unit daily diary.
41. NURSE DISPENSING OF LEAVE AND DISCHARGE MEDICATION
41.1
Purpose of this procedure
41.1.1 The purpose of this procedure is to ensure a structured approach for nurse
dispensing that meets the same standards as would be applied in the
pharmacy.
41.2
Scope
41.2.1 This procedure will apply to all units where patients/residents go on leave of
any length or are discharged requiring medication.
41.2.2 Only nurses who have successfully completed a pharmacy run certificated
training and competency assessment to dispense, can work under this
procedure. For the purpose of this procedure these nurses will be known
as ‘competent nurses’.
41.2.3 A separate dispensing procedure for use in exceptional circumstances by
nurses who have not successfully completed the certificated assessment and
training has been developed. (Appendix 1).
41.2.4 In the context of this procedure, the term dispensing includes the selection of
appropriate ‘one stop’ stocks already labelled for use on leave or at discharge.
41.2.5 It is only applicable if:

Delayed access to leave medication from the pharmacy would
significantly compromise discharge.

‘One stop’ dispensing supplies are available and the patient (or carer) has
been assessed as suitable to use pre labelled containers.
Or
41.3
Principles
41.3.1 This procedure has been developed to improve patient care whilst minimising
the risks associated with dispensing medication on the ward or unit.
41.4
The Procedure – Key Issues
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41.4.1Only those nurses that have successfully completed the pharmacy run
certificated training and competency assessment to dispense, can work under
this procedure. Throughout this document they are defined as a ‘competent
nurse’. If no such nurses are available then the ‘Nurse Dispensing Procedure
for Urgent Discharge and Leave Medication in Exceptional Circumstances’
may be used. (See appendix 15). In such circumstances, if it is essential that
more than 72 hours medication (96 hours over a bank holiday) be dispensed
or if more is needed then the duty doctor can be called to write an FP10
prescription.
41.4.2 If ‘one stop’ dispensing stocks are available, these should be used in
preference to getting new supplies dispensed by pharmacy, provided the
patient is deemed able to use them.
41.4.3In other situations, leave or discharge medication should be ordered from
pharmacy whenever possible. Planned leave or discharge should take into
account access to pharmacy services and arrangements to order medication
in advance whenever possible.
41.4.4 Second competent nurse, pharmacist or pharmacy technician trained to final
check must check all items dispensed.
41.4.5 The ‘dispensing record’ box on the leave section of the drug chart must be
initialled by the persons dispensing and checking the medication.
41.5
The Procedure
LEAVE MEDICATION
41.5.1 Only leave medication ordered on the drug chart by a nurse deemed
competent to order leave, or a doctor, can be dispensed.
41.6
Patients suitable to use ‘one stop’ stocks
41.6.1 ‘One stop’ dispensing stocks must be used if the patient (or carer) has been
assessed as suitable to use them.
41.6.2 The nurse undertaking the dispensing must take the drug chart to the clinic
room to minimise the risks of being disturbed.
41.6.3 The patient’s tray(s) of medication should be removed from the drug trolley
and placed with the drug chart.
41.6.4 Each item ordered should be in the patient’s tray(s). If a medicine is
unavailable or the quantity is not sufficient to cover the leave period, then a
request for the missing drug should be sent to the pharmacy. This should be
for an original pack and not just the quantity required for the leave. Dispensing
of the leave medication should be delayed until the missing stock is received.
41.6.5 In the event the patient’s medication is missing or insufficient and the leave
commences before the pharmacy can supply it, then the medication can be
supplied from ward stocks following the procedure described in section 3.3.
41.6.6 On occasions there may be two containers of the same drug, i.e. when the one
in use is due to run out. If the stock remaining in the opened container is
Page 96 of 130
insufficient to cover the leave period, then the unopened container should be
supplied instead.
41.6.7 Having ascertained that all the medication required is available the following
must be checked and confirmed as correct for each item:




The drug name, form and strength
The directions
The patient’s name
The expiry date
41.6.8 Having confirmed that everything is correct, the nurse must initial the drug
chart in the ‘dispensing record’ box of the leave section. A dispensing bag
with the patient’s name on it must then be placed with the medication and
chart, ready for checking.
41.6.9 A second competent nurse, pharmacist or pharmacy technician trained to final
check must then check the medication and if correct, they must initial the drug
chart in the ‘pharmacy’ box and place the medication in the dispensing bag.
41.6.10 The dispenser or checker are then responsible for ensuring the patient
carer) is counselled on the medication including:




(or
Explicit instructions on when ‘as required’ medication should be
taken.
Directions for use.
Very common or common side effects to watch out for.
The importance of bringing any unused medication back with them
when they return to the ward.
Interpreters can be booked to assist people who experience communication
difficulties in terms of language and visual or hearing impairment.
41.6.11 If this is the first time the patient/resident has left the ward or unit on the
medication then a patient information leaflet should be supplied with the
medication. If there is not one in the medication container already one can be
accessed via the medication section of the Trust’s website using the link to the
Choice & Medication website:
http://www.choiceandmedication.org/sussex
Information can be made available in other formats and community languages
to assist people who experience communication difficulties in terms of
language or visual impairment from your local pharmacy team.
41.7
Leave medication dispensed from ward stocks
41.7.1This must only take place when delayed access to the leave medication from
pharmacy would significantly compromise the start of the leave.
41.7.2 Situations in which this will apply are:

When the patient is using ward stocks and is not on a ‘one stop
dispensing scheme’
Page 97 of 130

Where ‘one stop dispensing’ applies but pre-labelled stock is
unavailable or is insufficient to cover the leave period.
41.7.3 The nurse undertaking the dispensing must take the drug chart to the clinic
room to minimise the risks of being disturbed.
41.7.4 Collect the empty containers and blank labels needed from the designated
storage place. These are supplied by pharmacy.
41.7.5 The patient’s own medication can be used for dispensing if ‘one stop’
dispensing does not apply to the patient. Otherwise, collect suitable stock
drugs to fill the leave request.
41.7.6 If the prescription cannot be filled due to unavailable stock; the pharmacy or
on call pharmacist must be contacted for advice.
41.7.7 Prepare the labels needed first, writing clearly the following information:






Drug name, form (e.g. tablet) and strength
Directions i.e. dose and frequency
The patient’s name
The quantity supplied .
Date supplied
Ward
Dispense each individual drug into an appropriate container and then apply its
completed label, before dispensing the next item.
41.7.8 When all the items have been dispensed, double check all the details before
initialling the ‘pharmacy’ box in the leave section of the drug chart along with
the quantity supplied marked against each letter and initialling the dispenser
box on the label. A dispensing bag with the patient’s name must then be put
with the dispensed medication. These bags are supplied by pharmacy.
41.7.9 A second competent nurse, pharmacist or pharmacy technician trained to final
check must then check the supply and if correct, they must initial the drug
chart in the ‘pharmacy’ box, initial the label and place the medication in the
dispensing bag.
41.7.10The dispenser or are then responsible for ensuring the patient (or carer) is
counselled on the medication including:





Explicit instructions on when ‘as required’ medicines should be taken.
Directions for use.
Very common or common side effects to watch out for.
The importance of bringing any unused medication back with them
when they return to the ward.
Make sure the patient has the ward number to ring for advice.
Interpreters can be booked to assist people who experience communication
difficulties in terms of language and visual or hearing impairment.
If this is the first time the patient has left the ward on the medication then a
patient information leaflet should be supplied with the medicine. If there is not
Page 98 of 130
one in the stock container to use, one can be accessed via the medication
section of the Trust’s website using the link to the Choice & Medication
website: http://www.choiceandmedication.org/sussex
Information can be made available in other formats and community languages
to assist people who experience communication difficulties in terms of
language or visual impairment from your local pharmacy team.
DISCHARGE MEDICATION
41.8
Patients suitable for ‘one stop’ medication
41.8.1 ‘One stop’ medication must be used if the patient has been assessed as
suitable to use them.
41.8.2 The nurse undertaking the dispensing must take the drug chart and discharge
form & prescription to the clinic room to minimise the risks of being disturbed.
41.8.3 The ‘pharmacy’ box in the regular medication and ‘as required’ medication
sections of the drug chart should be checked to see if the patient has
additional stocks of some of the drugs already at home. If this is the case,
additional medication does not need to be dispensed for these items.
41.8.4Before commencing dispensing, check that the medication prescribed on the
discharge form & prescription matches those currently being prescribed on the
drug chart. Unless there are clear documented instructions by the prescriber,
or another member of the medical team, explaining the discrepancy, the
discrepancy must be resolved before dispensing commences.
41.8.5 The patient’s tray(s) of medication must be removed from the drug trolley and
placed with the drug chart and the discharge form and prescription.
41.8.6 Each item prescribed should be in the patient’s tray(s). If a medicine is
unavailable or the quantity is not sufficient to cover at least 10 days post
discharge (unless fewer days are specifically requested) then a request for the
missing medication(s) only, should be sent to the pharmacy. This should be
for 10 days (unless fewer days are specifically requested). Dispensing of the
remaining leave should be delayed until the missing medication is received.
41.8.7 In the event that stock is missing or insufficient and the patient leaves the ward
before the pharmacy can supply it, then supply the missing drugs from ward
stock following the procedure described in section 3.5.
41.8.8 On occasions there may be two containers of the same medication i.e. when
the one in use is due to run out. If the stock remaining in the opened container
is insufficient to cover at least 7 days, or the days specifically requested if less,
then both containers should be supplied, explaining to the patient or carer that
they should finish the open container before starting the new one.
41.8.9 Having ascertained that all the medication required is available the following
must be checked correct for each item:


The drug name, form and strength
The directions
Page 99 of 130


The patient’s name
The expiry date
41.8.10 Having confirmed that everything is correct, sign the discharge form &
prescription in the ‘pharmacy’ section of the prescription, also stating that ‘one
stop’ medication have been supplied. A dispensing bag with the patient’s
name on it must then be placed with the medication, discharge summary &
prescription and drug chart, ready for checking.
41.8.11A second competent nurse, pharmacist or pharmacy technician trained to final
check must then come and check the discharge form & prescription against
the drug chart and then the medication. If correct, they must initial the
discharge form & prescription in the ‘pharmacy’ box and place the medication
in the dispensing bag.
41.8.12The dispenser or checker are then responsible for ensuring the patient (or
carer) is counselled on the medication including:




Explicit instructions on when ‘as required’ medication should be taken.
Directions for use.
Very common or common side effects to watch out for.
Providing the patient with the wards telephone number in case they
need advice.
Interpreters can be booked to assist people who experience communication
difficulties in terms of language and visual or hearing impairment.
41.8.13 If this is the first time the patient has left the ward on the medication then a
patient information leaflet should be supplied with the medication. If there is
not one in the container already, one can be accessed via the medication
section of the Trust’s website using the link to the Choice & Medication
website: http://www.choiceandmedication.org/sussex
Information can be made available in other formats and community languages
to assist people who experience communication difficulties in terms of
language or visual impairment from your local pharmacy team.
41.9
Discharge medication dispensed from ward stocks
41.9.1 This must only take place when delayed access to the pharmacy would
significantly compromise the discharge.
41.9.2 Situations in which this will apply are:

When the patient is using ward stocks and is not on a ‘one stop’
dispensing scheme.

Where ‘one stop dispensing’ applies but pre-labelled medication is
unavailable or insufficient to cover 10 days, or the period requested.
41.9.3 The nurse undertaking the dispensing must take the drug chart and the
discharge summary & prescription to the clinic room to minimise the risks of
being disturbed.
Page 100 of 130
41.9.4 The pharmacy box in the regular medication and ‘as required’ medication
sections of the drug chart should be checked to see if the patient has
additional stocks of some of the drugs already at home. If this is the case,
additional medication does not need to be dispensed for these items.
41.9.5 Before commencing dispensing, check that the medication prescribed on the
discharge form & prescription matches those currently being prescribed on the
drug chart. Unless there are clear documented instructions by the prescriber,
or another member of the medical team, explaining the discrepancy, the
discrepancy must be resolved before dispensing.
41.9.6 Collect the empty containers, blank labels and dispensing bag needed from
the designated storage place. These are supplied by pharmacy.
41.9.7 The patient’s own medication can be used for dispensing if partial ‘one stop
dispensing’ applies and the quality being supplied on discharge is being
restricted.
41.9.8 If the prescription cannot be filled due to unavailable stock, the pharmacy or
on call pharmacist must be contacted for advice.
41.9.9 Prepare the labels needed, writing clearly the following information:






Drug name, form (e.g. tablet) and strength
Directions i.e. dose and frequency
The patient’s name
The quantity supplied
Date supplied
Ward
Dispense each individual drug into an appropriate container and then apply its
completed label.
41.9.10 When all the items have been dispensed,, double check all the details before
initialling each label in the ‘dispenser’ box and the ‘pharmacy’ box in the
prescription section of the discharge summary and prescription along with the
quantity supplied marked against each letter. A dispensing bag with the
patient’s name on it must then be placed with the drug chart, medication and
discharge summary & prescription ready for checking.
41.9.11 A second competent nurse, pharmacist or pharmacy technician trained to
final check must them come and check the discharge summary & prescription,
first against the drug chart, then the medication and if correct they must initial
the ‘checker’ box on each label and initial the discharge summary &
prescription in the ‘pharmacy’ box and place the medication in the dispensing
bag.
41.9.12The dispenser or checker are then responsible for ensuring the patient (or
carer) is counselled on the medication including:




Explicit instructions on when ‘as required’ medication should be taken.
Directions for use.
Very common or common side effects to watch out for.
Providing the patient with the ward telephone number in case advice is
needed.
Page 101 of 130
Interpreters can be booked to assist people who experience communication
difficulties in terms of language and visual or hearing impairment.
41.9.13If this is the first time the patient has left the ward on the medication then a
patient information leaflet should be supplied with the medication. If there is
not one in the stock container used, one can be accessed via the medication
section of the Trust’s website using the link to the Choice & Medication
website: http://www.choiceandmedication.org/sussex
Information can be made available in other formats and community languages
to assist people who experience communication difficulties in terms of
language or visual impairment from your local pharmacy team.
41.10
Development and Consultation Process
41.10.1The following have been consulted during the development of this procedure.
 The Trust Drugs and Therapeutics Group
 The Trust Pharmacy Forum
 The Matrons
41.11
Monitoring Compliance and Review
41.11.1Compliance with this procedure will be monitored by the pharmacy team. Any
concerns about inappropriate application of the procedure, or practice not in
accordance with the procedure, will be discussed with ward / unit managers in
the first instance.
41.11.2The procedure will be reviewed by the Chief Pharmacists not later than three
years from the date of ratification. The procedure may be reviewed at any time
in response to failings of the procedure coming to light, or to the availability of
new local or national guidance that may influence the effectiveness of the
procedure.
41.12
Dissemination and Implementation
41.12.1The procedure will be disseminated via the Partnership Bulletin, by direct
mailing to all General Managers and lead nurses, and will be posted on the
Trust website. Availability of the procedure will also be announced via the
Drugs & Therapeutics Newsletter.
41.13
Document Control and Archiving Arrangements
41.13.1The pharmacy team will be responsible for uploading this procedure onto the
Trust website and for archiving any previous versions.
41.14
Cross reference

Medicines Code (latest version). Sussex Partnership NHS Foundation Trust

Standards for Medicines Management – Nursing & Midwifery Council (latest
version)
Page 102 of 130
42. OCCUPATIONAL THERAPISTS INVOLVED WITH MEDICINES
The purpose of this guidance is to clarify the legal and professional issues surrounding the
involvement in medication issues for occupational therapy staff. This guidance has been
developed by the Director of Occupational Therapy in consultation with the lead
occupational therapists governance group, as well as the Chief Pharmacist - Governance
and Professional Practice. It covers occupational therapy staff in all clinical areas and
service within the Trust.
42.1
Regulatory and professional context
42.1.1
In July 2009 a report was published scoping the role of allied health
professionals in prescribing and managing medication.
42.1.2
The College of Occupational Therapists (COT) and the Health Professions
Council (HPC) make is clear that occupational therapists must act within their
professional competence at all times, and ensure they have training if they are
taking on new roles and responsibilities.
42.1.3
Under the Medicines Act 1968 there is nothing to prevent an occupational
therapist handling medication after it has been dispensed, but it is vitally
important that the occupation therapist acts safely and appropriately within
her/his professional scope of practice.
42.1.4 The administration and supply of medicines are not basic occupational
therapy skills, falling outside the scope of occupational therapy practice. The
British Association of Occupational Therapists (BAOT) professional indemnity
insurance covers members for occupational therapy practice only. The
handling of medication is therefore not covered.
42.2
Clinical Context
42.2.1 An independent investigation into SUI2006/8119, commissioned by NHS
Yorkshire and Humber highlighted the conflict between guidance provided by
the College of Occupational Therapists to its members about medicine
management and the role and responsibility of a care coordinator.
42.2.2 It recommended that the College take a lead role in defining the skills and
competencies relating to medicine management that an OT working as a care
coordinator would need.
42.2.3 In October 2010 NHS South East Coast issued an independent investigation
into the care and treatment of Mr X. An issue was highlighted in that report
about the role of an occupational therapist acting as a care coordinator to a
client on clozapine, the recommendation is:
“We consider it would have been more appropriate if Mr X had been allocated a
clozapine-trained community psychiatric nurse as his care coordinate, with
Occupational Therapist 1 providing regular focused occupational therapy (OT) input.
Alternatively, if Occupational Therapist 1 was the allocated care coordinator, a
clozapine trained CPN should have had a formal and regular role in monitoring Mr X.”
42.3
Principles
42.3.1 Within the Trust the concerns and benefits of occupational therapists
undertaking certain aspects of medication management as a generic role
Page 103 of 130
where it is appropriate to their post, most usually as a member of a multidisciplinary community team have been considered.
42.3.2 Occupational therapists are not trained to provide advice about the use or
actions of medicines; they are skilled at assessing areas such as a person’s
attitude to their medication, and identifying people unlikely to adhere to their
medication regimen. Also in assisting in identifying side-effects and other
compliance issues such as confusion.
42.3.3 We have determined that to ensure due governance there is a need to provide
clarity in job descriptions and appropriate training so that occupational
therapists carrying out this role will be covered by the Trust’s indemnity
insurance rather than through that of their profession. All occupational therapy
staff involved in medication isssues must attend a training session on handling
medication specially designed for professions other than doctors and qualified
nurses.
42.3.4 Adherence to these principles will ensure:
 That all occupational therapy staff involved in specific medication
issues within the Trust will be appropriately trained and supervised (see
Procedure section).
 That appropriate safeguards are in place to promote the safety of, and
protect the rights of, service users, regardless of race, disability, gender,
gender identity, age, sexual orientation, religion or belief.
 Occupational therapy staff employed by the Trust will be covered by
Trust indemnity as long as this policy is adhered to.
42.4
Duties
42.4.1 The Director of Occupational Therapy will be responsible for the
professional governance of occupational therapy staff employed by the Trust.
42.4.2 Professional lead occupational therapists will work with service managers
to identify staff training needs and monitor compliance in attending training, as
well as using supervision to monitor and ensure competence in this area.
42.4.3 Individual practitioners are accountable and responsible for their own
practice. All occupational therapists must practice and abide by the code of
ethics and professional conduct as set out by the COT and the HPC and within
the policies, protocols and guidelines laid down by the Trust.
42.4.4 Service Managers will work with the lead occupational therapist in identifying
practitioners who need additional training to support their role in relation to
medication management and ensure that training is provided.
42.5
Procedure
42.5.1 All job descriptions for qualified occupational therapists must contain the
following phrase: “Have a basic working knowledge of the medication
prescribed for people under your care. To include usual dosage, common side
effects and the need for any special monitoring. Any reported or observed side
effects must be brought to the attention of the prescriber.”
Page 104 of 130
42.5.2 Occupational therapists can convey medication, but if the person has not had
that medication before:
 a patient information leaflet must be provided with the medication.
 the person must be advised that further information can be obtained on the
medication from their care co-ordinator or the prescriber if the occupational
therapist is the care co-ordinator and does not feel able to answer any
question raised.
42.5.3 Occupational therapists will provide written information on medication (or
direct the person to online resources) to reinforce advice given by the
prescriber or a memebr of staff qualified to give such information. They should
be able to access and provide standard information available on the Trust
website or on other approved websites, eg Choice and Medication website.
42.5.4 People on clozapine who have an occupational therapist as their main worker
must have an identified nurse who is monitoring the medication. This should be
documented clearly in the notes.
42.5.5 Where medication compliance and monitoring is the main clinical issue and
the person also has signfiicant occupational needs, they should be care
coordinated by a nurse with the occupational therapist providing targeted
interventions.
42.5.6 Occupational therapy staff involved in medication issues including
conveyance must be familiar with the Trust’s Medicines Code.
42.5.7 The Medicines Code defines roles in relation to the handling and
administration of medication. Occupational therapy staff will most usually fall
into the category of Authorised Employee – a member of staff who following
training (which may take place locally) has been authorised by the Appointed
Practitioner in Charge to undertake specific duties in relation to medication.
Any additional unit-specific procedure must be taken into consideration.
42.6
Monitoring Compliance
Adherence to this guidance will be monitored through supervision and annual appraisal
of the individual occupational therapist.
43. REFERENCES
1. Royal Pharmacists Society of Great Britain. The Safe and Secure Handling of
Medicines.
2. Nursery and Midwifery Council. Standards for Medicines Management 2007
3. NHS Executive (2000). Patient Group Directions HSC 2000/026 2000
4. Great Britain (1972). Medicines Act 1968 (as amended). The Stationary Office,
London
5. NHS Estates (1994) HTM 2002 Medical
6. NHS Executive (1997). Destruction of Controlled Drugs EL (97) 22 1997
7. Great Britain (1984). Misuse of the Drugs Act 1971 The Stationary Office, London
Page 105 of 130
8. National Patient Safety Agency. Promoting safer measurement and administration of
liquid medicines via oral and enteral routes. Patient Safety Alert /2007/PSA019
9. Mental Health Act Commission, Risks, Rights and Recovery, 12 th Biennial Report
2005-7, Published 2008.
10. National Patient Safety Agency . The adult patient’s passport to the safer use of
insulin. Patient Safety Alert/2011/PSA003
44. LINKED TRUST POLICIES AND GUIDANCE
1.
Mental Capacity Act 2005 Policy
2.
Working Formally with Commercial Organizations Policy
3.
Infection Control Policy and Procedure
4.
Policy and Procedure for the Management of Alcohol and Drug Misuse by Service
Users/Visitors on Trust Premises
5.
Learning Disability Services – Administration of Medication Protocol
6.
Training Policy
7.
Policy to use Photographs of Adult Inpatients to Reduce the Risk of Medication Errors
and for use when Vulnerable Adults go Missing.
8.
Consent Policy
Page 106 of 130
Appendix 1
Self-administration Flowchart
Patient is identified by the MDT as appropriate to commence “self-administration of medication
programme”.
Discuss with patient.
Patient declines inclusion (record in notes)
No further intervention at this time.
Sign appendix 2
Needs Identified:
 With containers – refer to pharmacy (appendix 8)
 Report to MDT
 Knowledge lacking about medication regimen?
Undertake psychoeducation (offer verbal and/or written
information about mental health illness,
medication information, whatever needs
identified in collaboration with the patient)
Patient gives consent
Sign appendix 2
Nurse (or designated
person) undertakes patient
risk assessment (appendix 3)
No Needs Identified:
Report to MDT
Assessed as competent to commence
stage 1 or stage 2 if fast tracked”
and if suitable lockers.
Liaise with pharmacy.
Needs met
Assessed as competent
to commence stage 1.
Liaise with pharmacy
Commence Stage 1
Patient successfully completes stage 1
Report to MDT – liaise with pharmacy
Competence recorded on (appendix 5)
To commence on stage 2 if suitable lockers.
Patient has difficulties with stage 1.
Record nature of difficulties (appendix 5)
and if required withdraw patient participation in the
scheme and review at a later stage.
See notes below**
Commence stage 2
Inform pharmacy
(Appendix 3) to be signed by the consultant
Complete (Appendix 5)
Commence stage 3
If suitable environment and successful
completion of stage 2
Complete (appendix 6)
**Notes:
If the nurse has concerns at any stage or the risk environment changes:
 Record the nature of the concerns
 Identify needs -? further psychoeducation
 Report back to MDT
 Supportive intervention
 Return to previous stage?
Page 107 of 130
Appendix 2
Self-administration: Patient Agreement / Consent Form
Patient’s name…………………………………………….. Ward
Part 1:
I request to be assessed under the requirements of the Sussex Partnership NHS
FoundationTrust’s self administration scheme.
Patient’s Signature ………………………………………………... Date:…………………
Nurse’s Signature …………………………………………………………………………….
Nurse’s name ……………………………………………………… Date:…………………
Part 2:
The self-administration scheme has been explained to me I hereby request the opportunity to
self-administer medication during my in-patient stay and take responsibility for ensuring safe
storage of these medications in the lockable facility provided.
 I understand that medications provided for self-administration are for my use only.
 I undertake to inform the Nurse in Charge if I am experiencing any difficulties.
 I understand that spot checks of my medication storage cabinet may be undertaken,
ideally with me present, by nursing and pharmacy staff.
 I understand that I can withdraw my consent at any time without any detriment in my
care.
Patient’s Signature ………………………………………………... Date:…………………
Nurse’s Signature …………………………………………………………………………….
Nurse’s name ……………………………………………………… Date:…………………
Withdrawal of Consent
I do not wish to get/remain involved in the self administration scheme due to:
…………………………………………………………………………….
I therefore refuse/withdraw my consent.
Patient’s Signature ………………………………………………... Date:…………………
Nurse’s Signature …………………………………………………………………………….
Nurse’s name ……………………………………………………… Date:…………………
On completion, this form must be filed in the patient's notes.
If you require this document in an alternative format, ie easy read,
large text, audio or Braille please contact the Pharmacy Team on
01243 623349.
Page 108 of 130
Appendix 3
Patient Risk Assessment and Decision Form for the Self–administration of
Medicines
Patient’s Name ……………………………………………………. Ward:………………
1. Was the patient self administering medication prior to admission?
Yes/No (If yes – how successfully?)
Comments:
2. Is the patient confused, or does he/she have an unstable mental state or a history of
alcohol/drug abuse? Yes/No (If yes – patient may only be suitable for stage 1 or should
not be included in the self-medication programme at present).
Comments:
3. Does the patient have a history of overdose, accidental or intentional? Yes/No (If yes
– patient may only be suitable for stage 1 or should not be included in the self-medication
programme at present).
Comments:
4. Has the patient a history of non-compliance with medication leading to a relapse or
risk of relapse? Yes/No
Comments:
5. Is the patient motivated to commence self-medication? Yes/No
Comments:
6. Can the patient open child resistant closures? Yes/No
Comments:
7. Does the patient need a compliance aid? Yes/No
Comments:
Page 109 of 130
8. Can the patient read standard medication labels in English? Yes/No
If no, what steps have been agreed to overcome this problem?
9. Does the patient have the right attitude to medication and insight into the importance
of the prescribed medication and how to take it? Yes/No
Comments:
10. Does the patient understand the importance of secure storage for medication and that
medication must not be shared, given or sold to others? Yes/No
Comments:
Assessment completed by…………………………... (name)
…………………………….……… (signature)
…..……….. (date)
Discussed at multidisciplinary meeting
……………. (date)
Not suitable for self-administration
…………… (date)
Consultant’s name & signature ………………………………………………………………
Or
Suitable for self-administration – stage 1
…………….. (date)
Consultant’s name & signature………………………………………………………………
If stage 1 has been successfully completed (or patient “fast tracked” on admission):
Suitable for self-administration – stage 2
…………….. (date)
Consultant’s name & signature………………………………………………………………
If level 2 has been successfully completed:
Suitable for self-administration – stage 3
……………. (date)
Consultant’s name & signature………………………………………………………………
Patient and ward have been risk assessed and the patient is holding the key.
On completion, this form must be kept in the patient’s notes and a copy must be
attached to the Drug chart.
Page 110 of 130
Appendix 4
Self-administration of Medicines – Patient Information Leaflet
Note: Each unit will need to amend this leaflet to reflect local storage and locking
mechanisms used. Make sure all the words in italics and this box are removed.
On this ward a self-administration scheme is in place. Its aim is to improve your knowledge
about your medicines and to help you take your medicines safely once you return home.
Self administration allows you to take more responsibility for taking your own medicines while on
the ward.
If you agree to take part in the scheme, you will have the chance to look after your own
medicines during your admission, under a certain degree of supervision. A qualified nurse or a
member of the pharmacy team will give you as much information and support as you require.
Eventually your medicines may be kept in a locked (cabinet /locker – delete as appropriate) in
your room. At first the (key/lock code – delete as appropriate) will be held by a nurse. The
nurse will supervise you but you will select which medicines you need at different times of the
day. The nurse will be there to ensure no mistakes are made and answer any questions you
may have.
As you become more familiar with your medicines, you may progress to a stage where you will
be given the (key/lock code – delete as appropriate) so that you can take full control over your
medicines without help. At this level it is of the utmost importance to keep your
(cabinet/locker locked – delete as appropriate) and (the key on your person at all times/the
lock code must not be shared with anyone else – delete as appropriate). However to ensure
you are coping well with your medicines nurses will perform regular and random checks and
discuss how you feel you are coping. This is to ensure that you are taking your medication
appropriately and that your safety and that of others is not compromised at any time.
If there are any patients on the ward who might coerce or threaten you to get your medicines,
we may have to (take your key off you/change the lock code and not let you know what it is –
delete as appropriate) while there is a risk to you. This will not be a reflection on well you are
doing. If this occurs you will still be able to store medicines in your room, but you will need to
ask the nurse to access your medicines at the times you need to take them.
The self-administration scheme is not compulsory, so you do not have to take part. If you
choose not to take part, your medicines will be given to you by the nurses in the usual way.
If you require this document in an alternative format, ie easy read,
large text, audio, Braille or a community language, please contact
the the Pharmacy Team on 01243 623349
(Text Relay calls welcome).
Page 111 of 130
Appendix 5
Daily Self-administration Progress Record – Stages 1 & 2
Patient’s name:
Ward:
MONDAY
B
L
Key: √ = Independently performs task,
X
T
TUESDAY
N
B
L
T
Week commencing:
WEDNESDAY
N
B
L
T
N
O
= Not applicable
THURSDAY
B
L
T
N
FRIDAY
B
L
T
SATURDAY
N
B
L
T
N
SUNDAY
B
L
T
Requests medication at correct
time
Reads instructions on bottles
Selects correct doses
Takes medication
Returns meds to appropriate
container
Leaves medication secure? Is
the locker secured (stage 2)
Initials
= Needed prompting
Comments on how well the patient is coping and on their insight and attitude to medication: (Please continue overleaf if necessary)
Signature
Page 113 of 130
Date
N
Appendix 6
Daily Self-administration Progress Record – Stage 3
Patient’s name:
NAME OF DRUG,
DOSE AND FREQUENCY
Ward:
NUMBER OF
DOSES
GIVEN
Week commencing:
NUMBER OF DOSES
REMAINING
ACTUAL
PLANNED
INITIALS
ACTUAL
PLANNED
INITIALS
ACTUAL
PLANNED
INITIALS
ACTUAL
PLANNED
INITIALS
ACTUAL
PLANNED
INITIALS
ACTUAL
PLANNED
INITIALS
Page 114 of 130
M
T
W
TH
F
SA
SU
Appendix 7
Patient Self-administration Assistance Sheet
Patient’s name………………………………………………….
Name of Medicine
Prescribed For…
Completed by…………………………………......
Ward……………………..
When to take it
Breakfast
Lunch
Teatime
Bedtime
Other Information
Designation…………………………………………. Date……………………………………..
Pharmacy check by (if applicable)……………………………………………… Date………………………………
Page 115 of 130
Appendix 8
Patient Self-administration Aide Memoire
Patient’s name:
Ward:
Week commencing:
Put a tick or enter your initials in the correct box each time you take your medicines at the correct time each day*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Breakfast
Lunch time
Tea time
Night time

If there is a time when you do not take your medication as you should have done, please be sure to tell a member of nursing staff as
soon as you can.
If you require this document in an alternative format, ie easy read, large text, audio, Braille or a
community language, please contact the Pharmacy Team on 01243 623349
(Text Relay calls welcome)
Page 116 of 130
Appendix 9
This form to be completed and returned to local Pharmacy Department for assessment
Compliance Aid Assessment and Request Form
Patient’s name: ………………………………………… DOB: …………………………..
Current Location (Ward or Community): ………………………………………………...
Permanent Address: .……………………………………………………………………….
…………………………………………………………………………………………………
GP…………………………… Community Pharmacist (if known)……………………….
Reason for request (more than one box may be ticked)
Confused
( )
Poor Memory
( )
Difficulty with containers
( )
Difficulty reading label
( )
Previous concordance problems
( )
Other ( ) Please Specify ……………………………………………………..
Who will be responsible for administering the patient’s medication following
discharge?
Patient ( )
Carer ( ) Other ( ) Please specify ………………………………
Who will fill the compliance aid after discharge?
Patient ( ) Carer ( ) Community Pharmacist ( ) Hospital Pharmacy ( )
Other ( ) Please specify .................................................................................................
Request made by …………………………………… Designation ………………………….
Signed ………………………………………………… Date …………………………….
Is the patient aware?
What the medication(s) is/are called
{ }
What common side effects may occur
{ }
What to do if side effects occur
{ }
What the medication (s) is/are for
{ }
What dose to take
{ }
Can alcohol be consumed
{ }
How to take the medication
{ }
Page 117 of 130
How long to take the medication for
{ }
Ability with labels:
Can read:
Computer { }
Large print { }
Understand instructions { }
Ability with Containers:
Summary of findings
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Patient is competent to self medicate
YES { }
NO { }
Signature of Nurse …………………………………………………………………………………
Date …………………………………………. Time …………………………...........................
ll
Page 118 of 130
Appendix 10
Medication Not Considered Suitable for Self-Administration
(See section 3 – ‘Exclusion’)
Actiq lozenges
Amobarbital (Amylobarbitone) capsules and Amytal tablets
Buprenorphine tablets and patches
Butobarbital (Butobarbitone) tablets
BuTrans patches
Dexamfetamine (Dexamphetamine) tablets and Dexedrine tablets
Diamorphine tablets
Diconal tablets and Dipipanone tablets
Durogesic patches and Durogesic DTrans patches
Eptadone oral solution
Fentanyl lozenges and patches
Hydromorphone capsules
Lisdexamfetamine capsules
Matrifen patches
Meprobamate tablets
Methadone oral solution, oral concentrate, linctus and tablets
Methadose oral concentrate
Metharose oral solution
Methylphenidate tablets and capsules (various brands)
Morcap capsules
Morphgesic tablets
Morphine oral solution, tablets and capsules
MST Continus tablets and suspension (sachets)
MXL capsules
Oramorph oral solution, oral concentrate, and unit dose vials
Oramorph SR tablets
Oxycodone oral solution, oral concentrate, tablets and capsules (various brands)
Pentazocine tablets, capsules and suppositories
Pethidine tablets
Physeptone oral solution and tablets
Ritalin tablets
Secobarbital capsules and Seconal Sodium capsules
Sevredol oral solution and tablets
Sodium Amytal capsules
Soneryl tablets
Suboxone tablets
Subutex tablets
Temgesic tablets
Tilofyl patches
Tramadol capsules and modified release tablets
Transtec patches
Tuinal capsules
Zomorph capsules
Note – this list may not be exhaustive.
Refer to a member of the pharmacy team if in doubt.
Date complied: February 2015
Page 119 of 130
Affix Patient Label Here
Patient
Name...........................................
Hospital/NHS
Number.............................
Date of
Appendix 11
Birth............................................
Appendix 11
Covert Administration of Medicines
To be completed and attached to the front of patient’s drug chart*
Outdated forms to be filed in the patient’s notes
*In the community it should ideally be attached to the patient’s administration record if being used.
Date of issue:.....................................................................................................................
Full reviews must take place at least every two months on acute wards and annually in
other areas. Mini reviews must take place at least fortnightly on acute wards and three
monthly in other areas.
Please list the drugs to be given covertly, including the agreed method of administration.
When was the patient last encouraged to take their medication? What problems were
encountered?
What other medication options have been considered, e.g. different route?
Continue overleaf
Page 120 of 130
In what way are the medicines to be given covertly essential and in the patient’s best
interests?
What is the desired outcome?
Tick if the provisions of the Mental Health Act (1983) been considered
Will regular attempts be made to get the patient to take their medication? If yes, how often?
The decision to covertly administer medication has been discussed and agreed with:
Role
Print Name
Signature
Date
Consultant/RMO
Named Nurse
Pharmacist
Family member/
carer/advocate*
*If no engagement by family, carer or advocate, please write ‘No engagement’ on the form.
A full review involving the family/carer/advocate will take place no later than …………..
Mini reviews by the MDT will take place every ………….. weeks/months
Date
Reviewed by
Date
Reviewed by
Date
Reviewed by
If all parties are NOT in support of the decision, please list names & objections/ concerns:
Original version August 2009
New version approved July 2014
Page 121 of 130
Appendix 12
One Stop Dispensing (OSD) Risk Assessment Form
Patient’s Name:
Ward/Unit:
 This form must be completed and signed by a Consultant and a competency-assessed nurse.
 Only patients with a fully completed form can be included in the OSD scheme.
Please circle the appropriate response:
1. Will a suitable carer be responsible for looking after the patient’s medicines during leave and/or following discharge?
YES
NO
If the answer is‘YES’ then the service user can be fully included in the OSD scheme.
If the answer is ‘NO’ then go to question 2.
Please circle the appropriate response:
2. What is the patient’s assessed overdose risk?
LOW
HIGH
If ‘LOW’ then the patient could be included in the OSD scheme (Go to question 3)
If ‘HIGH’, please describe the risks that render the patient unsuitable for the OSD scheme at present.
Note – regardless of assessment result, the patient’s eligibility for inclusion in the scheme, (or exclusion from it), must be kept under regular review as it may be subject to change and require
reassessment.
Please circle the appropriate response
3. Are there any other factors, such as compliance or patient’s vulnerability to
exploitation and harassment by others, that need to be considered?
YES
NO
If yes, please indicate what they are and whether they make the patient unsuitable for the scheme.
Decision (Tick as appropriate)
The patient is suitable for inclusion in the OSD scheme and may have their leave or
Discharge medication organized and recorded by a OSD competency assessed nurse.
The patient is NOT suitable for inclusion in the OSD scheme at present.
Signature of the Consultant or nominated deputy:
Date
Signature of the competency-assessed nurse:
Date
Page 122 of 130
Version 3 November 2011
Appendix 13
Sussex Partnership NHS Foundation Trust
Patient’s own medication checklist – see Medicines Code section 19.8 for more details
Unit or ward name:
Put the medicines name and strength at the top of each set of columns
*Medicines in patient filled cassettes, systems with movable partitions (e.g. Medidose) and sealed blisters containing more
than one medicine in the blister are not to be used. Only sealed blisters that have one medicine per sheet are suitable.
Please tick for each medicine
Y
N
Not
applic
Y
N
Not
applic
Patient’s own medication will be checked against the following criteria:
1. Does the medication have a dispensing label on it from a pharmacy or dispensing
doctor?
2. Is the patient’s name correct on the container’s label?
3. If in a monitored dosing system is the medicine in a separate sealed blister? (see* above)
4. Is the drug name on the label the same as the contents of the container (if identifiable)?
5. Is the drug strength on the label the same as the contents of the container (if
identifiable)?
6. Is the drug formulation on the label the same as the contents of the container (if
identifiable)?
7. Does the medicine look okay, e.g. not discoloured or cloudy?
8. Is the medication still within the manufacturer’s or dispenser’s expiry date (if identifiable?)
9. If already open and there is a different shelf life once opened is this in date (e.g. eye
drops, insulin)?
10. Are all the medicines in the container identical (if identifiable)?
11. If cold storage was needed can this be confirmed?
12. Was the medication dispensed within the last 6 months?
13. If an oral liquid, was it dispensed within the last 30 days?
14. I have assessed the medication and have no further concerns?
If the answer is No to any of the above questions the medication is not suitable for use.
Patient’s name: ………………………………………………..
Date checked: ……………….
Medicines checked by: ……………….……………………… (Name)
Medicines checked by: ……….……………. …… (Signature)
August 2009
If the patient brings in more than 3 medicines please start a new sheet and staple them together.
Page 123 of 130
Once completed store in the patient’s notes
Y
N
Not
applic
Appendix 14
Glasgow Antipsychotic Side-effect Scale (GASS)
Page 124 of 130
Page 125 of 130
Appendix 15
Nurse Dispensing Procedure for Urgent Discharge and Leave Medication
in Exceptional Circumstances
It is possible that wards /units will occasionally be faced with the problem of patients
requiring medication urgently, for hurriedly arranged discharge or for a short period away,
and the time available is not sufficient to allow the dispensing and delivery of the drugs from
the supplying pharmacy, or the nearest community pharmacy if a doctor is available to write
an FP10 prescription. In such exceptional circumstances, and where units do not have
nursing staff available that have successfully completed the pharmacy lead certified training
and assessment to dispense medication, it is permissible for the assigned practitioner in
charge to authorise the dispensing of the necessary medication from ward/unit stock. The
exception is controlled drugs that must be prescribed by medical staff.
However, nursing staff must remain aware that such dispensing of medication from ward
stock is a particularly high-risk activity and one that is not endorsed by the Nursing &
Midwifery Council unless nurses have been specifically trained to deliver this activity to the
same standard as a pharmacist.
1.
Dispensing – Key Issues
1.1
The dispensing of urgent discharge or leave medication is the responsibility of the
assigned practitioner in charge and may only be undertaken by that practitioner or by
another designated practitioner.
1.2
The dispensing process must be checked by another designated practitioner if
available, or if not, by an authorised employee.
1.3
Only the patient’s current medication may be dispensed, and it must be exactly in
accordance with the directions of the prescriber.
1.4
It is vitally important that the patient’s medication regime is carefully studied so that all
the medicines needed are correctly dispensed. Conversely, there may be occasions
when, for the period of absence in question, some medications will not be needed.
1.5
Only that medication due to be taken/used during the period of absence should be
dispensed.
1.6
Medications must be dispensed in sufficient quantity, (i.e. sufficient number of doses),
to exactly cover the period of leave or absence up to a maximum of 72 hours supply.
(Unless supply is needed to cover a bank holiday, when up to 96 hours may be
supplied).
1.7
On no account may more than 96 hours supply of medication be issued, either
for discharge or for leave. If a larger quantity is required then the patient (or agreed
representative) must be asked to return to collect either pharmacy dispensed
medication or an FP10 prescription for dispensing in the community. Alternatively,
some units may be able to organize the delivery of further supplies of medication to
the patient once dispensed by a pharmacy.
Page 126 of 130
1.8
Where patients normally take variable doses of medication (e.g. "one to two tablets"),
then sufficient quantity to allow the patient to take the higher dose should be
dispensed – unless the prescriber or assigned practitioner in charge considers it
unnecessary or inappropriate to do so. (It is very important that variable doses are
discussed with the patient or carer in order to ensure that they fully understand the
reason for the dosage and what criteria/symptoms will govern selection of the actual
dose to be taken).
1.9
The supply of urgent discharge or leave medication from ward / unit stocks may also
include ‘as required’ medication. If this is the case, the assigned practitioner in charge
should look back over the record of medicine administration for the last week and use
this record to assess whether a discharge supply is necessary, and if so, how many
doses should be supplied? In all cases, the decision to supply, or not to supply any
recently prescribed ‘as required’ medication on discharge must be discussed with the
patient or carer, and the assigned practitioner in charge must ensure that the patient or
carer fully understands which medication is being supplied and how, why and when it
should be taken by the patient.
1.10 Each oral medication needed must be dispensed into a separate medicine container
and fitted with a child resistant top - (Unless specifically inappropriate, e.g. patient with
compromised manual dexterity). Foil packed medicines are classed as child resistant
and can be packed in boxes.
1.11 Where patients are using topical preparations (creams, ointments, eye drops, etc) or
inhalers then the complete pack should be issued.
2.
Dispensing and Labelling Procedure.
2.1
Every medication must be correctly labelled in order to comply with The Medicines Act
1968. This must be done by the completion of ‘grid labels’, which are supplied
specifically for the purpose by the supplying pharmacy or by the local pharmacy team.
2.2
The persons undertaking the dispensing must take the drug chart, and the discharge
summary & prescription if applicable, to the clinic room to minimise the risks of being
disturbed.
2.3
The pharmacy box in the regular medication and ‘as required’ medication sections of
the drug chart should be checked to see if the patient has additional stocks of some of
the drugs already at home. If this is the case, additional medication does not need to
be dispensed for these items.
2.4
Before commencing dispensing, the nurse must check that the medication prescribed
in the leave section of the drug chart or on the discharge form & prescription matches
those currently being prescribed on the drug chart. Unless there are clear
documented instructions by the prescriber, or another member of the medical team,
explaining the discrepancy, the discrepancy must be resolved before any dispensing
takes place.
2.5
The nurse should collect the empty containers, blank labels and dispensing bag
needed from the designated storage place. These are supplied by pharmacy.
Page 127 of 130
2.6
The patient’s own medication or if not available, ward stocks, can be used for
dispensing.
2.7
If the prescription cannot be filled due to unavailable stock, the pharmacy or on-call
pharmacist must be contacted for advice.
2.8
All labels should be prepared ensuring that all are written clearly and all contain the
following information. These should be checked by the second person, and both
persons must initial the labels.






2.9
Drug name, form (e.g. tablet) and strength
Directions, i.e. dose and frequency
The patient’s name
The quantity supplied
The date supplied
The name and telephone number of the supplying ward or unit
Each individual drug must be dispensed into an appropriate container and its
completed label applied and the ‘dispenser ‘box initialled before dispensing the next
item. The second person must check that the correct medication has been selected,
by checking against the original containers used for dispensing, and that the correct
quantity has been dispensed. Once checked the ‘checker’ box on the labelled should
be initialled.
2.10 When all the items have been dispensed, both persons must ensure that all details are
double-checked. A dispensing bag with the patient’s name on it must then be
prepared.
2.11 If the checking nurse finds an error in the dispensing or labelling, this must be brought
immediately to the attention of the dispensing nurse, the error corrected and the item
rechecked. A ‘near miss’ incident report must then be completed and submitted by the
team manager.
2.12 The dispensing record must then be fully and accurately completed by the nurse, and
signed by both persons involved with the dispensing process. (See appendix A). The
dispensing record must be kept in a ring-binder held on the ward specifically for the
purpose.
2.13 The nurse is then responsible for ensuring the patient (or carer) is counselled on the
medication including:




Full directions for use.
Explicit additional instructions on when ‘as required’ medication should be taken.
A description of common side effects to watch out for.
Who to contact if the patient has any concerns about the medication.
Interpreters can be booked to assist people who experience communication
difficulties in terms of language and visual or hearing impairment.
If this is the first time the patient has left the ward on the medication, then wherever
possible, a patient information leaflet should be supplied with the medication. If there
is not one in the medication container used, one can be accessed via the medication
Page 128 of 130
section of the Trust’s website using the link to the Choice & Medication website:
http://www.choiceandmedication.org/sussex
Information can be made available in other formats and community languages to
assist people who experience communication difficulties in terms of language or
visual impairment from your local pharmacy team.
2.15 Units must ensure that they always have adequate supplies of medicine boxes,
bottles, tops, labels and dispensing bags, as the issue of medicines to patients in
unofficial containers is unacceptable.
3.
Record Keeping
A signed written record of all such issues must be kept by the unit and should detail the
patient's name, medication issued (reference letters from the prescription chart may be
used), and quantity, dosage instructions, the date of issue, and the names of staff taking
responsibility for the packing and labelling of the medication.
4.
Limitations
4.1
No more than a maximum of 72 hours supply of discharge / leave medication may be
made from ward stocks. (96 hours is permissible to cover a bank holiday).
4.2
The issue of discharge / leave medication from ward stocks must not include
controlled drugs.
4.3
Registered nurses who have received specific training from pharmacy staff and who
have successfully completed a structured assessment of competency in this area are
not limited by the terms of this interim procedure.
February 2014
Page 129 of 130
Appendix 16
Checklist for Ward Managers to Assess the Competence of Care Assistants to Check the Administration and
Recording of Controlled Drugs (CDs) in the Absence of a Second Qualified Nurse – v1 – November 2014
Introduction
This checklist has been developed to help ward managers assess care assistants to become ‘authorized employees’ to be able to second check when CDs
are administered in the absence of a second qualified nurse. The underpinning principle should be that this person would make a credible witness in a court
of law if they had to back up your version of events when they said they had witnessed you properly administering and recording a CD. They are not expected
to have any clinical input into the process. They are only being asked to initial/sign that they have witnessed that the correct medicine and dose was selected,
they saw it administered to the correct patient and the proper recording took place on the drug chart and in the CD register. Due to the limited use of CDs on
most wards, some of the assessment can take place using non-CD medicines as the process of identification, watching the administration and recording on
the drug chart applies equally to all medicines. Additional training on how to record in a CD register will need to be undertaken.
Ward: ………………………
Care Assistant’s Name: ……………………………………..
Responsible assessor’s name:…………………….................
Date
demonstrated
The care assistant is able to demonstrate that:
They can read drug names on a drug chart, but are confident to refuse to be a witness if they cannot read them?
They can correctly select a range of medicines from the drug trolley, including the correct dose?
They know how liquid medicines are correctly measured using oral syringes and measuring cups?
They know how to witness the administration of medicines, including unusual formulations like fentanyl patches?
They know how to record the administration on the drug chart, including when special administration or omission codes need to be used?
They know how to match the page in the CD register with the CD administered?
They know how to record a dose administered in the CD register?
They are aware of the guidance in the front of the CD register how to record CDs and what to do if an error is made recording?
They know how to check the CDs stock level after administration and what should happen if there is a discrepancy found with the register?
They know that if at any point they are unsure that everything was done correctly, they can refuse to witness the administration?
Depending on local circumstances, they know who should be called for advice if they feel they cannot witness the administration?
I confirm that I feel competent to take on the role of second checker when CDs are administered: ……………………………. (signature) ……………… (date)
I confirm that ……………………………………….. (care assistant’s name) has successfully demonstrated to me that she/he can undertake the role as second
witness when CDs are administered:
……………………………………………… (signature)
Page 130 of 130
……………… (date)