Download The Safe and Secure Handling of Medicines Policy

The Safe and Secure Handling of Medicines
Policy
DOCUMENT CONTROL:
Version
Ratified by:
Date ratified:
Name of Originator / Author
Name of Responsible
Committee/Individual
Date Issued
Review Date
Target Audience
Review Date:
Review Year:
Reviewed by (Group):
10.1
Clinical Quality Group
1 March 2016
Chief Pharmacist
Clinical Quality Group
12 December 2016 (updated FS Review below)
March 2019
This policy applies to all staff involved with the
use of medicines.
Forensic Business Division
8 November 2016
November 2017 (annual review)
Forensic Service Review
CONTENTS
SECTION
1.
INTRODUCTION
2.
PURPOSE
3.
SCOPE
4.
RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES
4.1
The Board of Directors
4.2
Medical Director
Clinical Governance Group
4.3
Clinical Effectiveness Committee
4.4
The Medicines Management Committee
4.5
Organisational Learning Forum
4.6
Chief Pharmacist (Accountable Officer for Controlled Drugs)
4.7
Trust Pharmacists
4.8
Pharmacy Technician
4.9
4.10
5.
5.1
5.2
Prescribing responsibilities of all staff: Practitioners with
prescribing, ordering, storing and administering of medicines
responsibilities
4.10.1
Staff definitions
4.10.2
Medical staff
4.10.3
Independent prescribing
4.10.4
Supplementary prescribing
4.10.5
Non-medical prescribing (NMPs)
4.10.6
Prescribers responsibility
4.10.7
Informed Prescribing
4.10.8
Appointed practitioner in charge / responsible person
4.10.9
Assigned practitioner in charge
4.10.10
Non-registered healthcare staff
4.10.11
Bank/agency staff
4.10.12
Staff who administer medication
4.10.13
Supplying Pharmacist (community hospital)
PROCEDURE/IMPLEMENTATION
Medicines which fall within this policy
Prescribing of medicines
5.2.1
Medicines reconciliation
5.2.1.1
Allergy
5.2.2
Patient involvement
5.2.3
Source of information available to patients
5.2.4
Prescribing principles
5.2.4.1
How medicines are managed on handover between
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CONTENTS
SECTION
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
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care settings
5.2.5
Prescription documentation
5.2.6
Initiation of treatment
5.2.7
Completing the prescription
5.2.8
Transcribing directions to administer
5.2.9
How the organisation is assured that medication
charts are accurate
As required medication (prn)
5.3.1
Prescription
5.3.2
Administration
5.3.3
Review
5.3.4
Leave/Discharge
Take home medication (TTO) or discharge drugs
Outpatient prescriptions
FP10’s
5.6.1
Issuing prescription
5.6.2
Lost Prescriptions Pads
5.6.3
SOPS for managing FP10’s
Use of patient’s own medication
Prescribing homeopathic/herbal remedies
Above BNF maximum prescribing lines
Prescription for hospital staff and their families
Staff self-administration of medicines
Patient group direction
Ordering medication from pharmacy
5.13.1
Ordering stock medication
5.13.2
Ordering named patient medication
5.13.3
Receipt of stock and named patient medication
5.13.4
Faxing of prescriptions to pharmacy
5.13.5
Ordering controlled drugs
Transfer of medicines between ward areas
Out of hours pharmacy service
Delivery of non-controlled medicines
Storage of medication
5.17.1
Containers for storage of medication
5.17.2
Storage of medication on wards/departments
5.17.2.1
Medicines storage room ambient temperature
monitoring
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CONTENTS
SECTION
5.17.3
Drug fridges
5.17.4
Siting of cupboards or trolleys
5.17.5
Controlled drugs cupboards
Custody and safekeeping of medicine
5.18
5.18.1
Keys for medicine cupboards, medicine trolleys and
drug fridges
5.18.2
Keys to the controlled drugs cupboard
5.18.3
Re-agent cupboard keys
Arrangements for the administration of medicines
5.19
5.19.1
Medicines and the Law
5.19.2
Who has the authority to administer medication
5.19.3
Patients Self Administration of Medication
5.19.3.1
Inpatient services General Self Medication Scheme
5.19.3.2
Specific Medicinal Products
5.19.3.3
Patients in the Community unable to self-administer
5.19.4
Principles of Administration
5.19.5
Action prior to administering medication
5.19.6
Consent to treatment
5.19.7
Checking administration
5.19.7.1
Complex calculations
5.19.7.2
Controlled drugs
5.19.8
Documenting the administration of medicines
5.19.9
Covert administration of medicines
5.19.10
Medications which have specific p rescribing,
administrative, storage, availability or monitoring
requirements
5.19.10.1 Injectable Medicines
5.19.10.2 Clozapine
5.19.10.3 Lithium
5.19.10.4 Oral Anticoagulants
5.19.10.5 Cytotoxics/Cytostatics and Chemotherapy
5.19.10.6 Antibiotics
5.19.10.7 Naloxone
5.19.10.8 Syringe Drivers
5.19.10.9 Enteral feeding and administering medication
5.19.10.10 Medical Gases
5.19.10.11 Flammable Liquids
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CONTENTS
SECTION
5.19.10.12 Dressings
5.19.10.13 Insulin
Advice about the uses and side effects of medication
5.20
Side Effects Monitoring
5.21
Transport of Medicine
5.22
5.22.1
Transport within wards and departments
5.22.2
Transport of medicines between health service
premises
5.22.3
Transport of medicines from the Supplying Pharmacy
5.22.4
Transportation by Taxi
5.22.5
Transport of Medicines to Patients at Home
5.22.6
Transport of Patients medicines by Community Staff
Medication Error/incidents
5.23
5.23.1
Definition of Medication Error
5.23.2
Action to take if on Error occurs
5.23.3
How the organization learn from medication errors
Disposal of Medicines which are no longer required
5.24
5.24.1
Disposal of non-controlled drugs
5.24.2
Disposal of controlled drugs
5.24.3
Disposal of Patient’s own Medication
5.24.4
Drug disposal in Community Service
Ward Closures
5.25
5.25.1
Temporary or routine ward/department closures
5.25.2
Permanent closure of ward/department
5.26
5.27
5.28
5.29
5.30
5.31
5.32
Investigation of Drug Discrepancy or loss occurring in the hospital
or community
Removal of and disposal of unknown substances
5.27.1
Action if a visitor is in possession of an unknown
substance
5.27.2
Action if a patient is in possession of an unknown
substance
Adverse drug reaction
Medicine Defect Reporting
Drug alerts, recalls and safety notices
Use of unlicensed medicines
5.31.1
Trust Procedure for the prescribing of unlicensed
medication
Definition of “off-label Medicines”
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CONTENTS
SECTION
Medicines Safety
5.33
Clinical Trials including pharmaceutical products
5.34
Contact with Pharmaceutical Industry Representation
5.35
New medicine related documents
5.36
Training Implication
6
Monitoring Arrangements
7
Equality Impact Assessment Screening
8
Privacy, Dignity and Respect
8.1
Mental Capacity Act
8.2
Links to any Associated Documents
9
REFERENCES
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APPENDICES
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Appendix 1 – Guidance to staff on Medicines reconciliation
Appendix 2 – Crushing Tablets and Opening Capsules
Appendix 3 – Adverse Drug Reporting
Appendix 4 – Guidance on High Dose Antipsychotic Prescribing
Appendix 5 – Pharmacy Medication Card Assurance Verification
Record
Appendix 6 – Allergy Assessment
Appendix 7 – Covert Administration Care Plan
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1.
INTRODUCTION
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The department of Health requires that NHS Trusts establish documents
and maintain an effective system to ensure that medicines are handled in
a safe and secure manner.
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Medicines Management focuses on optimizing the use of medicines and
is defined in the Audit Commission’s Report ‘A Spoonful of Sugar’ as
‘encompassing the entire way that medicines are selected, procured,
delivered, prescribed, administered and reviewed to optimize the
contribution that medicines make to produce informed and desired
outcomes of care’.
-
Aspects of medicines management run throughout the organization,
across all localities and service areas, and comprehensive medicines
management is crucial to the achievement of the Trust strategic and
operation objective. Medicines Management involves patients, carers
and all Pharmacy Services within the Trust.
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This policy has been written in accordance with:•
•
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•
•
•
•
•
•
•
•
•
The NMC Standards for medicines management (2004)
The NMC the Code: Standards of conduct, performance and
ethics for Nurses and Midwives (2008)
The Medicines Act (1968)
The Misuse of Drugs Act (1971)
The Misuse of Drugs Regulations 2001
The Safe and Secure Handling Medicines 2005 (revision to the
Duthe Report, 1988)
The Mental Health Act (1983) (amended by the Mental Health Act
2007)
Health and safety Regulation
Control of Substance Hazardous to Health Regulations 1988
(COSHH)
Essential Standards of quality and Safety
NPSA alerts and guidance
Health and Social Care Act 2008 (Registration Requirements)
Regulations 2009: Regulation 11 – Management of medicines and
medical devise.
And also any amendments to the primary legislation up to and including
December 2015
Policy Statement
In the Trust the principles which govern the management of medicines must
be applied to all the actives in which medicines or their administrative and
legal control is concerned.
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The Key principles are:
•
•
•
Compliance with current legislation;
Adherence to guidance issued by the Health Departments for England,
Wales, Scotland and Northern Ireland and other national guidance e.g.
NPC Guide, NPSA alerts;
Management of the risks to patients and staff arising from the use of
medicines.
These principles will be applied to the management and physical handling
processes involved in the initiation of treatment, prescribing, procurement,
production, acquisition, storage, distribution, dispensing, preparation,
administration to patients and the safe handling and disposal of any residual
medicinal product.
If situations occur that may require staff to go outside of policy then the chief
pharmacist must be contacted who will decide whether the course of action
is appropriate, and whether they can continue, or it needs further agreement,
following this the chief pharmacist will then consult with the team manager
and head of professional service for agreement and document the decision,
this will then be taken to medicines management for ratification.
2.
PURPOSE
The purpose of this policy is to set out the arrangements for managing
the risks associated with medicines in all care environments; and, to
enhance standards of professional practice in the safe prescribing,
dispensing and administration of medicines by:
•
•
•
•
•
Providing a procedural framework supporting the safe and secure use
of medicines across all Trust activities. This framework is to be used to
support the development of ward, department and base point specific
standard operating procedures.
Ensuring that the handling and storage of medicines within the Trust
meets legal requirements.
Creating a robust audit trail that will be monitored regularly.
Defining the roles and limitations of staff working within the Trust in
relation to medicines.
Detailing the lines of responsibility for the investigation of medicines
related incidents.
Additionally, the aims of this Policy are to ensure that:
•
all patients receiving treatment requiring medication do so in the correct
and proper manner;
•
all precautions have been taken to ensure that the proper
procedures have been followed in providing that treatment;
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•
Proper procedures have been followed such that all medicines
have been stored and transported to ensure that their integrity has
been maintained and to minimize risks to staff, patients and the
public.
The result of using the Policy (in conjunction with any other appropriate local
policies) should be that the right patient /patient receives:
•
•
•
•
•
The correct medication;
In the correct dosage;
By the correct route;
At the right time, and
For the right duration;
However, medicines management should not be viewed as a
mechanistic task, which becomes routine, as it requires thought and the
exercise of professional judgment with each practitioner being accountable
for their actions and omissions.
3.
SCOPE
This policy applies to those members of staff that are directly employed by
the Trust and for whom the Trust has legal responsibility who are involved
with the use of medicines. For those staff covered by a letter of
authority/honorary contract or work experience this policy is also applicable
whilst undertaking duties on behalf of the Trust or whilst working on Trust
premises and forms part of their arrangements with our organisation.
As part of good employment practice, agency workers are also required to
abide by the Trusts policies and procedures, as appropriate, to ensure their
health, safety and welfare.
All staff contracted to work within the Trust who are involved with the use of
medicines must familiarise themselves with the correct procedures
contained within this policy. Those in charge of wards, units and clinics are
responsible for ensuring that their staff, (especially new and locum staff),
follow procedures in this policy, which may differ from procedures used
elsewhere. Copies of the policy will be available at all inpatient and
outpatient sites as well as being accessible on the Trust intranet.
4.
RESPONSIBILITIES, ACCOUNTABILITES AND DUTIES
The duties and responsibilities for medicines procedures that may be held by
various grades of practitioners are shown below. However, all grades of
practitioners must:
•
•
Be aware of the tasks they may or may not perform.
Identify their training needs making their manager aware of any
training deficit.
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•
•
4.1
Maintain a personal record of all competency-based assessments.
Report near-misses, clinical incidents and serious incidents
regarding their prescribing, dispensing, storage and administration of
medicines.
The Board of Directors
The Board of Directors through the Executive Medical Director and
the Chief Pharmacist is responsible for Medicines Management within the
Trust.
4.2
Medical Director
The Medical Director is responsible for:
•
•
•
4.3
Medicines Management and Pharmacy Services lead at Board of
Directors
Medical leadership and supervision
Signatory to Trust Patient Group Directions
Clinical Governance Group
The clinical Governance Group is responsible for:
•
•
4.4
Establishing, auditing and maintaining effective processes for Medicines
Management.
Receiving, debating and taking action on as appropriate the Annual
Report of the Accountable Officer for Controlled Drugs.
Clinical Quality Group
The Clinical Quality Group is responsible for
•
•
•
4.5
Receiving, discussing and ratifying proposed medicines related policies
and suggested amendments to existing policies.
To receive audit results and ensure action plans are appropriate and
robust in relation to the audit results.
Chair of Clinical Effectiveness Committee to be a signatory to Trust
Patient Group Directions.
The Medicines Management Committee
The Medicines Management Committee is responsible for:
•
•
To develop effective medicines management policies which supports
compliance with medicines legislation and good professional practice
in prescribing, supplying, administering and monitoring of medicines
To ratify and register all unlicensed medicinal products supplied or
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•
•
•
•
•
4.6
administered through the Trust.
To promote safe medication practice by the systematic review of
medication errors.
To recommend to the Clinical Quality Group all documentation
associated with the prescribing and administration of medicines.
To recommend to the Clinical Effectiveness Group protocols which
enable non-medical practitioners to supply and administer medicines
To audit medicines policies and procedures and the administration of
medicines as part of the annual Clinical Audit Programme.
All medication errors/incidents will be subject to review by the Trust’s
Pharmacy Team. Themes and lessons learned from Serious Incidents
(Sis) will be reviewed in the Medicines Management Committee, and
will inform the medicines management training and policy review.
Organisational Learning Forum
The Organisational Learning Forum is responsible for:
•
•
•
4.7
Developing and managing a structured approach to active
organisational learning, where lessons learned are embedded in the
Trust’s culture and practice. The group will help to facilitate a fair blame
(no blame) culture.
Share lessons learnt from one service to other areas of the Trust in
order that any system failures discovered during investigations are
adopted by the Trust as a whole and pockets of good practice are not
isolated.
All medication errors/incidents are subject to review by the Trust’s
Pharmacy Team. Themes and lessons learned from Serious Incidents
(Sis) will be reviewed in the Medicines Management Committee, and
will also be shared at the Organisational Learning Forum
Chief Pharmacist (Accountable Officer for Controlled Drugs and
Medication Safety Officer)
The Chief Pharmacist is responsible, and accountable to the Trust boards
for:
•
•
•
•
•
•
Pharmacy Services
Medicines management throughout the Trust. Ensuring timely
reporting against the monitoring requirements of this policy
Ensuring processes are in place supporting the appropriate
acquisition, storage, usage and disposal of medicines across the Trust
Providing a monthly report from the Medicines Management Committee
to the Clinical Governance Group
Providing an annual report to the Clinical Governance Group in their
capacity as Accountable Officer for Controlled Drugs
Providing a quarterly report to the Clinical Governance Group from the
Pharmacy Local Intelligence Network (LIN)
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•
•
•
4.8
Providing a three monthly report on medication related errors
Signatory to Trust Patient Group Directions.
Providing advice on the medicines management element of the Trusts
Clinical Audit Programme
Trust Pharmacists
Whilst the Trust medicines are supplied through either service level
agreements with the acute hospitals within the localities or via a contract with
local pharmacists, these are pharmacists employed who are responsible for
supporting the best use of medicines throughout the Trust including:
•
•
•
•
•
•
4.9
The safe, effective and economic use of medicines
Appropriate storage of medicines in clinical area
Supporting the Trust’s Clinical Audit Programme in relation to
medicines management
Appropriate investigation of medicines related incidents
Support staff training in relation to medicines management
Monitor prescription cards in line with the 10 point plan
Pharmacy Technician
These staff offer a service Trust-wide, but are based within the Doncaster
locality and will inspect the stocks of medicines held on the wards or in
departments at any time to ensure the medicines are in date and
stored/disposed of under the proper legal and environmental conditions.
4.10
Prescribing responsibilities of all staff: Practitioners with prescribing,
ordering, storing and administering of medicines responsibilities
4.10.1
Staff Definitions
4.10.2
Throughout the Policy, Certain specialist titles describe healthcare staff that
have defined responsibilities regarding the management of medicines. In
general, only staff with contracts (honorary contracts) of employment to work
with the Trust are assessed as having any involvement with medicines. All
nurses or practitioners who are either new or unsure about certain practices
should administer in pairs.
Medical Staff
Medical staff are responsible for prescribing medicines for patients. They
and any other authorized prescribers must comply with current legislation,
national guidance and the Medicines Policy, when performing these duties.
With the exception of Clozapine, which can only be initiated by a Consultant
Psychiatrist, who in turn must be registered with ZTAS, all qualified doctors
may prescribe licensed medication on inpatient charts, leave prescriptions
(TTOs) and outpatient prescriptions.
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Off-license prescribing must be Consultant-led, unless supported by the
Trust Formulary or national/local guidance such as NICE, and should be
recorded in the patients clinical record.
4.10.3
Independent prescribing
Prescribing by a practitioner (e.g. doctor, dentist, nurse and Pharmacist)
responsible and accountable for the assessment of patients with
undiagnosed or diagnosed conditions and for decisions about the clinical
management required, including prescribing.
•
4.10.4
Non-medical prescribers must not prescribe unlicensed medicines.
However, medication which is licensed, but outside its licensed
indications may be in exceptional circumstances prescribed by an
independent non-medical prescriber, if such use is justified by current
best practice (e.g. national NHS guidance or local Trust guidance).
Non-medics prescribing medicines outside the terms of the product
license must accept professional, clinical and legal responsibility for that
prescribing.
This prescribing must be carried out within their
professional competence/
Supplementary Prescribing
Supplementary prescribing with the agreement of patients enables nurses,
pharmacists and that AHPs previously identified, to make adjustments to
medication based on agreed clinical management plans, thus facilitating a
more flexible approach to care delivery and the development of new
professional roles.
The Department of Health (2004) defines supplementary prescribing as “A
voluntary partnership between an independent Prescriber (a Doctor or
Dentist) and a Supplementary Prescriber to implement an agree patient
specific Clinical Management Plan (CMP) with the Patient’s agreement”.
4.10.5
Non-Medical Prescribers (NMPs)
NMPs are nurses, pharmacists, or certain AHPs who have satisfactorily
completed the supplementary and independent prescribing course. They
should only prescribe within their agreed area of expertise and competence,
Please refer to the Trust’s Non-Medical Prescribing Policy.
4.10.6
Prescribers Responsibility
It is the responsibility of any authorized prescriber to:
•
•
•
•
Write the prescription legibly and correctly
Include all relevant details of the patient on the prescription
Prescribe medication in accordance with the standards in the policy
Check the patients’ medical records prior to writing any new
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•
•
•
prescription
Follow local and national prescribing standards
Pay particular attention to the accuracy of complex drug calculations
Discuss the proposed treatment plan with the patient and their
carer/relatives (subject to the patients agreement) and record a
summary of this discussion in the patients records stating clearly:
•
•
•
•
•
4.10.7
What medication is to be prescribed
The aims of the treatment plan
How long the medication should be taken for
What alternative treatment plans have been discussed
Review date and monitoring
Informed Prescribing
The Trust appreciates that face to face assessment, by the prescriber, of a
patient prior to any prescribing decision is the ideal situation, however the
reality is that in many instances this is simply not possible or in the patient’s
best interest – most notably in out of hours situations, community teams
where patient assessment may be by another healthcare professional (HCP)
or occasions where a patient receives a repeat prescription from us as part
of their on-going care.
In such instances the Trust supports national and professional guidance
which requires prescribers to work within their competencies and assure
themselves of the patient’s health and their need for the medication prior to
prescribing. This assurance may be informed by telephone conversation
with the patient or their carer, the patient’s clinical notes or care plan, referral
letters from other HCPs, adequate feedback from other HCPs who have
assessed the patient, other sources that are considered reliable. When
making such prescribing decisions, due regard should be given to the
prescriber’s experience, the seriousness of the patient’s clinical condition
and specific drug considerations such as potency, monitoring requirements
and abuse potential.
You are responsible for any prescription you sign, including repeat
prescriptions for medicines initiated by colleagues, so you must make sure
that any prescription you sign is safe and appropriate.
4.10.8
Appointed
Practitioner
Manager/Ward Manager)
in
Charge/Responsible
Person
(Service
This is the senior practitioner appointed to take charge of a ward or
department e.g. Ward Manager or Team Leader. In the event that the
person in charge is not from a professional nursing background appropriate
to take on the duties and responsibilities within this policy (e.g. community
team leader with a social work background), another senior member of the
nursing team will undertake the role of appointed practitioner in charge with
respect to controlled drugs, and may take the role of appointed practitioner in
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relation to all medicines management issues.
This staff member has ultimate responsibility for:
•
•
•
•
•
•
•
•
•
•
•
•
•
ensuring that this policy and other associated procedures in
relation to medicines administration are being followed correctly
the safekeeping of medicines on the ward, department or base point
and will ensure their safe and appropriate storage at all times.
ensuring that SOPs are relevant to their area of practice, are consistent
with the standards of this policy and that all staff have read and signed
SOPs appropriate to their role.
ensuring that the staff performing physical security checks and stock
reconciliation is appropriately rotated to ensure secure delegation is
maintained.
arranging for an appropriate investigation to take place if there are any
exceptions or discrepancies.
ensuring that unwanted medicines are disposed of in appropriate
pharmaceutical waste bin prior to collection.
ensuring that all Controlled Stationery on the ward, department or base
point is held securely. Where a department is closed for any reason up
to 7 days the Responsible Person will ensure that all medicines are
stored in cupboards as specified in Section 5.17.
signing for receipt of any medicines delivered to the ward or
department. This process will involve checking the received stock
against requisition, and patients own medication against the
prescription, as well as ensuring security of storage through transit has
been maintained.
ensuring that access to medicines is restricted, by control of keys to the
medicine cupboards and refrigerators, or other alternative approved
storage areas. This responsibility remains with the Responsible Person
even if they decide to delegate this duty.
checking stock levels at least once every six months where a ward or
department is not served by a pharmacy top-up service.
ensuring that a running balance of Controlled Drugs is recorded after
each transaction and recorded under the last entry for each medicine in
the Controlled Drug Register.
Administration of medicines. This duty may be delegated to another
practitioner, but the appointed practitioner /Responsible person in
charge must exercise supervision as necessary and be satisfied that
the staff member to whom they have delegated the task has received
relevant training.
If a situation arises where medication, which has been prescribed
has not been written in accordance with the standards in this policy,
the practitioner may still administer the medication provided they are
satisfied the prescription is legible and safe, and that any delay in
administration would be detrimental to the patient. The prescriber
must be contacted immediately and informed of the deficiencies
with the prescription being re-written correctly within 24 hours.
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4.10.9
Assigned Practitioner in Charge
This is the senior practitioner on duty (i.e. team manager) who in the
absence of the Appointed Practitioner in Charge/Responsible Person has
been rostered as the professional in charge for that shift. Whilst in charge
this person is responsible for all the duties as set out above in section 4.5.7
4.10.10
Non-Registered Healthcare Staff
These are clinical support workers, trainee and assistant practitioners,
healthcare workers, support workers and nursing assistants who assist in
medication duties. These staff must have the relevant training or Trust
approved training, allowing them to undertake certain functions with
respect to assisting with medicines administration, or administering
medication in agreed circumstances, such as community homes.
The following situations are suitable for support staff to administer or aid in
the administration, provided the task has been delegated to them as an
individual authorised for that level of administration:
•
•
•
•
•
•
Administration of oral medication, such as in a community home or
supported living
The application or insertion of creams, ointments or drops
Nursing a child who is using a nebuliser
The supervision of a dependent patient to ensure their medicines are
taken effectively
Simple eye care
Simple dressings
The Individual Authorised to administer medicines retains the responsibility to
ensure that a medicine has been administered correctly; and that
responsibility cannot be delegated. In line with this the individual authorised
to administer will identify the correct medicine and correct patient to whom
the medicine is to be administered.
Practitioners in training must be given every opportunity to become
proficient in medicines related activities under appropriate supervision. The
supervising practitioner has responsibility for such medicine procedures at all
times.
4.10.11
Bank/Agency Nursing Staff
Before administering medication, agency or bank staff should have
attended mandatory training or local induction and be familiar with the
policies of the Trust. Regular bank or agency registered nursing staff
confident in Trust practices may administer medicines with approval of the
appointed practitioner in charge. It is the responsibility of the registered
nurse to report any issues regarding their competence.
Page 16 of 108
4.10.12
Staff who Administer Medication
The individual authorised to administer medicines will be responsible for:
•
•
•
•
4.10.13
ensuring they have an understanding of the use, action, usual dose,
side effects and handling hazards of the medicine(s) being
administered.
ensuring they are certain of the identity of the patient to whom the
medicine is to be administered before initiating any administration
activity.
retaining the responsibility to ensure that a medicine has been
administered correctly; (this cannot be delegated). However in certain
circumstances support staff may aid in the administration of medicines.
In these circumstances the administrator will ensure that the support
staff has sufficient training and information to aid the administration of
the medicines safely.
They have received appropriate training to administer medication,
especially when given parenterally or via enteral feeding tubes.
Supplying Pharmacist (Community or Hospital)
Supplying pharmacists are responsible for ensuring that prescribers are
always aware that a medicine they have requested is only available as an
unlicensed product. Pharmacists will share the responsibility as the
purchaser of the product, particularly when this involves specifying the
product to be purchased. Pharmacists are responsible for ensuring that the
manufacturer holds the appropriate license to manufacture and that the
product complies with the product specification.
5.
PROCEDURES/IMPLEMENTATION
5.1
Medicines Which Fall Within This Policy
Medicines, whether for internal or external use, will be regarded, for the
purpose of the policy, as comprising the following categories:Controlled Drugs controlled under the provisions of the misuse of Drugs Act
1971, with stringent requirement 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 equal 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.
Page 17 of 108
Other pharmaceutical preparations. Disinfectants, reagents and other
preparations are not used directly to treat patients. However, the use of
these products must still be subject to agreed and approved procedures.
Full attention must also be given to the requirements of current Control of
Substances Hazardous to Health (COSHH) Regulations.
It is important to understand that procedures listed in this document
apply to all medicines used in the Trust. These include topical lotions,
applications, injectable fluids, medicated dressings, dietary products and
complementary medicines.
Where they exist Standard Operating Procedures (SOPs) must be
followed and where missing must be developed accordingly.
5.2
Prescribing of Medicines
5.2.1
Medicines Reconciliation
“The aim of medicines reconciliation on admission to hospital is to ensure
that medicines prescribed on admission correspond to those that the patient
was taking before admission” (NICE Medicines Optimisation NG 5) and
involves:
•
•
•
Collecting information on medication history using the most recent
and accurate sources of information to create a full and current list of
medicines. Wherever possible, information should be obtained prior to
admission.
Checking or verifying this list against the current prescription,
accounting for any discrepancies and actioning them appropriately.
Communicating through appropriate documentation, any changes,
omissions and discrepancies.
Within the Trust, a medicine reconciliation document has been produced
which meets the required standards, is auditable, and can be completed by
suitably trained staff. Where staff carrying out the reconciliation are not
medically trained and discover discrepancies between the record and what
the patient is actually taking, this should be discussed with prescriber
responsible for the patient within the team.
When patients are referred in to a team, inpatient and community, medicines
reconciliation should occur, this includes when patients have been to the
acute hospital for treatment overnight. For community teams, patients should
be asked about changes in medication at each visit and should be reviewed
at least annually, this must be done in teams who are prescribing medication
for the patient.
In community settings the medicines reconciliation form should also indicate
who is responsible for prescribing each medication.
Page 18 of 108
This document is to be completed at the point of admission, and referred
to when prescribing medication for the patient. (For further guidance staff
should refer to appendix 1).
5.2.1.1
Allergy
Assessment:
Take a history and undertake a clinical examination, using the guideline to
help ascertain likelihood of it being an allergy. Appendix 6
Documenting and
professionals:
sharing
with
information
with
other
healthcare
Record in their notes, and drug cardex as:

Drug Allergy/Hypersensitivity

None Known (NKDA)

Unable to ascertain (must be documented as soon as information is
available)
If an allergy has been documented include (where information is available):

Drug Name (generic and brand if known)

Signs symptoms and severity

Date when it occurred
New Allergies identified whilst under our care:

Drug name, generic and brand, strength and formulation

A description of the reaction

Indication of the drug

Date and time of reaction

Number of doses/days prior to reaction

Route of administration

Which drug/classes of drugs to avoid in the future
Maintaining and sharing drug allergy information:

Ensure drug allergy/hypersensitivity is documented separately from
adverse drug reactions so it is clearly visible.

Included in all GP referral and hospital discharge letters

Ensure medicines reconciliation is carried out in line with NICE
guidance
Providing Information and Support to Patients

Discuss the persons suspected allergy with them and provide
structured written information, record who gave this and when.

Ensure the person is aware of what drugs/classes of drugs they need to
avoid in the future, and to advise them to check with the pharmacist
before taking over the counter medication

Advise them to carry this information with them, and to share this
information whenever they visit a health care professional.
Page 19 of 108
Non Specialist Management and referral to specialist services:

Consider stopping the suspected drug and advise to avoid in the future

Treat symptoms of the acute reaction; send people with a severe
reaction to hospital

Document details as above

Provide person with information
Refer to a specialist drug allergy service if they have:

A suspected anaphylactic reaction

A severe non immediate cutaneous reaction e.g. Stevens-Johnson
Syndrome

This should be via primary care, and be communicated in any
discharge letter.
5.2.2
Patient Involvement
Patients have beliefs, attitudes and life experience which will influence
their medicine taking behaviors, taking these into account and
prescribing with that knowledge may have a positive effect on concordance.
Concordance refers to a consultation and negotiation process between a
health care professional and a patient, which has an ethos of a shared
approach to decision making. Within this context it is the process of
prescribing and medicine taking based on partnership, and the following
three essential elements define the process:
1.
Patient have enough knowledge to participate as partners
To aid this, patients must be provided with information which is:
•
•
•
•
•
2.
Tailored
Clear
Accurate
Accessible
Sufficiently detailed
Prescriber consultation involve patient as partner
To achieve this, patients must be:
•
•
3.
Invited to talk about their concerns and expectations
Have their treatment regimens fully explained
Patients are supported in taking their medication
This will be achieved by giving patients:
•
•
Ample opportunity to discuss their medication
The effective sharing of information between all professionals involved in
the patients care
Page 20 of 108
•
5.2.3
Involving the patient in all reviews of their treatment regimes
Sources of Information to Patients (not relevant where patients receive
manufacturers patient information leaflet with medication packs
Information to patients is available in the following ways:
• From practitioners involved in their care and treatment
• From the information leaflets which are contained within the medication
packs
• From the Trust pharmacy department
• Through 1:1 sessions with the specialist pharmacists employed within the
Trust
• From the pharmacy information leaflets
• MIND and other independent organisations also offer information to
patients around treatment and medication
• Long term outpatients will receive a complete set of patient information
leaflets every three months
• Via the Trust website (Choice and medication)
5.2.4
Prescribing Principles
• The patient’s clinical record should always be checked before a new
prescription is written.
• Prescribers should have access to a pharmacist who is able to provide
advice on the drug treatment plan.
• Prescribers should follow local and national prescribing standards.
• Prescriptions should always carry specific patient directions and
never be issued with the instruction “as directed”.
• Particular attention should be paid to checking the accuracy of
complex drug calculations.
• The proposed treatment plan and the discussions with the patient or
their representative regarding what the medication is, what the aims of
treatment are, how long it should be taken, potential side effects,
alternatives and what to do if stopping it as well as how the response to
drug therapy is to be monitored should be clearly documented in the
patients clinical notes.
• Patients should be provided with information on their treatment.
• Prescribers should be trained and assessed as competent before
being required to prescribe.
• Where available electronic prescribing systems should be used.
• Actual and potential prescribing errors should be recorded and reviewed
regularly to raise awareness of risk, and to improve practice.
5.2.4.1
How medicines are managed on handover between care settings
•
Changes to medication must be documented in any correspondence
Page 21 of 108
•
between areas, e.g. discharge letter, clinic letter, transfer letter.
This should include details and rationale of:
o
o
o
o
•
5.2.5
Medication stopped
Medication started, including review periods
Any medication monitoring required and who is responsible
Allergies and sensitivities
When patients are received from any care setting medicines
reconciliation must be completed (Appendix 1) where there is
prescribing responsibility for the receiving team.
Prescription Documentation
Medicines may only be prescribed on authorised stationery
•
Authorised inpatient prescription stationery Leave prescription sheet
•
Discharge prescription sheet Outpatient prescriptions
•
FP10 (NC)
•
FP10SS FP10MDA
In community settings the prescription may come from the local acute trust or
general practitioner and be followed with a
•
Letter of instruction (DCIS)
•
Medicine Administration Record (MAR) – Community Homes generated
by the supplying pharmacy
Write clearly
Use capitals for the drug name - This is to be expressed as the
Recommended International Non –Proprietary Name (rINN) unless:
•
•
•
•
•
•
It is a combination product for which no rINN exists.
It is a modified release preparation where brand substitution could
potentially lead to symptomatic change.
Use black ballpoint pen (prescribing in pencil is illegal)
Pharmacists may use a green ballpoint pen on drug cards to ensure
points of clarification or validation are clearly attributable to them. (2/14)
Write figures clearly
If a decimal point is used, ensure it is clearly visible (exaggerate if
necessary), do not use a comma.
Date and Sign
•
Use full signature
•
Specify bleep number if appropriate
•
Print name (in capitals)
•
It is illegal to use a photocopied, doctor’s signature
Page 22 of 108
Patients Details
Details that must be clearly written on the prescription are:
•
Patient’s name (including aliases, or “known by”)
•
Date of birth (age)
•
Ward clinic name, or patient’s address
•
Consultant
•
Patient’s hospital number and/or NHS number (where available,
exceptions may include crisis or home visits for example)
•
Known allergies and sensitivities to medicines
Additional Requirements in Community Practice
Prescriptions issued in Community Practice must indicate a quantity to be
supplied which should be for a period not exceeding 28 days unless:
•
•
•
•
•
Treatment is being stabilized.
The medicine is presented in a pack of more than 28 days and splitting
the pack is unreasonable.
Patients are going on holiday when, exceptionally, up to 3 months
supply can be made to ensure continuity of treatment.
For patients receiving regular medication from community teams, such
as Access team and Assertive Outreach may use a repeat prescription
using the Outpatient prescription form from Lloyds for a period of up to
six months. A record should be made on the Trust approved form when
a new prescription is issued and required.
Patients who are under substance misuse services may receive FP10
MDA/FP10SS prescriptions, which allow repeat dispensing; these must
be used as outlined in the Standard Operating Procedure for
Controlled Drug Prescribing (Drug and Alcohol Business
Division).
Function of the Prescription Chart
•
To direct the administration of the medicine to the patient.
•
To provide a permanent record of the patients treatment with medicines.
•
To indicate the patient’s allergies and sensitivity to medicines.
•
To facilitate the provision of the correct medicine from pharmacy.
•
To assist compliance with the requirements of the Mental Health Act
1983 (amended by the Mental Health Act 2007).
•
For patients currently detained under the Act, a copy of the
relevant consent to treatment form (T1 to T5) must be stored with the
current sheet
A well-written prescription sheet enables the rapid and accurate
interpretation of the medicines required by the patient. All prescriptions
must be clearly written in permanent black ink – this facilitates legible faxing
and/or photocopying. It includes the following information that constitutes a
legal prescription, thus permitting dispensing:
Page 23 of 108
5.2.6
•
No more than one current prescription chart must exist at any one time
for any patient. Where more items need to be prescribed more
regularly than there are spaces on the sheet, then a second chart
may be used, and both must be available when medication is
prescribed, administered or requested from Pharmacy. In such
circumstances, both prescription sheets must indicate the existence of
a second sheet (i.e. 1 of 2 and 2 of 2).
•
When a patient is re-admitted, including for respite care, a new
prescription sheet must be used. The prescription chart of patients
transferred from one Trust unit to another may be transferred and
do not require re-writing.
•
When
patients
are
transferred
from
other
Trusts
with
accompanying prescription charts, these must be re-written within
24 hours (48 hours at weekends and 72 hours at a bank holiday). In
addition to the main prescription sheet there may be other charts
(e.g. injectable fluid regimen, anticoagulants). The main prescription
sheet must make reference to any therapy indicated on separate
special charts and any other officially agreed special chart e.g. warfarin.
Initiation of Treatment
Only suitably authorised independent and supplementary prescribers have
the authority to prescribe medicines for patients under the care of the Trust.
Practitioners must not administer medicines that have not been authorised
by an authorised prescriber. This authorisation must be in writing, in the form
of a signed prescription (for community teams administering medication a
letter of authorization), in advance of the administration of the medicine.
Medical students are not permitted to prescribe medicines within the Trust.
Staff may also administer medication from a Patient Group Directive, Patient
Specific Direction, or agreed emergency medication
5.2.7
Completing the Prescription
•
Date
o To be written as dd/mm/yy.
o This indicates the date the treatment commences which may or may
not coincide with the date of admission.
o This start date must be carried forward to any rewritten prescription
sheets in the future.
o Where dose or frequencies of administration are changed, this is
regarded as a new prescription and must be written with a new start
date.
Page 24 of 108
•
Name and Form of the Medicine
o The approved or generic name of the medicine must be written
clearly in CAPITAL
o LETTERS. Drug names are not to be abbreviated under any
circumstances.
o A medicine may have numerous brand names but only one
approved name. If the medicine is a combination of two or more
medicines (with no approved name) or has unique release
properties or bioavailability, then the brand name will be accepted.
o The form of a medicine must be specified – solid dose will be
assumed unless otherwise stated.
o Non-approved abbreviations of the name of the medicine, e.g.
“CBZ” for Carbamazepine, CPZ for Chlorpromazine, and Li for
Lithium must not be used.
•
With respect to tablet and capsule release characteristics only the
following abbreviations may be used with in the Trust:
o EC – Enteric coated.
o MR – Modified release.
o LA - Long Acting
o SR – Sustained Release
o LAI - Long Acting Injection
Combination products: For oral medications containing more than one
drug, write
the approved name followed by the strength of each component, then the
number of dose units, e.g. Co-amilofruse 5/40 i od.
Dose
The DOSE must be expressed in metric units. Quantities of less than 1 gram
must be written as milligrams. Decimal points should not be used, for
example 500mg not 0.5g so as to avoid confusion. Whenever a decimal point
is necessary, the prescriber and the practitioner administering the drug must
exercise great care. The terms MICROGRAM and NANOGRAM must not be
abbreviated but must be printed in full and used for quantities less than one
milligram.
Liquid
preparations
should
show
the
DOSE
in
milligrams/micrograms OR the strength of the preparation AND the dose in
millilitres.
With regards to the prescribing of insulin this must always be prescribed as
units, and in line with the NPSA alert on insulin it must not be prescribed
using the abbreviations U or IU
Dosage Forms:
Capsule
Syrup
Suspension
Injection
Cap
Syr
Susp
Injection
Page 25 of 108
Suppository
Eye Drops
Eye Ointment
Tablet
Sup
Gutt
Occ
Tab
Only the following abbreviations are acceptable within the Trust:
Mg
Milligram
G
Gram
Kg
Kilogram
L
Litre
Ml
Millilitre
Mmol
Millimole
Microgram and Nanogram must be written in full
Route of an Administration
This must be stated for all prescriptions and only the following abbreviations
are acceptable:
IM
Intramuscular
INH
Inhalation
IV
Intravenous
NEB
Nebulisation
PO
Oral
PR
Per rectum
PV
Per vagina
SC
Subcutaneous
SL
Sublingual
TOP
Topical
PEG
Percutaneous
All other routes of administration must be written out in full.
Dosage Frequency
•
For ‘as required’ (prn)medicines the frequency of administration and
indication for use must be written by the prescriber. A maximum dose
within a 24-hour period must be stated, and this must include any
regularly prescribed doses. Abbreviations such as 4 should not be
used – 4-hourly should be written in full. (For full details staff should
refer to Section 5.3 of this policy).
•
For “regular medicines” the prescribing times should
accordance with regular medicine rounds wherever possible.
•
For antibiotics the prescribing times should be in accordance with
regular medicine rounds wherever possible, and equally spaced to
promote effective treatment.
Page 26 of 108
be
in
•
Depot injections must be prescribed with the time interval expressed
using the term “every” (e.g. every 3 weeks rather than 3-weekly,
which can be misinterpreted. This can be abbreviated as 3/52). The
date that the first depot injection is to be given must also be clearly
stated.
•
Be aware of drugs which are given at weekly intervals. For drugs
given less frequently than once daily (e.g. methotrexate, fentanyl
patches, alendronate), use crosses on the prescription chart to
indicate the days when the drug should not be given.
•
Medicines that are intended to be given once only must be prescribed
in the ‘once only’ section of the prescription sheet.
•
For any medication where the dose varies at different times of the day,
it must be written up as two separate prescriptions.
When stating the dose frequency only the following abbreviations are
acceptable:
Od
Om/mane
On/nocte
Bd
Tds
Qds
Prn
MDU
STAT
AC
PC
Q#h
STAT
Once a day
Each morning
Each night
Twice daily
Three times a day
Four times a day
When required
As directed
At Once
before food
After food
every number of hours e.g. Q4h every 4 hours
At Once
Some other abbreviation which are commonly used
PGD NKDA
Max
eGFR
INR
NICE
NSAID
LMWH
Unit
Patient Group Direction
Not Known Drug Allergies
Maximum
Estimated glomerular filtration rate
International Normalise ratio
National Institute of Clinical Excellence
Non-Steroidal anti-inflammatory drug
Low Molecular weight Heparin
in full
Prescribing
Signature
Each prescription item must be validated by the full signature of a registered
Page 27 of 108
medical practitioner or authorised Prescriber. The signature must be
legible or the printed name of the Prescriber must be written next to the
signature.
Doctors’ initials or abbreviated signatures are not considered an adequate
means of identification or authorisation. See Policy for Clinical Record
Keeping Standards and Clinical Records Management.
Letters of Instruction/Prescriptions for Community Nursing staff to
administer against:
Community Nursing staff may receive requests to administer medication to
patients in their own home, such as antibiotics, insulin and enteral
medication.
These must include:
•
•
•
•
•
•
•
•
•
Patient Details, including NHS number
Allergy and Sensitivity status
Drug and form
Dose and rate
Frequency
Flush/Lock if appropriate
Route
Diluent as appropriate
Duration
These forms will normally be sent to community nursing services via the
single point of access.
Changing the Dose, Frequency or Route
If changing a dose (e.g. 20mg to 10mg) the whole section must be crossed
out and rewritten.
If changing the route (e.g. IV to oral) the whole section must be crossed
out and rewritten.
If increasing the frequency of doses, the new time is to be stated on the
chart and a line drawn to show when the increase is to start.
Length of Treatment
•
Any prescription (excluding controlled drugs) is valid for a maximum
period of six months. A prescription for controlled drugs is only valid for
28 days.
•
Antibiotics are issued for a maximum of 7 days unless the prescriber
indicates a specific duration of treatment.
Cancellation of Treatment
Page 28 of 108
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 cancellation must be dated and signed in full and all detail must remain
legible.
When stopping medication, the chart must be annotated clearly with a
vertical line on the day of stopping and a line through the section with the
drug name.
The drug name and all prescribing details must remain legible, as the chart
is a legal record.
Sign and date the ‘stop’ box on the chart.
When the ‘Stop Date’ box is used in anticipation of the treatment
cancellation date, this indicates that at 12.00 midnight on the date specified
the prescription must be discontinued and no further doses are to be
administered.
Cancellation of areas of the medicine administration record by the Prescriber,
or by a designated practitioner or pharmacist, is another permitted method
of indicating when the medicine should be administered and when it should
be omitted.
E.g. XXXX_XXXX_XXXX
Amendments to prescriptions are NOT permitted. Changes to doses or
frequency require cancellation of the old dose and a new entry written for the
new dose.
Range of Medicines Which Can Be Prescribed
Prescribing should be within the relevant district formulary:
http://www.rdash.nhs.uk/about-us/public-declarations/medicines-formulary/
Any newly introduced psychotropic medicines onto the market may only
be prescribed in the Trust after submission for consideration and approval by
the Medicines Management Committee.
Any medicines provisionally
approved will be
subject to a probationary period, after which time final approval will be
considered.
In exceptional circumstances, if an urgent request for a new
medication is thought to be necessary, then a request can be
made to the Chair of the Medicines Management Committee for
approval.
Wherever possible, Trust doctors must not prescribe or recommend
medicines that are not approved for use by General Practitioners.
Administering medication from a remote prescription/direction to administer
The prescribing of medicines in this way should not be routine.
Page 29 of 108
However, the Nursing and Midwifery Council (2008) requires a hard copy of
the request prior to administration, for inpatient units staff should follow the
guidance on sending the request by email using the NHS mail facility. A copy
of this email should be attached to the patient’s drug card, and the
prescription signed the next working day.
A Pharmacist may receive a verbal order from a doctor to alter a prescription
item (Medicines and Ethic Guide 2008). This only relates to Pharmacists
and no other member of pharmacy staff can take a verbal order to alter a
prescription.
All alterations must be written clearly and signed by the pharmacist. The
pharmacist must read the alteration or addition back to the doctor who must
then confirm it.
The doctor must sign any new prescription within 24 hours (or the next
working day in the case of weekends and bank holidays).
For a patient prescribed medication on a prescription and administration
chart:
•
The alterations and additions will be made in black ink
•
A pharmacy advise not will be attached to the chart requesting the
prescription to be signed by the doctor within 24 hours
•
If the pharmacist is on a ward or outside unit or in any situation where
the medical notes are available they must make a clear entry in
indelible ink in the patient’s medical notes stating the circumstances
leading to the alteration.
•
If the prescription is on an outpatient prescription form the pharmacist
will annotate the prescription clearly and leave out for signing by the
doctor
•
Prescriptions for controlled drugs cannot be altered or ordered in
this way.
This procedure is to enable the clarification of prescriptions during
normal working hours and not for emergency prescribing of rapid
tranquilisation in crisis situations.
Community Nursing Staff (Doncaster)
Where the original prescription is not available the nursing staff can accept
instruction containing the same information as above from the following
sources:•
•
A faxed copy of the original signed prescription
A signed referral form letter or authority to administer form.
Page 30 of 108
•
•
•
•
•
•
•
5.2.8
An email from the prescriber using the NHS number as the patient
identifiable data. (not acceptable for controlled medication).
An entry made by the prescriber on an electronic record system
requiring a smart card or unique username and password which the
nurse can access directly, for example TPP system (not acceptable for
controlled medication).
Entry on to the RDASH Drug sheet written by the prescriber (not
acceptable for
controlled medication)
If this identified minimum information is not present, the prescriber must
be
contacted and requested to prescribe.
If the authority is incomplete*, ambiguous or illegible to read the
instructions, the healthcare professional should not continue to
administer medication until the details have been checked with the
prescriber or a new authority issued.
Transcribing instructions to administer (Hawthorne and Hazel Ward and
Heatherwood School Deaf School) (see SOP for details).
The initial drug chart on admission to these specified services may be
transcribed by a registered nurse from either the discharge paperwork
accompanying the patient (i.e. discharge summary if coming from hospital) or
GP letter if admitting from community).
•
•
•
This transcription must be checked and initialed by another
registered nurse, where only one registered nurse is present
the guardian or parent can be used as the second check.
The transcribed details are NOT a prescription and so cannot be
used for further medicines supply, administration from stock
medicines or for discharge unless countersigned by an appropriate
prescriber.
In schools this should be carried out at the beginning of each term,
this should be checked weekly for any changes.
See 5.2.5 and 5.2.7 for the minimum data set to be transcribed specially
designed drug charts are in place in these services.
5.2.9
How the organization is assured that medication charts are accurate
As part of the medicines management service, the Pharmacy Team will
monitor inpatient prescription cards in line with the 10 point plan, see section
7 Monitoring and Appendix 5, an additional 5 point Antibiotic plan will look at
prescribing of antibiotics, in line with Antibiotic Stewardship. and areas not
covered will be expected to follow these principles.
5.3.
As required medication/pro re anta (prn)
The Purpose of when required medication is to treat conditions or situations
that do not require regular medication.
Page 31 of 108
Before writing up any PRN medication consider the likely need for it and
whether there is a better method available, such as the use of a PGD for
homely remedies or the use of the once only section of the drug card.
Ensure that prescribing and use is in line with Trust guidance and policies
Always remember the law of unintended consequences, when writing this
form of medication, so they must be clear and unambiguous
Consideration of the ability of consent and capacity should be made, in line
with trust guidance.
Where covert medication has been agreed and MCA 1 & “the guidance on
covert PRN medication should be included. If a patient is being administered
medication under the mental health act then an MCA 1 is not required.
Common mistakes include:
•
Unintended overdoes
•
Being used for the wrong indication
•
The use of preventative inhalers
•
Creams or antifungal liquids e.g. nystatin or acyclovir for cold sores.
5.3.1
Prescription
A clear need must be identified for the need for PRN medication, rather than
it might be needed. This should be carried out MDT. If it is out of hours and
normal team medic is unavailable than consideration of the once only section
of the drug card should be strongly considered.
An unambiguous indication must be stated e.g. for pain, for rapid
tranquilisation, if refuses regular oral medication.
Clear dosage instructions must be stated
•
What dosage e.g. 1mg, one puff.
•
Suggested maximum frequency based on clinical need, ideally in hours
e.g. maximum every 4 hours.
•
Maximum total dose per 24 hours.
•
If a dosage range is written it must be clear when to use different
doses.
If you need to prescribe the same drug by two different routes, this must be
written as two separate prescriptions.
If you only wish it to be used a certain number of times before active review
consider crossing out any additional slots on administration record. It must
be reviewed at least every seven days.
Take into account any regular medication the patient is taking, this should
also be indicated in the total maximum 24hourly dosage where appropriate,
Page 32 of 108
guidance should be given if PRN medication may be given just before a
regular dose of the medication e.g. Lorazepam.
Where there is a T2/T3/Sn 62 in place this must reflect PRN medication as
well.
If the use of medication is going to take the total dose of that medication or
class of medication above BNF limits, then this must only be written after
discussion with the patient’s Consultant or their deputy and this must be
clearly documented within the patient’s records. If the high- dose medication
involves anti-psychotics the High-dose antipsychotics protocol must be
implemented and this must be clearly recorded.
A clear treatment plan should be included in the patient’s medical record,
including a maximum period before review. This should include what
alternatives should be considered prior to the decision to administer, in order
to deliver person centred care, including unintended consequences, such as
increased falls risk.
5.3.2
Administration
The use of PRN medication must be care planned
Consider is the use of medication the most appropriate way of dealing with
the issue, e.g. for agitation has talking or distraction been considered.
1.
2.
3.
Is the prescription clear and unambiguous?
What regular medication has the patient already received?
When was the PRN last given, how much have they already been given
in the last 24 hours
Explain the purpose and likely effects of the medication to the patient, and to
report any problems to the nurse. Due consideration should be taken of
capacity issues, where patients are unable to understand the nature of the
PRN medications.
After signing to say it has been administered document in the patients care
record a brief entry on why it was given and with what effect. The use of
PRN should be handed over between shifts. The reason for administration
must be consistent with the prescriber’s defined indication.
5.3.3
Review
PRN medication must be reviewed at a maximum of seven days in acute
settings, and at patient reviews for non-acute settings allowing for bank
holidays etc., by the patient’s team.
Consideration should be given as to whether it is any longer required, should
it be given regularly, or is PRN still appropriate. It is suggested in the
absence of good clinical reasons if a medication has not been used within
seven days it should be discontinued.
Page 33 of 108
If it was written up out of hours then it should be reviewed by the regular team
as soon as is practicable.
If the patient moves wards, e.g. from an open ward to a secure ward, because
of significant change in the patients presentation then the PRN medication
must be reviewed by the team, to assess if it is still required and if the
suggested times/doses are still appropriate.
5.3.4
Leave/Discharge
When a patient is going on leave the PRN medication should be reviewed, if it
is felt to be needed still then the TTO should reflect how many doses the team
would like the pharmacy to issue. In most cases PRN medication will no
longer be required, and the inpatient card amended accordingly.
A clear description to the patient should be given on how to use it.
Where appropriate instructions for carers or relatives should be provided,
ideally in a written format.
Guidance should be included in the discharge letter on how it should be
reviewed, and by whom.
5.4
Take Home Medication (TTO) or Discharge Drugs (inpatient wards only)
Prescribers are responsible for ensuring that any TTO prescriptions are
written and the Nurse in Charge of the ward is responsible for these being
received in pharmacy in sufficient time for the medicines to be dispensed and
returned to the ward.
Ideally, this should be 24 hours prior to any period of leave or the
discharge of a patient, so that the medication will be available when the
patient is ready to leave.
These prescriptions can be authorised in one of
three ways:
•
An instruction, written in ink, signed and dated by a Prescriber, on a
Trust prescription form.
•
A computerised prescription held on a Trust approved computerised
prescribing system, entered by a Prescriber and validated by password
controlled electronic signature.
•
A Patient Group Direction, approved by the Trust.
•
The prescriber should prescribe every medication that the patient
is taking on a regular basis (including prn medication)
•
For a patient going on leave the prescription should clearly state
the number of days required, and when leave is expected to start
Page 34 of 108
•
•
For patients who are being discharged they will usually receive a 28day supply of medication from pharmacy. This should allow sufficient
time for the discharge letter to reach the General Practitioner (GP). If
for clinical reasons fewer days are supplied, e.g. risk of overdose the
GP must be informed
A Patient Information Leaflet must be supplied with each medicine.
NB: Registered nurses MUST NOT dispense drugs for patients to
take home.
All TTOs coming into a ward or department shall be received by a
Designated Practitioner, or authorised person who must:
•
Check them against the medicine card or leave card or TTO form to
confirm that all details are correct i.e. name, medicine, dose and
directions
•
Lock them in the medicines cupboard immediately
•
Report any discrepancies to the supplying pharmacy immediately
It is extremely important that the patient receives
information about their medicines prior to discharge.
adequate
The patient should know the purpose of the medicine; how to take it, how
long it is to be taken for, and what side effects they may experience. This is
the responsibility of the Designated Practitioner, who may choose to
involve Authorised Pharmacy Staff in this process. It is the responsibility of
the Designated Practitioner who discharges the patient from the hospital to
confirm with the patient that they have received adequate information. Any
information communicated verbally must be backed up and supported by
an appropriate leaflet.
Controlled Drugs to Take Out
Controlled drugs should be ordered in the same way as TTOs and must
conform to the legal requirements and be written in full, which has been
personally complete by a medical practitioner in accordance with legal
requirements. Controlled drugs prescriptions must be written in the Doctor’s
handwriting stating:
•
Patient’s name, address and unit number
•
The drug name (controlled Drug band name where appropriate), does
and directions
•
The form (tablets, liquid)
•
The total quantity to be dispensed in words and figures
Page 35 of 108
•
Signed and dated by the Prescriber
The original prescription must be sent to pharmacy for dispensing along with
the drug chart.
Procedure for the delivery and receipt of controlled drugs for TTO purposes
is detailed in Section 5.10.4.
5.5
Outpatient Prescriptions
GPs should usually be asked to prescribe all medication for outpatients.
Outpatient prescriptions should be limited to urgent items, hospital only items
or to initiate a new treatment that needs closer monitoring, and for patients
under certain teams in order to improve concordance, such as Assertive
Outreach or Early Intervention Services, or patients seen in their own homes
by prescribers.
5.6
FP10 FP10 NC FP10SS and MDA
Prescribers seeing patients in the community have access to a supply of
FP10’s. are written by prescribers employed by the Trust but dispensed by
community rather than hospital pharmacies.
Controlled stationery in relation to prescribing includes blank FP10NC
FP10MDA and FP10SS prescriptions, prescription stamps, and prescription
order forms.
Ordering of blank prescriptions can only be undertaken by authorised
personnel, and must be ordered from the appropriate, for the area, supplier.
•
•
•
•
•
•
•
•
•
•
5.6.1
They are classed as controlled stationary.
Must be signed for when ordered by administrative staff.
Prescription numbers must be recorded.
Locked away securely
A record of receipt must be maintained
When issued to individual prescribers they must be signed for and a
record kept including the prescription number.
Prescribers should keep them in a manner so that they are secure
when not in use
In substance misuse services where prescription printing software is in
use, access to these systems must be secure.
Where prescriptions are spoilt, they must be marked void, before being
securely shredded, and a record made.
Prescriptions issued to prescribers must be signed for and a record
kept, it is the responsibility of the prescriber for their safe keeping
Issuing FP10 Prescriptions
Prescriptions once generated may be issued in one of the following ways:
•
Directly to the patient/Representative
Page 36 of 108
•
•
•
Recorded delivery to the patients address
By staff to the pharmacy
Collection by the pharmacy staff
In all situations staff must be satisfied of the authorization of any carrier,
identification must be sought. A record of all prescriptions issued must be
maintained in the patient record.
5.6.2
Lost Prescription Pads
In the event of a lost or stolen prescription all prescribers should
•
Inform their Line Manager the same day
•
Complete an incident form
•
Inform the Chief Pharmacist or Medical Director who will alert all
pharmacies and liaise with the police and the Prescribing Pricing
Authority providing as much information about serial numbers as
possible.
•
The prescriber will be advised to write all prescriptions in red ink for the
next 2 months
If the loss occurs out of hours contact the Out of Hours on call Director and
implement the following procedure.
•
Notify the police
•
Email all pharmacies to alert them – Go into email – all groupsPharmacists safety alerts – Type in details – send
•
Staff would then follow the in hours process on the first routine working
day.
This should be done by the manager to whom this has been reported
to.
5.6.3
Standard Operating Procedure for FP10’s
All areas should have a specific standard operating procedure for managing
these prescriptions, which will contain the details on how these standards will
be carried out. They can be found in the policies section of the web.
5.7
Use of Patient’s Own Medicines
The Trust has a duty of care to ensure that any patients own medicines used
while they are under the inpatient care of the Trust are both safe and fit for
purpose. It acknowledges that medicines brought in are the patient’s
property and staff required the permission of the patient to dispose of their
medicines.
Medicines brought into hospital by a patient can be administered to them
during their stay until new supplies can be obtained from pharmacy, or if they
are assessed by pharmacy as being suitable for use in that:
•
The medicine can be easily identified from the backing on the strip pack
Page 37 of 108
or markings on the tablet/capsule
•
•
The Medicine has not expired and appears to be in a good condition
The medicine is prescribed by an authorized prescriber and is on the
inpatient medicine card
•
The patient does not object to their own supply being used
PATIENT’S OWN MEDICATION IS NOT TO BE USED IF:
•
There are any doubts about the identify or quality of the medicines
•
The patient objects
NB: MEDICINES BROUGHT INTO HOSPITAL BY ONE PATIENT MUST
NEVER BE USED FOR ANY OTHER PATIENT
5.8
5.9
Prescribing Homeopathic/Herbal Remedies
•
Homeopathic and herbal medicines are subject to the licensing
Provisions of the ‘Medicines Act 1968’ although those on the market
when the Act became operative (which means most of those now
available), received Product Licenses without any evaluation of their
efficacy, safety or quality
•
There are some patients who will be on homeopathic and/or herbal
medicines and will wish to continue receiving these whilst on the
inpatient wards
•
Such a request should be discussed with the Responsible Prescriber
who must consider the appropriateness of the therapy to both the
condition of the patient and co-existing treatments
•
If it is agreed that any homeopathic and herbal medicines can continue
then these will be listed on the prescription card
•
In the event that the patient is requesting homeopathic or herbal
remedies that they have not already been taking prior to admission the
Authorised Prescriber must discuss the request with the patient and
only list it on the prescription card if they feel they are competent to do
so
Above BNF Maximum Prescribing Limits (combined maximum)
•
All prescriptions for psychotropic medications (including combinations)
should usually be within BNF limits, apart from cross titrations
•
Any prescribing antipsychotics above BNF maximum MUST BE
discussed in the multi-disciplinary team meeting (ideally two
professionals involved in the patients care. The decision to prescribe
Page 38 of 108
must be done by a consultant.
•
The rationale for the decision to prescribe above BNF maximum limits
and the monitoring requirements must be documented in the patient’s
records using the relevant form.
•
Patients on high dose antipsychotics must be readily identifiable to the
team.
Prescribing above the BNF maximum limits is an unlicensed form of
prescribing and it is therefore the Consultant’s responsibility to ensure GMC
and specialist colleges guidance is followed and treatment plan well
documented (see appendix 4).
5.10
5.11
Prescriptions for Hospital Staff and Their Families
•
Medical staff and non-medical prescribers should not prescribe for
themselves or their family in line with current General Medical Council
(GMC) recommendations
•
FP10 (HP) prescription forms should NEVER be used by medical staff
or non-medical prescribers to prescribe for themselves or their families.
These are only for use by registered outpatients to take to outside
pharmacies when the hospital pharmacy is closed
Staff Self-Administration of Medicines
•
•
•
5.12
On no account must any member of staff take for themselves or give to
another person medicines that has not been prescribed for them
Hospital medicine supplies are for the use of Trust patients only in
response to a prescription from a doctor or other authorized prescriber
Staff who require treatment for minor ailments must be referred to the
Occupational Health Department or purchase medicines from a local
pharmacy.
Patient Group Direction
•
Whilst it is necessary that all medicines administered by a practitioner
are given on the authority of an authorized Prescriber, in some area
certain medicines can be initiated by practitioners in accordance with a
Patient Group Direction (PGD)
•
This is specific and detailed written direction for the administration or
supply of named medicines, (including those classified as prescriptiononly), by named designated practitioners in a specific clinical situation.
PGDs will be drawn up within the Trust by doctors, pharmacists and
other healthcare professionals, and approved by the Medicines
Management Committee. It applies to groups of patients or other
patients who may not be individually identified before presentation for
treatment (Crown Report 1998)
Page 39 of 108
•
o
The condition or situation to which the protocol applies
o
Characteristics of the staff authorized to take responsibility for the
supply or administration of medicines under the PGD
o
A description of the treatment available under the PGD
o
The Management and monitoring of the PGD
•
It is the responsibility of the senior Registered Nurse of each ward,
department or are to ensure that if medicines are administered without
a written prescription then a valid and current PGD is available to guide
practitioners in their area and that the person administering the
medicine has received training and is competent in working within a
PGD. A list of all practitioners signed off for each PGD must be sent to
pharmacy, to be kept with the original document.
•
Copies of approved PGD’s must be available in each area and must
reflect accurately practice in that area
•
A PGD cannot be introduced without authorization from Clinical Quality
Group. Staff should refer to the Medicines management section of the
clinical polices on the Trust intranet for details of existing PGDs.
Approved PGDs will be signed by the Chief Pharmacist, Medical
Director and Chair of the Clinical Quality Group.
•
•
5.13
The contents of every Patient Group Direction must comply with that outlined
by the Department of Health (March 1999) review of prescribing, supply and
administration of medicines and HSC 2000/026 Patient Group Directions,
giving details of which is incorporated in to The Human Medicines Regulations
2012, Further guidance is included in NICE guidance MPG2
All original PGDs will be stored by the Pharmacy Department, along
with a copy of the list of those authorised to use them.
Ordering Medication from Pharmacy
This guidance relates to medication being ordered by staff on inpatient units,
and for community teams.
Where community nursing staff are administering medication in patients own
homes or in special schools medication will normally be provided by:
•
•
•
•
Requesting Hospital Team (e.g. IV antibiotics)
The patients GP via FP10
Non-medical prescriber prescription
Dressings will be supplied by the community nursing services
In community homes the medication will be supplied by the GP via an FP10
and a local pharmacy
Page 40 of 108
5.13.1
Ordering Stock Medicines
Stock medicines are medicines, which are commonly prescribed for patients
on the ward/Community bases or items required in the event of an
emergency. Ward/Community team stocks are retained on the ward/unit
regardless of whether they are currently prescribed for any patient.
•
A list of common medicines (including those legally classified as
controlled drugs) dressings and reagents, along with the appropriate
quantity to be stocked on the ward or department will be decided jointly
by the Management Team or clinical lead.
•
The stock list should be subject to regular 6 monthly reviews at ward or
department level. The responsible person will ensure procedures are in
place to ensure all staff involved in their use is familiar with the range of
stock kept on the ward or department
•
For area that receives a pharmacy-based top-up service, Pharmacy
Services are responsible for the ordering of medicines to maintain stock
levels.
•
For those areas that receive a self-listed top-up service, the individual in
charge at the time is responsible for the regular completion of top-up
ordering of stock medicines from the Pharmaceutical Provider
•
At all other times and under all other circumstances the individual in
charge of an area is responsible for the ordering of stock to maintain
adequate levels through contact with the local Pharmaceutical Provider.
When an item is considered to be required urgently it the responsibility
of the individual in charge to communicate this to the local
Pharmaceutical Provider.
Stock medicines may be ordered by:
•
•
•
•
•
5.13.2
Supplying a written requisition from the appropriate order book or an
order sheet signed by a Responsible person or Designated Practitioner
Only one book should be in use at any one time
Using a fax machine to send a copy of the above
By means of the pharmacy top-up service.
Urgent orders can be accessed from Lloyds by writing them up as
patient own prescription and sending to the local pharmacy, ward staff
will need to organize their own transport.
Ordering Named Patient Medicines
•
Individual patient supplies are those medicines dispensed and labeled
for a particular patient. Once the patient is discharged from the
ward/unit the medicines must be returned to the pharmacy. Individual
patient medicines are also known as ‘named patient medicines’
Page 41 of 108
•
Individually named patient medicines are supplied for the sole use of
the patient whose name appears on the label, and are not to be
dispensed to any other patient
•
Clozapine is always supplied as an individual patient item as all patients
who receive this medication are registered on a database and have
regular blood tests to monitor them for the development of
agranulocytosis. Clozapine must never be administered to a patient
whose name does not appear on the label
•
Medicines for named patients may be ordered by:
o Submitting the patient’s prescription sheet to the Pharmacist
providing clinical services to the ward or department.
o Using a fax machine to send a copy of the prescription sheet
o By means of the pharmacy top up service
o By using the electronic prescribing system (where available)
o Carriage of a requisition to the local dispensary
o In the case of Controlled Drugs through carriage of a completed
Controlled Drug Requisition Book to the local pharmacy.
Community Practice
Responsibility for the ordering of medication remains with the patient, except
for medications supplied via the Trust such as long acting injections or
Clozapine. However, good practice would indicate that where a member of
staff is responsible for administering the medication they ensure the service
is aware of potential stock shortages.
In certain circumstances registered community staff may collect a patient’s
medication from their pharmacy (e.g. a housebound patient with no carer
support). Under those circumstances the registered staff will go directly from
the dispensing pharmacy to the patient. Where patients own medication is to
be kept at the team base, and issued on an intermittent basis a record must
be made of medication is ordered, and issued, it is the responsibility of the
team manager to check the medication against what was ordered, then
record what has been issued, ideally getting the patient to sign for
medication on receipt, the team should have a system to record what has
been issued and when a new prescription is required. This should be
recorded on the Trust approved documentation.
5.13.3
Receipt of Stock and Named Patients Medication
All medicines must be checked against the request and delivery notes which
must be retained for a period of 2 years. Any discrepancies between the
requested and received amount of medicines must be reported to the
pharmacy department immediately.
Community Practice
Community base points should not routinely be holding non-stock items. See
Page 42 of 108
above for more detail.
Community based clinics may hold patient’s dispensed stock for use in that
clinic. These items must be clearly marked for the individual patients use.
5.13.4
Faxing of Prescriptions to Pharmacy
In line with locality arrangements prescriptions may be faxed to pharmacies
supplying under Service Level agreement
Caldicott Guidelines for sending faxes
1.
2.
3.
4.
5.13.5
Use a safe haven fax
Double check the number before sending
Tell the recipient to wait by the fax
Ask them to phone you when it has arrived
Ordering Controlled Drugs
Controlled drugs are defined by the Misuse of Drugs Act 1971 and regulated
by the Misuse of Drugs Regulations 2001 (with associated amendments).
Due to the nature of these drugs legislation dictates how they are to be
prescribed, ordered and stored and all Trust guidance on controlled drugs is
written in line with this legislation.
It covers schedule 1 and 2 controlled drugs, and within the Trust
Temazepam and Tramadol are to be treated as a schedule 2 Controlled
Drug.
In addition the following shall also be considered as Controlled Drugs for the
purpose of administration:
•
•
Schedule 3 controlled drugs such as Barbiturate.
Strong Potassium Chloride Solution BP 15%
Therefore each of these is subject to Trust regulations regarding ordering,
storage, administration, destruction and recording of controlled drugs.
For full guidance staff should refer to the Trust Controlled Drugs Procedure,
but the general principles are as follows:
•
The responsibility for ordering, receipt and storage of Controlled Drugs
is that of the Assigned Practitioner in Charge of the ward/department
•
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 signature
Page 43 of 108
•
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
container
o Where appropriate a porter or messenger may deliver Controlled
Drugs in a temper evident package. The porter or messenger
must sign the Controlled Drugs Requisition Book to accept
responsibility for carriage of the drugs. The Designated
Practitioner must receive the package and sign the Controlled
Drugs Requisition Book to accept delivery after checking the
contents of the package.
•
The Designated Practitioner will check the contents of the container in
the presence of another designated practitioner, authorised member of
the pharmacy staff or an authorised employee. These two staff will
check the:
o Quantity of the medication
o Strength of the medication
o Expiry date of the medication
NB: IF THE BOX CONTAINING THE CONTROLLED DRUGS HAS THE
MANUFACTURER’S SEAL INTACT THERE IS NO NEED TO OPEN THE
BOX
•
Once this check has been completed the Designated Practitioner will
enter the new stock into the controlled drugs register on the appropriate
page. This entry will be witnessed by the second member of staff with
them both signing the ‘ordered by’ and ‘received by’ section of the book.
•
In the community services any patients new supplies of controlled
drugs, which are to be administered by Trust staff at some time in the
future should be signed, as stock, into the patient’s clinical record. This
will be done by the first registered member of staff who is aware of the
new stock. (e.g. diamorphine prescribed during the week in readiness
for a week-end administration will be signed in by the staff mid-week
when in arrives.)
•
•
All records must be in permanent black in and retained for two years
Controlled drugs must be stored in a locked, specified CD cupboard,
which has been approved by a pharmacist and is reserved solely for the
storage of controlled drugs
•
Access must be limited to Designated Practitioners and authorised
members of pharmacy staff
•
Ward controlled drug cupboards to be inspected at a minimum of
biannual intervals by an authorised member of pharmacy staff
•
The order book and register are controlled stationery and as such
MUST be kept under lock and key when not in use
Page 44 of 108
•
o
Any discrepancy between the order and delivery quantity MUST be
reported
To the supplying pharmacy immediately
•
Stocks of controlled drugs within wards and departments must be
checked and signed for at least once a week, unless in active use, in
which case they are to be checked daily.
•
In the community services good practice will be to record and sign the
stock level at each administration and have it countersigned by a staff
member or another person – who may be a family member.
•
Any discrepancies must be reported to the line manager and an IR1
completed.
•
The line manager will investigate the discrepancy and if the matter
cannot be resolved the relevant pharmacy department is to be
informed.
•
Where an incident is due to suspected theft or burglary by a person
external to the Trust, the police must be informed.
•
TTO or discharge medication which contains controlled drugs is not to
be recorded as ward stock
•
Any controlled drugs brought in by patients must be recorded in the
back of the controlled drugs book, and signed out when they are either
taken back to the pharmacy or returned to the patient. This must also
be documented in the patients records
•
Should any ward or department be closed on either a temporary or
permanent basis all controlled drugs must be returned to pharmacy
Security of Controlled Stationery
The Responsible Person will ensure that all Controlled Stationery on the
ward, department or base point is held securely.
Any loss or theft of any item of Controlled Stationery will be reported to the
Responsible Person for the ward or department and their Line Manager, and
to the Trust Chief Pharmacist at the earliest opportunity. An Incident form
must be completed.
5.14
Transfer of Medicines between Ward Areas
Medicines must not be transferred from a ward or department within normal
pharmacy opening hours.
However, it is recognized that there are occasions when medication for
individual patients may not be available in clinical area stocks. This may be
Page 45 of 108
for a number of reasons including:
•
•
Urgent out of hours admissions who are prescribed non stock
medication
Changes in medications due to changes in mental/physical health
status
If the medication is urgently required the following process must be
followed:
1.
The nurse in charge of the clinical area will contact other clinical areas
(on site) to check if they have any available stock of medication
required
2.
When it is ascertained that stock is available elsewhere, a member of
staff should take the completed/signed prescription chart to the ward
where the medication is to be borrowed from
3.
The nurse in charge of the area should, prior to giving any medication
to the member of staff:
•
Check the prescription sheet for dosage, medication, route,
frequency
•
Check the patient’s name on the prescription sheet
•
Record on the ward 24-hour report the type, dose and quantity of
medications given to another area
•
Record on the ward 24-hour report the name of the member of
staff collecting the medication
•
The transfer of medication book should be completed
NB: Only stock medicines may be borrowed and the complete
container must be transferred to the receiving ward.
4.
Controlled drugs must not be borrowed except in an extreme
emergency.

Only one dose at a time can be issued and this must be issued
directly to the patient on the receiving ward. In these
circumstances the following process must be followed:
•
A nurse from the patient’s ward must visit the issuing ward with
the patients prescription chart
•
A record must be made in the Controlled Drugs register of the
issuing ward ensuring the Controlled Drug is booked out directly to
the patient in the receiving ward
•
A nurse from the issuing ward must accompany the patient to
Page 46 of 108
witness the administration of medication
5.15
Out of Hours Pharmacy Services
•
Outside of normal hours staff should consider
1.
2.
Local RDaSH wards/teams for non CD stock transfer first then
Refer to contact sheet for relevant local pharmacy supplier hours and
order via TTO paperwork and processes. No delivery service is
available so requested medicines will need to be collected.
URGENT request up to 11pm can be handled by the local pharmacy
provider
URGENT request after 11pm will handled through Lloyds wholesaler
(AAH) – see contact sheet for details. This attracts a £300 callout fee.
•
•
5.16
Delivery of Non Controlled Medicines
All medicines will be delivered to wards/departments in a secure container.
Where appropriate, a porter or courier may deliver medicines in a tamper
evident package or locked box.
A Designated Practitioner/Responsible person must receive the package or
box and will:
•
Check the medicines against the delivery note/order book
•
Sign the note and keep it (for 2 years) as a record that the supply was
complete
•
Lock the medicines in the medicine cupboards immediately
•
Report any discrepancies to the supplying pharmacy immediately
5.17
Storage of Medicines
5.17.1
Containers for Storage of Medicines
Pharmacy does not re-use plastic or glass bottles. When empty, plastic
bottles may be disposed of in the normal rubbish bags. Oral, non-toxic liquids
may be returned to pharmacy. Empty glass bottles may be disposed of in the
usual way. Child- resistant containers (CRCs) are used routinely on
discharge items. If a member of the ward staff feels that CRC’s would be
difficult for the patient to open they should contact the supplying pharmacy to
discuss suitable alternatives.
5.17.2
Storage of Medicines on Wards/Departments
•
The Appointed Practitioner/Team Manager in Charge is responsible at
all times for the safekeeping of all medicines on their ward or
department
Page 47 of 108
•
The design and location of all ward or department medicine storage
cupboards must be approved by Authorised Pharmacy Staff and
regularly monitored
•
All internal and external medicines, disinfectants and re-agents must be
stored in locked cupboards, trolleys attached to a wall or other secure
cabinets – all reserved solely for medicinal products. The only
exceptions to this requirement are medicines for clinical emergencies,
intravenous fluids, flammable Fluids, Medical Gasses, sterile topical
fluids, nutritional products and some bulky medicated dressings which,
because of their bulk, are stored in a clean area (as agreed between
the Appointed Practitioner in Charge and an authorized member of the
Pharmacy Staff)
•
The medicines trolley may only be removed from its fixings during
medicine rounds
•
•
The nurse in charge of the medicines round must never leave the drugs
trolley unattended at any time. The nurse must not be disturbed during
the medicine rounds unless there is a dire emergency. In such an
emergency the trolley must be locked
Internal medicines must be stored separately from other medicines.
Under no circumstances must medicines be transferred from one
container to another, nor must they be taken out of their container and
left loose
•
All medicines in transit must be in a sealed tamper evident container
•
Controlled drugs must be stored in a separate designated Controlled
Drugs Cupboard
•
Where cold storage of medicines is necessary a lockable, temperature
controlled/monitored medicines fridge must be made available, which
must be reserved solely for the purpose.
Where the ward or department holds a supply of medicines for use in a
medical emergency this will be held in a tamper evident container. This
container need not be kept in a locked cupboard, but will be located in an
area that is most likely to have a constant staff presence that is not obvious to
the general public.
On some ward areas (and subject to risk assessment) to enable timely
treatment the following medicines can be exempted from locked storage
•
•
•
GTN tablets and Spray for the treatment of angina pain*
Inhalers of β adreno-receptor agonist as bronchodilators*
Nicotine Replacement Therapy supplied under a PGD*
*Subject to a risk assessment an individual authorised to administer
medicines may assess a patient on an inpatient area as suitable to have
control of and take these medicine themselves provided the following
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conditions are met:
•
•
•
•
5.17.2.1
5.17.3
The patient understands what their medicines are for and the how to
take them correctly.
Suitable safe keeping arrangements are available to prevent misuse by
others
The medicines are labeled with the patients name and instructions for
use.
A record of the dose and frequency of administration is made on the inpatient drug administration chart.
Medicines storage room ambient temperature monitoring
•
Unless stated otherwise in product literature and labels the majority of
medicinal products, that do not require refrigeration, can be stored under
conditions of controlled room temperature without compromise to their
stability and recommended shelf life. These products are usually
labelled ‘do not store above 25°C’
•
A maximum minimum thermometer should be placed in all rooms where
medicines are stored and the temperature of the room monitored on a
daily basis (preferably at the same time each day, and what is
considered to be the hottest time of the day) to ensure that medicines
stored in the room are stored within the recommended limit.
•
The room temperature should be recorded on ‘Daily Room Temperature
Monitoring Form’.
•
If the temperature reaches above 26°C, contact pharmacy services for
medicines advice with regards to opened liquids. At this temperature
and for a short duration tablets, powders and capsules should be stable.
•
Contact the Estates office to request 24 hour monitoring by calibrated
thermometer, to detect whether this is a short or long term situation.
•
Request a visit from the pharmacy team to review the options available
to mitigate against this problem if this is likely to be a long term problem.
•
Complete an incident form with regards to the temperature of the area,
and the medicines affected.
Drugs Fridges
•
•
•
Medicines that require refrigeration should be stored in an
approved medicines fridge, which must be used solely for the storage of
medicines requiring refrigeration
The fridge must be connected to the electricity supply in such a manner
that does not allow accidental disconnection, e.g. attached by a spur to
the mains electricity supply
Medicines must never be stored in the kitchen fridge
Page 49 of 108
•
•
5.17.4
The medicines fridge temperature must be checked daily and recorded
on the Trust’s fridge temperature monitoring form. The temperature
should be within 2C – 8C
Pharmacy or Estates must be contacted if there is a problem (area
specific)
Siting of Cupboards or Trolleys
Cupboards and trolleys must be sited where most convenient for staff, whilst
also allowing adequate space and permitting surveillance to afford maximum
security against unauthorized entry. Medicine cupboards will generally be
sited where they may be subjected to higher than average humidity or
temperature. Re-agent cabinets, were used, must be sited in area where
testing is carried out.
5.17.5
Controlled Drugs Cupboards
No ward or department must store Controlled Drugs unless there is an
appointed Practitioner in Charge responsible for their storage and use.
Controlled Drug Cupboards must be reserved solely for the storage of
Controlled Drugs and be secured to the wall. These cupboards may be
separate from others or inside other locked medicines cupboards used to
store internal medicines.
Community Services
In the community services the storage of patients own medication (including
controlled drugs) remains the services user’s responsibility, except new
beginnings where storage is maintained on patient’s behalf. However where
appropriate, professionals should advise on good storage practice.
5.18
Custody and Safe Keeping of medicine
5.18.1
Keys for medicine Cupboards, Medicine Trolleys and Drug Fridges
•
Keys for the external medicine cupboard, internal medicine cupboard,
medicine trolley, medicine refrigerator must be kept together on one key
ring reserved solely for these keys. The keys must be clearly identified
•
The keys must be kept on the person of a ward/team manager, in the
event of no designated practitioner being on duty in a ward or unit; the
keys must be handed to a designated practitioner on a ward or unit in
the near vicinity. This information must be made known to the staff on
both wards
•
In a community setting the keys may be held by non-nursing staff, as
long as they are authorised by the team leader.
•
The key must never leave the ward/unit or be left unattended. They
Page 50 of 108
should be carried by the designated practitioner at all times. The only
exception being when the designated person is covering for more than
one area
•
5.18.2
5.18.3
•
No other person should have access to the medicine cupboards except
in the presence of the key holders, with the exception of authorized
pharmacy staff for the purpose of stock control
At Community team bases where a number of designated practitioners
may require access to the medicine cupboards at different times a
secure system must be agreed between the Assigned Practitioner in
Charge and the locality pharmacist
•
Keys must not be handed over to medical staff or other non-key holders
•
Lost keys must be reported immediately to the ward/department
manager. In the event that the keys cannot be found, all locks must be
changed immediately
Keys to the controlled Drugs Cupboard
•
The Controlled Drug Cupboard 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
•
No practitioner can have access to the Controlled Drug cupboard
except with the agreement of the Practitioner in Charge, officially
holding the key. The key must not be handed over to medical staff
•
Authorised pharmacy staff may have access to the Controlled Drug
cupboard key for the purpose of performing statutory checks
•
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. The information must be made known
to staff in both the ward and department and to the manager in charge
of that section.
Re-agent Cupboard Keys
The key to the re-agent cupboard will be kept separately and in a place
designated by the Appointed Practitioner in Charge
5.19
Arrangements for the Administration of Medicines
5.19.1
Medicines and the law
•
The Medicines Act (1968) controls the manufacture, distribution and
importation of medicine and requires that medicines available only on
Page 51 of 108
•
•
•
•
prescription must be given as instructed by the authorised prescriber (a
doctor, a dentist or a nurse or pharmacist or OHP prescriber). Changing
the dose or giving prescribed medicines to a different person without the
authorised prescriber’s permission is against the law.
While the law states who can prescribe medicines it allows anyone to
administer them provided they follow the authorised prescriber’s
instructions.
Non-registered practitioners may only administer medicines after
receiving appropriate training and assessment at local level in
accordance with local guidance.
An epinephrine (adrenaline) injection, Glucagon, Naloxone, Aspirin,
Glyceryl Trinitrate may be legally administered without a prescription for
the purpose of saving life in an emergency (Medicines Act 1968).
However, it remains a prescription only medicine until such time as it
needs to be administered.
The administering of a medicine authorised for a patient will occur by
one of three ways:
•
•
•
•
•
By an individual authorised to administer medicines
By the Prescriber.
By the patient or carer who meets agreed self-administration
criteria.
Where the authority to administer is of questionable legibility,
incomplete, or ambiguous to the person authorised to administer, the
medicine will be withheld until the instruction has been checked with the
prescriber or a new authority issued.
A single person administration system is in place with the exception of
the following instances:
•
Calculation of complex dose e.g. doses expressed by weight or
surface area. This is for the calculation only. It should be done
prior to the first dose, and any subsequent changes of treatment.
The details of the calculations can be recorded in to the patients
treatment goals for future reference.
•
Administration to children under 16 years of age without parental
consent, assessed not to be Fraser competent.
•
Administration of Controlled Drugs – see section 15.9.7. In
exceptional circumstances, such as lone workers in special
schools it may be necessary to administer controlled drugs such
as Midazolam Buccal without witnesses, In these situations the
medication is the patient’s own and not stock.
•
Intrathecal injections – Hospice.
o
With the exception of emergency medication in the
circumstances as stated above medicines can only be
administered in line with a valid prescription issued by an
authorised prescriber.
•
The prescription must be legible, signed, dated, and written in
Page 52 of 108
•
•
•
•
5.19.2
black ink or on an approved electronic prescribing system.
The name of the drug, dose, form, route and maximum
frequency, in hours, of administration should be stated.
Any illegible or ambiguous prescriptions must be brought to
the attention of the prescriber, and clarified.
For any patients who are subject to consent to treatment rules
staff must check that the appropriate consent form is in place and
that the treatment to be administered is recorded on the form prior
to any medication being administered.
Where possible patients should only have one prescription chart in
use at any given time here this is not possible, all current
prescription charts for the patient is to be marked with the total
number of charts in use.
The relevant allergy section on the prescription chart must be
always completed by the prescriber. If the patient states none:
‘none known’ is to be recorded.
Who has the authority to administer medication?
•
•
•
•
•
Medical staff, registered nurses, and student nurses (under the
supervision of a registered nurse) Health Care Assistants, who have
undergone Trust approved training
Student nurses will be given every opportunity to become proficient in
the administration of drugs under the supervision of a registered nurse.
The registered nurse who supervises the student remains accountable
for the correct administration of the drug. Both the registered nurse and
student are to sign the prescription chart.
In community settings a non-registered member of staff may prompt a
patient to take their medication or supervise them removing medicine
from labeled containers which have the patients name on, or a
compliance aid. Under no circumstances are untrained staff to select
the medicine(s) on the patient’s behalf.
Health Care Assistants, who have undertaken trust approved training
may administer medication to patients, unsupervised, in agreed
circumstances, and must follow the same rules as qualified staff.
Area’s this has been agreed are Community Homes and Supported
Living. Other areas wishing to utilise this must discuss this with their
Service director and the Chief Pharmacist.
Non-registered staff that are to be involved in the handling of patients
medicines must undergo appropriate competency training.
5.19.3
Patient self-administration of medication
5.19.3.1
Inpatient services General Self Medication Scheme
Patients in the inpatient services may only undertake routine selfadministration of their medicines where a ward has in place a specific local
Page 53 of 108
procedure approved by the Trust Chief Pharmacist, and Medical Director.
•
The benefits of such an approach include:
o
o
o
o
o
o
o
Helping patients achieve/maintain a great degree of independence
during their stay.
Identifying compliance issues prior to discharge.
Improving services user’s knowledge of prescribed medicines.
Promoting drug administration at the most appropriate time.
Reducing wastage of primary care derived medication.
Preventing medicine hoarding and consequent inappropriate
resumption of discontinued treatment.
Minimising delay at discharge.
Protocols and procedures can be found on the Trust website
5.19.3.2
Specific Medicinal Products
Where patients are prescribed GTN tablets and sprays for the relief of angina
pain, or inhalers of β adreno-receptor agonist as bronchodilators, it is
appropriate to allow the patient immediate access to the medicines when
they are required.
An individual authorized to administer medicines may assess a patient as
suitable for this type of self-administration provided the following conditions
are met:
•
•
•
•
•
The patient understand what their medicines are for and the how to
take them correctly
That the self-administration of such medicines has been considered as
part of the patient’s multi-disciplinary risk assessment, and the
Consultant in charge of their care is in agreement
Suitable safe keeping arrangements are available to prevent misuse by
others. In this case this does not necessarily mean in a locked
cupboard
The medicines are labeled with the patients name and instructions for
use
A record of the does and frequency of self-administered medicine is
made on the in-patient drug administration chart.
Community Service
Within community services it is a patients right to self-administer their own
medicines if willing and able to do so. However, some patients have difficulty
managing their medicines safely and sometimes Trust staff are the only
people to see these patients and, therefore, can highlight the need for help.
Page 54 of 108
5.19.3.3
5.19.4
Patients in the community who are unable to self-administer medication
•
Trust staff that are caring for or managing patients who are selfadministering medication should be aware of factors which can affect a
patient’s ability to self-medicate.
•
Self-administration from dispensed containers may not be possible for
some patients and in such cases the advice of a community pharmacist
or the patient’s GP must be sought. The most appropriate form of help
can then be identified.
•
If a patient requires a compliance aid such as monitored dose
container, this must be dispensed, labeled and sealed by a pharmacist.
If there is a delay in allocating a pharmacist to fill a compliance aid, staff
must inform the patient that Trust staff are unable to fill compliance aids
due to the risk of error. This information must be clearly documented in
the patient’s clinical record.
Principles of Administration
•
The individual authorized to administer medicines will be responsible for
ensuring they have an understanding of the use, action, usual dose,
side effects and handling hazards of the medicine(s) being
administered.
•
This person will ensure they are certain of the identity of the service
user to whom the medicine is to be administered before initiating any
administration activity, in line with the trust policy on patient
identification.
The individual authorized to administer medicines will check that the
authorization for administration is within this policy.
•
5.19.5
Action prior to administering medication
Prior to administering any medication the staff member must observe the
following principles.
1.
Be able to confirm the identity of the patient.
•
•
Within an in-patient setting this will be confirming that the name
and hospital number expressed on the authorization for
administration corresponds with that on the patients identity
bracelet or photographic ID, ad wherever possible, verbally
confirming this detail with the patient themselves.
Within a community based setting, or where an in-patient is to
wearing an identity bracelet or there is no photographic ID, this will
be verbally confirming the name, address and date of birth
expressed on the authorisation for administration with the patient,
or where appropriate, the patient’s career.
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2.
Check the consent status of the patient.
3.
Check that the medicine has already been Administered
4.
Check that the drug to be administered has not past it’s expire date.
5.
Give the correct drug.
prescription.
Check the label on the drug against the
6.
Give the correct dose.
before administration.
If unfamiliar with the drug or dosage, verify
7.
Give the drug in the right form - Check whether tablets or liquid.
8.
For oral liquid medication in non-standard doses, i.e. not multiples of
5ml, approved oral syringes MUST be used.
9.
Give the drug at the correct time. It is important to give medication as it
is prescribed in order to maintain therapeutic levels of treatment.
10. Check that the drug is administered by the route specified, and that the
formulation used is appropriate to that route. Administration by enteral
feeding tube is covered by the CCG policy for the Management of
Patients with an Enteral Tube Insitu.
11. At no time are any medicines to be left unattended by the administering
staff member.
12. Where more than one medicine is specified for administration, they will
consider whether any of the medicines may dangerously interact with
each other.
5.19.6
Consent to Treatment
Wherever possible the proposed medication should be discussed with the
patient in a way which gives them the opportunity to openly ask questions
and express their agreement with the treatment.
“Consent” within the context of this policy is the voluntary and continuing
permission of the patient to receive a particular medication.
However, for a patient to give valid consent or not, they must have capacity.
Therefore, the authorised prescriber must first undertake an assessment of
the patient’s capacity.
This consent is based on the patient having been provided with:
•
Adequate knowledge of the purpose, nature, and likely effects of the
treatment
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•
Information as to any commonly known risks associated with the
treatment
•
Details as to the likelihood of the treatment succeeding
•
Information about any alternative treatments which are available
Any agreement to proceed with treatment which is given under unfair or
undue pressure is not consent. (Mental Capacity Act Code of Practice 2005)
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 patients consent,
but also in meeting the continuing obligation to provide the patient with
adequate information.
All discussions relating to treatment are to be recorded in the patient’s
clinical records. The assessment of the patient’s capacity to give consent, or
not should also be documented.
Information given to the patient by a Pharmacist or other practitioner about
the treatment is provided in addition to that given by the prescriber, not as an
alternative.
Treatment of patients who lack the capacity to consent
Decisions taken on behalf of a person who may lack capacity to make a
particular decision for themselves must comply with the requirements of the
Mental Capacity Act 2005 and the supporting Code of Practice in that, “An
act done or decision made under this act for or on behalf of a person who
lacks capacity must be done, or made in his/her best interest”. (Mental
Capacity Act 2005, Code of Practice, page 66)
Whilst not defining best interest, the Act requires that the best interest
checklist is used and the following five key principles observed before any
decisions may be made on behalf of a person who lacks capacity:
•
A presumption of capacity – every adult has the right to make his or
her own decisions and must be assumed to have capacity to do so
unless it is proved otherwise
•
The right for individuals to be supported to make their own
decisions and must be given as much help as possible before anyone
concludes that they cannot make their own decisions
•
That individuals must retain the right to make what might be seen as
eccentric or unwise decisions
•
Best interests – anything done for, or on behalf of people without the
capacity to make a particular decision must be in their best interests,
and
Page 57 of 108
•
Least restrictive intervention – anything done for, or on behalf of people
without capacity to make a particular decision should be the least
restrictive of their basic rights and freedoms
Treatment of patients detained under the Mental Health Act 1983 (amended
by the Mental Health Act 2007)
The Mental Health Act 1983 (amended by the Mental Health Act 2007)
provides the prescriber with a 3-month period in which to develop a
treatment programme to meet the patient’s needs (for patients detained
under a Section of the Act which legislates for consent to treatment
provision). However, even though the Act allows for treatment to be
administered without the consent of the patient the prescriber should still
adhere to the same principles of seeking consent as described above.
NB:
The 3-month period starts from when treatment or medication
is first prescribed.
For treatment after this 3-month period:
The responsible clinician will receive notification from the Mental Health Act
Administrator within their locality that the patient’s consent to treatment
needs to be reviewed and on receipt of this notification the responsible
clinician must:
•
•
•
•
•
•
Seek the patient’s consent for the treatment to continue beyond the 3month period
Record the discussion in the clinical notes including an assessment of
the patient’s ability to consent
If the patient consents to continued treatment, complete a Form T2
If the patient refuses consent or is deemed unable to provide a reliable
consent, the responsible clinician must request a second opinion doctor
(SOAD) visit from the Mental Health Act Commission
If the SOAD agrees with the responsible clinician that treatment is
necessary and should be given, the SOAD will complete a form T3
A copy of T2/T3 will be attached to the patient’s prescription card
NB: No treatment is to be administered to any patient detained under
the Mental Health Act without a check being made that there is a valid
T2/T3 in place.
For further details staff should refer to the Mental Health Act Code of
Practice.
5.19.7
Checking Administration
It is good practice that, wherever possible, all medicines are prepared and
administered in the presence of another practitioner. If this is not possible for
any reason a single registered nurse may carry out administration, but NOT
for the following:
Page 58 of 108
•
•
•
Schedule 2 Controlled drugs (staff are to refer to the Trust
Standard Operating Procedure for Controlled Drugs )
Prior to administration, the calculation of complex doses, including
weight related doses, the administration itself may be done by a single
practitioner
Rapid Tranquillisation
The purpose of the second person is as a check of the correct administration
of the drug (i.e. right patient, right drug, right dose, right route and dose, and
form), and that the appropriate paperwork is completed.
Where the second person is a qualified professional they should also review
the clinical appropriateness of the dose (this will exclude nurse assistants
and pharmacy technicians for example)
It is the administering nurse’s responsibility to observe the patient taking any
oral medication.
The following may be appropriate for counter-signatories/witnesses:
5.19.7.1
•
Registered nurses
•
Doctors
•
Pharmacists
•
Pharmacy Technicians (directly employed by the Trust)
•
Appropriately trained healthcare professional
•
Student nurses under supervision by someone other than the first
signatory
•
Nurse assistants , Health Care Assistants or Clinical Support Workers
Complex calculations
These checks, such as for syringe drivers may take place away from the
place of administration, such as the District Nurse community base. These
should only be done by staff competent to work out such calculations.
5.19.7.2
Controlled Drugs
A member of healthcare staff is permitted to witness specific tasks that they
are competent with and sign to confirm that the task has been performed
accurately and correctly. For the purposes of witnessing Controlled Drug
tasks the scope of the tasks are
•
Receipt of controlled drugs
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5.19.8
•
As a second person check of the correct administration of the controlled
drug and ensure an accurate entry is made in the register with regard to
drug, dose, dose form, quantity and resultant balance.
•
Balance checks
•
Destruction of controlled drugs
Documenting the Administration of Medicines
•
Following the administration of the medicine the staff member must sign
the prescription chart/MAR sheet or make an appropriate entry on an
electronic patient record system such as TPP. This signature signifies
that the patient has taken/been administered the medication. Students
administering medication should have their signature countersigned by
the supervising practitioner.
•
If any medication is not administered, the code must be recorded on the
approved administration card/prescription chart using one of the Trust’s
recognised codes (see below), an entry made in the clinical records,
and the prescriber informed. (If not already aware).
CODES FOR OMITTED MEDICINES
AWOL - Absent without leave.
O/L – Patient on authorised leave.
O/S – Out of stock
R – Patient has refused medication
NBM – Patient is nil by mouth
S/A – Patient has self-administered
O – Omitted on the instruction of a Doctor
V – Patient vomiting
FAILURE TO RECORD THE ADMINISTRATION OR OMISSION OF A
MEDICATION CONSTITUTES A MEDICATION INCIDENT AND MUST BE
REPORTED.
•
Following administration the individual authorised to administer will
observe the patient to monitor both the positive and negative effects of
the medicine(s) administered.
•
As a general principle, by disguising medication in food or drink, the
patient or patient is being led to believe that they are not receiving
medication, when in fact they are. This is not acceptable as the patient
has not consented to administration.
•
If a 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 the prescriber has confirmed that it is appropriate to do so. If
Page 60 of 108
this is the case the actual time of administration is to be recorded on
both the prescription chart, and in the patient’s clinical records.
•
5.19.9
Any patients who are classified ‘Nil by Mouth’ for any reason are to be
given all their prescribed medication unless specifically advised
otherwise by Medical staff.
Covert Administration of Medicines
Covert medication refers to medication that is hidden in food or beverages.
The covert administration of medication is the practice of hiding medication in
food or beverages so that it will be undetected by the person receiving the
medication. Pills may be crushed or medication in liquid form may be used.
This practice exclusively applies to patients who are not validly consenting to
treatment. It is intended to ensure that patients refusing treatment as a result
of their illness will have access to effective medical treatment.
The decision and plan will be detailed in the patients care plan and case
notes.
Process
Content of the process should include the following stages:
•
Legality: If they are detained for treatment under the Mental Health Act
1983 (e.g. section 2, section 3) then covert medication can be used if
this is the most appropriate and least restrictive and proportionate
approach to treatment, for the treatment of their mental illness only.
•
Capacity: If they are informal (or detained under the mental health act,
and refusing physical medications) patients then the patient must have
an assessment of whether they can accept or refuse medication, by
ward nursing staff, using the framework of the Mental Capacity Act
2005. If they have capacity then covert medication cannot be used
(see mental health act for exception). If they lack capacity then the
following stages need to be considered.
•
Representation: Is their care, such as use of medication, decided by a
Donee, Deputy or Advance Decision?
•
Collaboration: Discuss within the ward multidisciplinary team for joint
decision making/evidencing rational practice.
•
Alternatives: Jointly explore alternatives to covert medication.
•
Necessity: A doctor, ward nurse and pharmacist consider the necessity
of the medication.
•
Advocacy: Any family or carer or advocate is consulted. If
unbefriended, advocacy from an IMHA (if detained under the Mental
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Health Act 1983) or IMCA (if managed under the Mental Capacity Act
2005) must be considered.
•
Evidence: Care Plans show assessment of capacity and assessment
of need, with who was involved in these. MCA1&MCA2 forms should be
used to document this.
•
Administration: The method of giving the medication covertly is
generated in partnership with a pharmacist. Each dose of medication is
offered normally, if refused it may then be administered covertly. The
pharmacy should be contacted to generate a care plan documenting
the agreed method, along with any necessary dosage changes
(Appendix 7)
•
Documentation: Using of covert medication, and how, is documented
explicitly on the prescription chart.
•
Nursing staff should request a pharmacist to complete a covert
medication care plan outlining the agreed method of administration
(Appendix 7)
•
Safety: Systems are in place for safe, optimal practice with a clear audit
trail of events, including evidenced reviews.
•
Review: Review by the ward manager and ward multidisciplinary team,
on a planned and regular basis.
Supervision: Nursing staff giving covert medication have ongoing
training/clinical supervision. The pharmacy service offers support to all inpatient areas, giving advice on management with covert medication.
The service can be contacted in 01302 798308.
5.19.10
Medications which have specific prescribing, administrative, storage,
availability or monitoring requirements
5.19.10.1 INJECTABLE MEDICINES
This
area
is
subject
to
an
http://www.nrls.npsa.nhs.uk/resources/?entryid45=59812
NPSA
alert
Research evidence indicates that the incidence of errors in prescribing,
preparing and administering injectable medicines is higher than for other
forms of medicine. However, the use of injectable medication has many
healthcare benefits for patients such as the improved monitoring of
compliance through the use of depot injections.
Within the Mental health part of the Trust the most commonly used injectable
medicine is depots, and staff should refer to the Trust procedure on the
Page 62 of 108
administration of depot injections for further guidance.
ADMINISTRATION OF RAPID TRANQUILISATION
There is a Trust procedure in place which gives guidance on the use of rapid
tranquilisation, and clinical staff employed in areas where rapid
tranquilisation may be used should be familiar with its contents. For further
details staff should refer to the rapid tranquilisation,
Community Services, including the hospice.
For medicines administered via syringe driver, staff should follow the SOP.
For all other injections technical information and risk assessments can be
found at: http://medusa.wales.nhs.uk/Logon.asp. This must be checked for
all new medications staff are unfamiliar with.
Staff administering parenteral medication must have completed approved
training, and be judged competent by their line manager prior to
reconstitution and administration of an injection.
When administering IV antibiotics in the community the first dose must have
been administered in hospital, prior to transfer in to the community.
Administration of IV antibiotics to children in the community
Eligibility criteria:
•
All referrals for IV medication administration in the community must be
discussed with the CCN Team before planned discharge. Acceptance
may be dependent upon available capacity within community
resources, however wherever possible referrals will be prioritised.
•
The child/young person or their carer/guardian must consent to
treatment being continued in the home environment.
•
Referrals must be correctly completed on the appropriate Community
Children’s Nursing Team referral form.

The CCN team reserve the right to decline a referral until the
correct information is provided or if the suitability of the home
environment compromises the safe administration of the prescribed
medication. Referrals will not be accepted on a Friday afternoon for
medication on a Monday.
•
The child must be stable
•
A treatment review or completion date has been set and documented
by the responsible prescriber.
•
The child/young person must have received the first two doses of any
medication in the hospital setting prior to discharge.
Page 63 of 108
•
The child/young person must have patent IV access and secure, clean,
transparent, adherent dressing applied (UK DH, 2007).
•
The child/young person must be discharged with the required
medication and drug chart/authorisation sheet for CCNT staff to
administer the required medication in the community.
•
All medication including diluents and flushes needed to complete the
course of prescribed treatment will be prescribed and provided by the
referring source and enough consumables for the first week of
treatment dose in the community (except sharps bin).
•
The time of administration and completion of the required medication
dose must be within the operational hours of the service (Monday –
Friday 09:00-17:00) On a weekend the child will need to attended the
children’s observation unit at Doncaster Royal infirmary and the CCN
will arrange this
The IV medication requested must be clinically suitable for the safe
administration outside of a hospital setting e.g., consideration of the risk
of adverse effects and specific monitoring requirements.
•
•
The requested medication must be on the RDaSH formulary available
on the intranet/internet. (Unless specifically requested by microbiology).
Consultation with the ANP for the CCNT must be undertaken if
medication outside of this list is clinically indicated.
•
A clean area within the home will be available for the safe preparation
of medication and that a home assessment will be conducted by the
CCN at the first home visit. Should a suitable area not be available at
time of home visit the family must be made aware that the
CCN/registered nurse will not be able to administer the mediation and
the child will be required to return to the hospital.
Exclusion criteria:
•
Eligibility criteria cannot be met.
•
Safeguarding concerns.
•
The Risk assessment completed at the first home visit highlights area of
concern.
•
Known allergy or risk of allergy to the medication or device. History of
previous allergic reactions to medication being prescribed or similar
group of medicine.
•
Administration of antibiotics via intramuscular injection.
•
Administration of blood or cytotoxic medication.
Page 64 of 108
•
Treatment regimens exceeding once or twice daily doses will only be
considered in exceptional circumstances depending on the child’s
condition and service capacity. e.g. middle day doses where child is still
required to attend hospital for early morning or late evening doses
Nursing/medical responsibilities
The child and family must be discharged with all the medication and
equipment for 1 week. If the CCN team are not informed with enough time to
co-ordinate visits or treatment sheet or referral form is not completed
appropriately the child will return to the ward for the dose until these are
correct.
The
CCN/registered
children’s
nurse
administering
medications
intravenously will have successfully undertaken an IV training
programme/medicines management training and annual IV update. The
CCN/registered nurse will have completed competencies for the
administration of IV medication and have read supporting procedure
documentation. Access to injectable medicines guidance will be available at
all times.
The CCN/registered children’s nurse are individually responsible and
personally accountable for their actions or omissions, they must adhere to
the code (NMC, 2008) and have the right to refuse to administer a
medication via the IV route if the NMC standards for medicine management
have not been met (NMC, 2010) or if they do not feel they have the skills or
are competent to deliver the medication via that route to a specific patient.
The CCN/registered children’s nurse will have undertaken anaphylaxis
training and will carry an anaphylaxis kit at all times when delivering IV
medication.
The CCN/registered children’s nurse administering the IV medication will
ensure they have the knowledge and understanding of the medication to be
administered prior to the home visit. The nurse must confirm:
•
the indication for use
•
recommended dose and frequency of use
•
method of preparation and administration
•
rate of administration
•
any special monitoring or requirements
•
adherence to local infection control policy
•
contraindications
Page 65 of 108
•
side effects and potential adverse reactions and how to clinically
manage and report (MHRA yellow card scheme)
After a referral to the team has been accepted the CCN will calculate the
medication dose and infusion rate with the and check with recommendations
within the current BNF. The adrenaline dose will be calculated and
documented within the child’s record and checked by a second registered
nurse.
The CCN/registered children’s nurse administering the IV medication will
ensure the prescription is:
•
Not for a substance to which the patient is known to be allergic or
otherwise unable to tolerate.
•
based, whenever possible, on the patient’s informed consent and
awareness of the purpose of the treatment.
•
Clearly written, typed or computer-generated and indelible.
•
specifies the substance to be administered, using its generic name and
its stated form, together with the strength, dosage, timing, frequency of
administration, start and finish dates, route of administration, flushes
and diluents as necessary and final infusion volume.
•
is signed and dated by the authorised prescriber (NMC, 2010).
•
That the dose is appropriate for the child’s age, weight and condition.
•
When calculations of the dose needs to be undertaken to either prepare
or administer the medication, these should be done and checked with
another qualified nurse. Following assessment of the clinical risks this
will be facilitated with a two person visit for the initial visit and should
there be no further changes a 1person visit thereafter. Where the doses
require complex calculating or there has been a change or is small
dose i.e:3.3mls. Then there will be a 2 registered nurse visit each time.
Prescribing
All IV medication including diluents and flushes must be prescribed by a
medical practitioner or independent nurse prescriber on the appropriate drug
administration/authorisation/prescription chart which is suitable for CCN staff
working in the community.
The prescriber must provide clear, precise instructions regarding the
medication which is to be administered in accordance with best prescribing
practice guidance.
Verbal orders for commencement of, or changes to IV or other medications
Page 66 of 108
must not be accepted.
Supply and storage
For patients being discharged from a hospital ward, the full course of
antibiotics, diluents, and flushes must be prescribed and dispensed by the
discharging hospital.
All medication must be supplied in the original packaging and labeling to
include child name, details of dose in micrograms/milligrams/grams and
volume in millilitres (mL), diluent and infusion volume. The drug information
sheet (package insert) must be available to ascertain displacement values.
The CCN/registered children’s nurse must ensure all medicinal products are
stored in accordance with individual summary of product characteristics
(SPC) recommendations, when unclear seek further guidance on storage
requirements from pharmacy department.
Where storage at room temperature is appropriate drugs should be stored
below 25 °C in a clean, dry place, out of direct sunlight and close to where
the procedure is to be carried out and away from children and pets e.g. top
shelf or wall mounted cupboards (RCN, 2001).
Medication that needs to be kept cooler than room temperature may be
stored in the top of a domestic refrigerator away from food in a rigid, airtight
container e.g. plastic box with lid. The refrigerator temperature should be
kept between 2 and 8°C.
5.19.10.2 CLOZAPINE
Any patients who are prescribed Clozapine will be monitored through the Clozapine
clinics, which are within each of the Trust’s localities. For further details staff should
refer to the Trust Clozapine clinic protocol, and the procedure for the initiation,
administration, and monitoring of Clozapine, or contact their local clinic.
5.19.10.3 LITHIUM
The prescribing of Lithium to patients will be done in line with the Trust
Lithium guidance, and staff should refer to this for further details on
treatment and monitoring, including NPSA guidance
5.19.10.4 ORAL ANTICOAGULANTS
The prescribing of oral anticoagulants should be in line with the local district
policy, and can be prescribed on the locally agreed forms, which must be
attached the patients drug card. Reference to this prescription must be
made on the drug card.
Page 67 of 108
5.19.10.5 CYTOTOXIC/CYTOSTATIC CHEMOTHERAPY
•
An increasing number of Patients will be receiving chemotherapy in the
community, as the provision of care is moved from the secondary to
primary sector.
•
Practitioners administering these drugs must be trained and competent
to do so and should attend annual updates. They should have a written
prescription stating clearly the drug name, dose rate (if appropriate),
frequency and timing and route of administration and, where
appropriate, a review date of the treatment. This should be signed and
dated by a Prescriber.
•
An assessment should be made of the suitability of the patient’s home
environment
including
telephone
access
in
case
of
emergency/anaphylaxis.
•
Cytotoxic waste must be disposed of in a cytotoxic waste bin or other
receptacle, which should be supplied by the hospital at the same time
as the supply of the drug. For further information refer to the Trust’s
Waste Management Policy.
5.19.10.6 ANTIBIOTICS
Authorised prescribers should follow the local Primary Care Trust’s policy
for the prescribing of antibiotics. (NICE)
http://www.rdash.nhs.uk/about-us/public-declarations/medicines-formulary/
As a minimum when prescribing antibiotics staff must:
•
•
•
•
•
Clinical Indication and compliance with local guidance
Clearly documented in patient notes and should comply community
guidance in locality for drug selection, dose and duration
Swab/culture (if indicated). Sample taken prior to initiation or in
response to empirical 1st line failure as per guideline
Review at 48/72 hour
Duration/review date/stop date and indication stated these are clearly
stated either on the drug card
5.19.10.7 NALOXONE AMPOULES 400mcg.
Naloxone injection is an antidote to opiate-induced respiratory depression,
and should be available in all clinical locations where diamorphine or
morphine injections are stored or administered, in line with NPSA guidance.
Ward and Department
•
All areas where morphine or diamorphine ampoules are stock items
Page 68 of 108
•
must also have naloxone 400mcg ampoules as a stock item.
All areas where morphine or diamorphine ampoules are not stock items
must ensure naloxone 400mcg ampoules are prescribed as ‘prn
medicines for relevant patients when diamorphine or morphine
injections are prescribed.
Community
Naloxone ampoules will be a stock item at base points and available
for use by community nurses when dealing with patients using
diamorphine or morphine injections. Administration should be via PGD or
under instruction by a medical practitioner.
Naloxone prefilled syringes may be made available via the substance
misuse clinics where agreed, and issued using an approved PGD
5.19.10.8 ADMINISTRATION OF MEDICATION VIA A SYRINGE DRIVER.
•
Syringe drivers are used for the continuous administration of drugs over
time and are used to deliver a variety of medications via a
subcutaneous route.
•
Accurate and effective assessment of symptoms is key to the success
of the treatment regimen. This should be a regular activity carried out in
collaboration with the patient, his/her carers and the GP. The
practitioner should be familiar with the device used as calculating the
rate of delivery can vary between different models of syringe driver.
•
Education and information are essential for successful management of
the patient at home and for compliance with the drug regimen.
•
Patients receiving analgesia via a syringe driver require as a minimum,
daily visits from the practitioner to change the syringe and access to
support and advice between visits.
•
Under medicines legislation, except in very restricted circumstances,
mixing drugs together, where one is not a vehicle for the administration
of the other, creates an unlicensed medicine. The person undertaking
this preparation, unless an exemption applies, must hold a
manufacturer’s license.
•
Regulation 20 of the Human Medicines Regulations 2012 exempts
nurse and pharmacist independent prescribers as well as
supplementary prescribers from these restrictions. (The manufacturing
restrictions do not apply to doctors and dentists - regulation 3 refers.) It
allows these prescribers to mix medicines themselves or direct others
to mix. Directions must be in writing.
The list of acceptable combinations can be found in the Standard Operating
Procedure:
Administration of Drugs via the CME Medical T34 Syringe Driver (12/14)
Benefits of Supplementary Prescribing for Palliative Care Syringe Driver
Page 69 of 108
Use
Supplementary prescribing offers a way to offer holistic patient care through
a clinical management plan (CMP) set up to support all symptomatic
therapies as their need arises.
•
A CMP can be put in place at the earliest opportunity, as the transfer of
care is made from the doctor to the nurse, and can include the
possibility of syringe driver use even though it may not be required until
a later stage.
•
The agreement of the CMP with both the doctor and the patient means
there is timely opportunity for discussion of future possible treatment
plans with them both and specifically the patient well in advance of
need
•
The development of a template CMP which is then adapted for
individuals offers a way to support timely symptomatic control as the
need arises.
•
The development of a template CMP means that there is less work for
individuals each time a CMP is required, and treatment strategies can
relate to local or national formulary choices and treatment guidance.
•
The relation of CMP choices to guidance would support stability data
available for drug doses within syringes is paramount to patient safety.
Need outside of this ‘standard’ guidance through larger doses or
greater product combinations would allow relevant dialogue with the
doctor where necessary, and perhaps instigate the need for a specific
individual CMP in a few cases. This can offer an opportunity for the
doctor and nurse to reassess whether continuing care is appropriate
through the CMP.
5.19.10.9 ADMINSTRATION
OF
MEDICATION
VIA
ENDOSCOPIC GASTROSTOMY (PEG) TUBE
A
PERCUTANEOUS
•
Patients with PEG tubes may receive medication via this route. The
tube should be flushed before and after administration of medication
with recently boiled water.
•
Medication should never be mixed with the feed. A chemical or physical
reaction may occur, which may adversely affect the drug, food or both.
Guidance should be sought from the prescriber and acute trust,
alternatively the use of NEWT guidelines www.newtguidelines.com can
be used.
•
Medication should be prescribed in liquid form to prevent tube
blockage. If a drug is not available in liquid form, advice must be sought
from a pharmacist or medical practitioner as to whether it can be
crushed and flushed down the tube
Page 70 of 108
•
The policy for the Management of Patients with an Enteral Tube Insitu
should be followed at all time.
5.19.10.10 MEDICAL GASES
With respect to the safe storage of medical gases the following precautions
must be observed: 













The number of cylinders held as stock in any department should be
kept to a minimum.
Cylinders must be firmly secured at all times to prevent them falling
over
They should be stored under cover, preferably inside and not subjected
to extremes of heat
Naked lights must not be allowed within the immediate vicinity of a
cylinder
No oil or grease should be applied to the cylinder or tap connector
Allow for segregation of full and empty cylinders and permit
separation of different gases within the store
Have warning notices posted prohibiting smoking and naked lights
within the vicinity of the store
Allow for a strict rotation of full cylinders to enable the cylinders with the
oldest filling date to be used first
The storage should be designed to prevent unauthorized access and to
protect cylinders from theft
Excessive force or any tools must not be used to open or close a
cylinder valve
Cylinders with damaged valves and defective equipment must be
labeled appropriately and withdrawn from use
Notify the emergency services of the location and contents of the
medical gas cylinder store.
Contact suppliers for more specialist advice where necessary.
The arrangements for the maintenance and repair of medical devices
(which includes flow meters and oxygen regulators) within the Trust localities
are as below.
Doncaster
A combination of in house and service level agreements with the Doncaster
and Bassetlaw Hospitals NHS Foundation Trust.
Rotherham.
A combination of in house and service level agreements with the Rotherham
NHS Foundation Trust.
Page 71 of 108
Scunthorpe
Medical Physics at Scunthorpe General Hospital, North Lincolnshire and
Goole NHS Foundation Trust.
OXYGEN ADMINISTRATION
•
Patients should be correctly assessed for the use of oxygen. A risk
assessment must be included in relation to safety and recorded in the
clinical records. Medical grade oxygen is regarded as a drug and may
only be prescribed by a doctor or appropriately qualified practitioner.
The prescription should include the type of appliance to be used, the
appropriate percentage of oxygen, the flow rate and the duration of
administration.
•
Patients and carers must be educated in the safe use of oxygen in
relation to smoking and hygiene of tubing and mask. Concentration of
oxygen and duration of administration should be the minimum required
for efficacy and patients and carers should be educated in its safe
usage
•
Safety guidelines must be adhered to and appropriate warning notices
displayed on vehicles in which oxygen cylinders are transported.
5.19.10.11 FLAMMABLE LIQUIDS
Flammable liquids are issued from pharmacy and labeled “flammable”
COSHH data sheets must be available for all flammable liquids kept on the
premises. The data sheets must be kept in a central point available to all
staff.
To reduce the risk of combustion or explosion:•
•
•
•
•
•
Keep stock levels to a minimum
Avoid spillage
Keep bottle closed. Replace the screw cap immediately after use
Keep well away from naked flame or electrical apparatus
Do not store in a refrigerator
Store all flammable liquids in a locked metal cupboard that displays an
appropriate hazard notice
ALCOHOL GEL
It should be noted that as alcohol gel is also a highly flammable substance;
the precautions as stated above must be followed.
If nursing staff need to store alcohol gel in their car it must not be stored
anywhere where it would be subject to direct sunlight. Alcohol gel must
therefore be stored in nursing bags, pockets and/or in the boot of the car.
Page 72 of 108
5.19.10.12 DRESSINGS
•
In Doncaster Community Nursing Staff will provide dressings in line with
the Doncaster Dressings Formulary
5.19.10.13 INSULIN
•
•
•
•
•
•
5.20
All regular and single insulin (bolus) doses are measured and
administered using an insulin syringe or commercial insulin pen device.
Intravenous syringes must never be used for insulin administration.
The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or
‘IU’, are never used.
When Community Nursing Staff are requested to administer insulin they
must have either a prescription or letter of instruction including the
brand, dose and time of each dose. Prior to administration they must
assure themselves that the insulin is in date and has been stored
appropriately
All clinical areas and community staff treating patients with insulin have
adequate supplies of insulin syringes and subcutaneous needles, which
staff can obtain at all times.
An insulin syringe must always be used to measure and prepare insulin
for an intravenous infusion. Insulin infusions are administered in 50ml
intravenous syringes or larger infusion bags. Consideration should be
given to the supply and use of ready to administer infusion products
e.g. prefilled syringes of fast acting insulin 50 units in 50ml sodium
chloride 0.9%.
All healthcare staff involved in prescribing administering or monitoring
Insulin must undertake the on line training available at
http://www.nhsiq.nhs.uk/8473.aspx
Advice about the Uses and Side Effects of Medication
•
Each ward/department should have a copy of the current BNF and
access to the “BNF on line” and manufacturers summary of product
characteristics (spc) (http://www.medicines.org.uk/emc.aspx) for
reference.
•
Before patients are commenced on a medication any advance
statement/directive must be taken into account. They should also be
given the appropriate information, in a suitable format to enable them to
give valid consent about their treatment.
•
Where patients lack capacity they must be given the information as
soon as their capacity is regained.
•
With the agreement of the patient, information about any proposed
treatment regimens should be given to their carer/relative.
•
Further information on medicines can be obtained from Pharmacy staff.
Page 73 of 108
5.21
•
Information leaflets can be obtained from the pharmacy and also the
Trust intranet
•
Formal teaching for staff on medicines /medicines management can be
organised through the Trust training department.
•
Where a Pharmacist is part of the clinical team they should be the first
point of access for information or advice on medicines within the team.
Side Effects Monitoring
The experience of adverse side effects from the medication they have been
prescribed is sometimes stated by patients as the reason for their noncompliance. For this reason it is important that wherever possible there is
systematic monitoring of side effects particularly when a new medication has
been prescribed.
Whilst there are a number of side effect monitoring tools available for
clinicians to use, as a provider of Mental Health and Learning Disability
services it is recognised that a high percentage of prescribing is in relation to
antipsychotic medication and “adherence with antipsychotic medication is
perhaps the main determinant of relapse in schizophrenia (Robinson, et al.,
2002). The tolerability or experience of side effects of a particular
antipsychotic medication has been regarded as both one of the key factors
predicting continued adherence (Tacchi and Scott, 2005; Lambert, et al.,
2004) and crucially the experience of adverse antipsychotic side effects is
commonly stated by patients as an important reason for non-adherence
(Patel and David, 2007). This highlights the importance of an open and
systematic discussion regarding medication-related side effects, as an
acknowledgement of the risks as well as benefits of a particular treatment
help to establish a collaborative approach between clinicians and patients
and contribute to a therapeutic rapport. Antipsychotic side-effect rating
scales have been used over the years to help identify and quantify the
various side effects that can occur on these medications.” (extract from
Waddell and Taylor 2008)
The Glasgow Antipsychotic Side-effect (GASS) is the method for routine side
effect monitoring employed by the Trust. The GASS is validated for
assessment of side effects associated with second or third generation
antipsychotic medication (sometimes referred to as atypical antipsychotic
medication).
However, many people are prescribed first generation
antipsychotic, especially as a depot injection, or have a combination of first
generation and second or third generation medication. In such cases, an
alternative side effect assessment such as the Liverpool University Side
Effects rating Scale (LUNSERS) should be used. If you are unsure as to
which assessment scale should be used you should consult with a
pharmacist or consultant psychiatrist.
The frequency of formal side effect assessment is guided by clinical need so
should be considered:
Page 74 of 108
•
•
•
•
•
If the patient (or carer) reports a change/potential change in the side
effects experienced.
If said effects/potential side effects give rise to concern.
Following initiation of new antipsychotic medication.
Following a significant increase in prescribed dose.
As a minimum, patients prescribed antipsychotics will have formal side
effect monitoring recorded at least annually.
5.22
Transport of Medicines
5.22.1
Transport within wards and departments
Medicines may only be transported by Trust staff or authorized staff of
supplying Trusts. No Medicines are to be left unattended at any time during
transportation.
5.22.2
Transport of medicines between health services premises
Medicines accompanying a patient who is begin transferred to another
hospital or unit may be transported with the patient in the ambulance, taxi, or
other form of transport. It is important that the medicines are packaged
securely and labeled with the final destination.
5.22.3
Transportation of medicines from the Supplying Pharmacy
All medicines will be transported in locked tamperproof containers.
On arrival at the ward/department they will be left in a designated area or
room.
Delivery vans carrying medicines must not be externally distinguished from
other Health Service vans.
Delivery vans must not carry any unauthorized passengers
Delivery vans are to be locked when unoccupied.
Once delivered to the ward/department the responsibility for the security of
the medicines rest with the practitioner in charge who will unpack the
contents, check them against the delivery note, and lock them away.
5.22.4
Transportation by Taxi
Taxis should not routinely be used for the transportation of medicines,
however, if an emergency arises and there is no alternative staff should:
•
Use a hospital contract taxi.
•
Check the driver’s identification.
Page 75 of 108
5.22.5
•
Make sure the medication is in a tamper evident container.
•
Contact the address to which the medication is to be delivered to let
them know what time the Taxi left with the medication, and request that
they confirm receipt.
Transport of Medicines to Patients at Home
Discharge or leave medicines may be transported home by the patient or
their carer.
Patients who leave the hospital or unit before all their medicines have been
dispensed should be instructed to return later to collect them.
The transport of medicines to a patient’s home at other times must be
authorised by the practitioner in charge of the ward/department.
5.22.6
Transport of Patients medicines by Community Staff
Medicines may be carried by community staff in relation to their role. This
will include medication required for emergency treatment, to be administered
via a PGD, to be administered against a prescription of letter of authorization,
or similar. Where staff are going to a patients home to administer the
medication, such as a long acting injection, they must have the depot card
with them. Community Nurses may carry stock drugs, needed to carry out
their jobs, such as dressings, adrenaline and medication for PGD’s.
The security of medicines issued to Community Based/Visiting staff will be
the responsibility of the individual authorized to administer or Prescriber to
whom they are issued.
Upon delivery all medicines will be stored away from public access and in a
locked container.
Except when carried on the person of the individual authorized to administer
or Prescriber the container will be kept locked and out of sight at all times
(e.g. in the boot of their car).
Staff that are not registered nurses may deliver medication to a patient for
self-administration.
Staff delivering medication to a patients home should record this in the
patient record, ideally getting the patient to sign for it.
In the unusual event staff remove medication from the patients home; this
must be signed for by the patient and a record made in their clinical record.
In the event that the patient is not at home to receive the medication it is to
be returned to the medicine cabinet in the team base.
Under no
circumstances are staff to post the medication through the patient’s letterbox.
Page 76 of 108
Staff must always endeavor to return to base at the end of their working day
to return any unused medication, however in exceptional cases they may be
taken home, to allow for lean working. This does not include medication such
as TTO’s In these situations it must be agreed by the team manager, and the
medicine must be stored securely at home out of the reach of children and
others, ideally in a locked case. The medication must be kept in a locked
container, such as a brief case.
5.23
Medication Errors/incidents
5.23.1
Definition of a Medication Error
A Medication error is a preventable incident associated with the user of
medicines, which may put a patient at risk. Such incidents may be related to
any of the steps of the medicines process of medication user e.g.
Prescribing errors
Omission of regularly prescribed medication
Drug/does selection
Route/time of administration
Illegible/incomplete prescriptions
Dispensing errors
Wrong Drug
Wrong dose
Wrong quantity
Wrong formulation
Unavailability of dose for administration at scheduled time
Dispensing out of date drug
Dispensing an incorrectly formulated drug
Absence of PILS in TTO medications
Administration errors
Administering the drug to the wrong patient
Administering the wrong drug
Administering the wrong dose
Administering the drug at the wrong rate
Administering via the wrong route
Administering the drug at the wrong time
Non-justifiable omission of the dose
Administering an out of date drug
Administering an incorrectly formulated drug
Patient counseling
Failure to counsel a patient on the accurate use of their medicines
Page 77 of 108
Patient Monitoring
Failure to monitor the appropriate patient parameters, to ensure the safe and
effective use of a drug
Dispensing errors should also be reported to the Chief Pharmacist of the
relevant pharmacy
Errors are often made under pressure of work, or by failure to follow policies.
It is essential that an atmosphere of openness prevail, so that staff who
realise any mistakes feel able to report them to avoid any detrimental effects
on patients
5.23.2
Action to take if an error occurs
The staff member who notices the error must:
•
Maintain the patients safety
•
Inform the appropriate prescriber and seek advice on any action
required
•
Review the services user’s car plan in light of any advice given
•
Report the error using the Trust’s electronic reporting system giving
details of the incident, immediate action taken, and any factors which
may have contributed to the error
•
Report the error to the Service Manager/Matron
•
The relevant prescriber’s line manager (or On Call cover) is responsible
for dealing with prescribing errors concerning the patient. Errors must
be discussed with the manager with the knowledge of the Prescriber.
The manager should significant prescribing errors with the Prescriber
and the Clinical Pharmacist. Supporting statements will be required
from the staff concerned. Where system in place, local drug error tools
should utilized
•
Inform the patient and offer reassurance. In the event that the patient
has a condition which impairs their cognitive or intellectual functions,
the Doctor in charge of their care will be consulted so that a decision
can be made about informing them and/or their relatives/carers or the
error.
•
If it is a dispensing error the Trust Chief Pharmacist or nominated
deputy will investigate and supporting statements will be require from all
staff concerned in the event that the patient, relative or carer are
dissatisfied with the outcome of the incident, the Trust’s Complaints
procedure will be followed.
Page 78 of 108
•
5.23.3
The team manager may wish to use the EDMET tool (LINK) to assess
the error with the person concerned.
How the organization learns from medication errors
All medication errors/incidents will be subject to review by the Trust’s
Pharmacy Team. Themes and lessons learned from serious incidents (Sis)
will be reviewed in the Medicines Management Committee and will inform the
medicines management training and policy review
Themes and lessons learned from Serious Incidents (Sis) will also be shared
at the Organisation Learning Forum
5.24
Disposal of Medicines which are no Longer Required
When disposing of medicines it is important to make the distinction between
controlled and non-controlled drugs as different criteria’s apply and no
pharmaceutical waste is to be disposed of using a sink or sluice
5.24.1
Disposal of non-controlled drugs
Any medicines, which are no longer required by the ward or department, are
to be disposed of in the pharmaceutical waste bin, provided for the purpose.
5.24.2
Disposal of controlled drugs
•
Controlled drugs must not be returned by wards or departments
•
Where they are no longer required, they must be removed by
Authorized Pharmacy Staff. Upon removal of the controlled drug, the
authorised member of the Pharmacy staff will enter the appropriate
stock balance and sign the Controlled Drugs Register. The transaction
must 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
Authorised Pharmacy staff must be returned to the pharmacy
department where an appropriate entry will be made into the pharmacy
Controlled Drug Register.
Care Homes
Where community Nurses are supporting the care of a patient in a care
home i.e. maintaining a syringe driver and the patient dies, the following
process must be followed:
•
•
All medications are to remain a the care home for 7 days
If the Care Home is a residential home, then the home makes
arrangements for them to be collected by or taken to their pharmacy for
Page 79 of 108
destruction.
If the Care Home is a nursing home, it is the responsibility of the home to
destroy and dispose of them.
5.24.3
Disposal of patient’s own medication
Any medication brought into hospital by a patient is their property and as
such cannot be destroyed without their permission. In the event that the
patient agrees to the destruction of the medication it is to be placed in the
pharmaceutical waste bin.
If the patient/carer refuses to agree to the disposal of the medicines they can
either:
•
Be recorded in the patient’s clinical records and held in a sealed bag in
a separate section of the medicines cupboard from all other stock until
they can be returned to the patient on discharge.
Or if the patient insists:
•
Be returned home. However, the patient and or their carer/relative
must be advised that as the treatment regime will be reviewed whilst
the patient is on the ward, it is likely that the supplied discharge
medication will be different, and this poses a real risk that the wrong
medication may be taken in future
If there are safety concerns in relation to the medication being returned home
the nurse in charge consultation with the Consultant in charge of the patients
care may make a decision to refuse to return the medicines and have them
destroyed. For the safe disposal of any medicines staff should refer to the
guidelines issued by their supplying pharmacy.
5.24.4
Drug disposal in Community Services
Community staff will advise patients or their carers to return unwanted drugs
to their community pharmacists.
Normal practice would be that community staff should not remove medicines
from a patient’s home. Disposal of unwanted medicines is the responsibility
of the patient, their carer or the person responsible for clearing the house.
Where a patient has their medicines ordered and/or delivered by their
community pharmacy, staff may support patients by contacting that
pharmacy to arrange for removal.
In exceptional circumstances, following a risk assessment and in line with
maintaining a duty of care to the patient, where a patient (or other resident) is
considered to be at risk, medicines may be removed. Staff should:
•
Contact the principal prescriber of the medicines, to alert them to the
Page 80 of 108
•
•
•
risk and allow arrangements to be made for future prescribing – this
may be the patient’s GP or specialist
Obtain consent from the patient or their carer for the removal of the
medicines
Remove the unwanted medicines directly to the nearest available
community pharmacy for appropriate disposal. A record of what has
been removed should be made, and the patient/carers signature
obtained, using the approved form.
Where consent has not been obtained and the risk is considered high,
contact your line manager for further advice
This should be documented (to include the basis of the risk and
names/quantities of medicines removed) and discussed with the line
manager at the earliest opportunity and within 24 hours
5.25
Ward Closures
5.25.1
Temporary or routine ward/department closures
Where a ward or department is closed for any reason for up to 7 days the
Responsible Person will ensure that all medicines are appropriately stored in
cupboards as specified in this policy
The individual in charge at the time of such a closure will be responsible for
ensuring the keys are stored in a secure place which has been agreed as
suitable between the Responsible Person and the Trust Lead Pharmacist.
Wherever possible, the doors to the ward or department will be kept locked
during the period of closure.
5.25.2
Permanent closure of a ward/department
The Management Team will be responsible for notifying the Trust Chief
Pharmacist of the permanent closure.
The Trust Chief Pharmacist will then be responsible for arranging the return
and credit of disposal (as appropriate) of all medicines stocked on the ward
or department. Relevant registers will be stored as per Trust Records
Management policy.
5.26
Investigation of Drug Discrepancy or Loss Occurring in the Hospital or
Community
It is acknowledged that in the community setting prescribed drugs are owned
by the patient; however the following will apply throughout the Trust.
•
Any knowledge or suspicion of drug loss or discrepancy of drugs, for
which the staff member is responsible for administering and recording
the balance of, must be reported immediately to the Responsible
Person and their line manager. Discretion must apply in all instances
Page 81 of 108
5.27
•
Where an incident is due to suspected theft or burglary by a person
external to the Trust, staff will refer to the Security Manager and the
Police must be informed.
•
In all cases an incident form should be completed as per trust incident
reporting policy.
Removal of and disposal of unknown substances
Unknown substance may be illicit in nature and in accordance with its duties
under the Misuse of Drugs Act. The Trust does not knowingly permit the use
of or dealing in illicit substances on its premises. In the event that staff
become aware of someone on the premises having an unknown substance
on them they should follow the guidance as detailed below:
5.27.1
Action if a visitor is in possession of an unknown substance
If any visitors are seen to be in possession of a suspected illicit substance
they will be asked to leave the premises
If any visitor is seen or suspected to have passed illicit substances to a
patient or other visitor they will be asked to leave. The nurse in charge of the
ward will then consult with the Modern Matron about the need to report the
matter to the Police , and bar any further visits by the person concerned
(please refer to the Trust ‘Guidance for Nursing staff when incidents of drug
misuse are encountered on Trust premises’ See 5.7.2 in the policy.
5.27.2
Action if a patient is in possession of an unknown substance
In the event that it is a patient who is suspected to have illicit substances on
them the nurse in charge of the ward will discuss their suspicions with them
and ask that they voluntarily hand over the substance for destruction.
This discussion must be held in the company of another staff member and
this staff member must witness the actions of the nurse in charge once the
substance has been handed over.
The illicit substance will be:
•
Placed in an envelope
•
The envelope will be labeled with a reference number linking it to the
entry in the controlled drugs register
•
The envelope will be sealed and both the nurse in charge and the
witnessing staff member will sign and date across the sealed flap of the
envelope
•
This envelope will then be locked in the ward controlled drug cupboard
Page 82 of 108
•
An entry will be made in the controlled drug register under the heading
of unidentified substance
•
In order to maintain patient confidentially their name will not be
documented in the controlled drug register
•
Pharmacy are to be notified of the illicit substance on the next working
day, and they will make arrangements for the removal and safe
disposal of the substance
•
If staff involved in the removal of illicit substances from a patient have
reason to suspect that the quantity involved is great than of personal
use, advice should be sought from the Service Matron as to the need
for the matter to be reported to the Police
NB: Under no circumstances will any suspected illicit substances be
returned to the patient
If the patient refused to hand over the illicit substance for destruction they are
to be place on 1:1 nursing observation and the matter discussed with the
Modern Matron and the patient’s Consultant.
All actions taken are to be recorded in the patient’s clinical record or in the
event of a visitor, on the ward 24-hour report.
5.28
Adverse drug reactions
Any drug may produce unwanted or unexpected adverse reactions.
Detection and recording of these is of vital importance. Prescribers,
pharmacist and nurses are urged to help by reporting adverse reactions to
the Medicines and Healthcare Products Regulatory Agency (MHRA) on prepaid yellow forms, which are available in the BNF or on the BNF website
(http://www.bnf.org/). The BNF also provides further detail on the type of
medicines and type of reactions, which should be reported. (staff can also
refer to appendix 3 for further details)
If the reporter of the adverse effect is not the lead clinician, they must be
made aware of the problem, and the patients record updated accordingly
5.29
Medicine Defect Reporting
Medicines may be considered defective for two principal reasons.
•
•
Physical defects caused by damage or contamination noted by an
individual handling the medicine at any point in the Medicines Trail.
Efficacy defects caused by reactions that in the judgment of a
professional caring for the patient(s) concerned indicate an unexpected
response
Within the Trust the following procedure applies when a defect is found or is
suspected in any medicine:
Page 83 of 108
•
Inform the supplying pharmacy who will advise on all reporting,
recording and investigating on the defect
•
Retain any remaining product and any associated products or
equipment (e.g. administration sets, infusion devices etc.) and clearly
mark it “Defective: not for use”
•
Notify the Chief Pharmacist who is responsible for formally reporting all
defective medicines to the authorities, the manufacturer concerned, and
other wards and departments as necessary. In addition to this the
Chief Pharmacist is also responsible for:
•
•
•
The retention of suspected defective medicines for analysis, return
or impounding.
Recall to the Pharmacy Department of all potentially defective
medicines.
The dissemination of information relating to potentially defective
medicines within the Trust.
•
Complete an electronic IR1 report, recording details of the product and
defect
•
If the product has been administered to a service, inform the doctor
responsible for the patient and record the defects in the patients clinical
record
•
Report the incident to the Appointed Practitioner in Charge
Suspected defective medicinal products are notifiable by doctors and
pharmacists to:
The adverse Incident Centre, MHRA, 2/2G Market Towers, 1 Nine Elms
Lane, London SW8 5NQ.
5.30
Drug alerts, recalls and safety notices
The Medicines Control Agency and the Medical Devices Agency are
responsible for notifying Health Authorities and Trusts of product defects,
which may have implications on a wider, sometimes national, scale. Such
notification will then be circulated to Trust units by their supplying pharmacy.
All such notifications received must be immediately brought to the attention
of the assigned practitioner in charge, or member of healthcare staff in
charge of the unit.
The staff member in charge must follow the instructions received regarding
the identification and withdrawal of the defective product and bring any
withdrawn medicines to the attention of the ward/unit pharmacist or other
authorised pharmacy staff.
Page 84 of 108
A record of the action taken must be made in the ward/unit 24-hour report.
5.31
Use of unlicensed medicines
•
In the UK no medicine can be marketed for human use without a
Product License (PL) granted by the Licensing Authority (Department of
Health). The PL specifies the indications for which a product may be
used and also the dose, and route of administration etc. Licensing
arrangements are determined by the Medicines Act 1968 and
implemented through the Medicines and Healthcare products
Regulatory Agency (MHRA). Under the Consumer Protection Act of
1987 the manufacturer of a drug, which has a UK product license is
liable for damages if the product is defective.
•
Unlicensed medicines fall into 5 broad categories:
•
•
Products derived from licensed medicines and prepared by the
NHS or commercial unit with a “specials” manufacturing licence or
prepared in a hospital pharmacy department under a Medicines
Act exemption, e.g. the manufacture of a suspension from tablets
•
Or capsules or special low-dose formulations for children
•
Products, whose licence has been abandoned, suspended,
revoked or not renewed
•
Products for which a licence has yet to be granted, but which are
available and licensed outside the UK
•
Medicines used outside the terms of their Product Licence, e.g. for
an unlicensed indication, via an unlicensed route, or at an
unlicensed dosage
•
Unlicensed medicines undergoing clinical trials
Prescribers have a duty in common law to take reasonable care and to
act in a way consistent with the practice of a responsible body of their
peers of similar professional standing. In using an unlicensed medicine
the Prescriber must act responsibly and with reasonable care and skill.
Not to meet these standards lays the Prescriber open to claims of
negligence liability.
The responsibility for use of unlicensed medicines lies with the Prescriber.
Mechanisms must be in place to ensure that a Prescriber knows when a
medicine prescribed/supplied is unlicensed and that he/she is aware of
his/her responsibilities.
Most common drugs have product licenses, however, there are two
circumstances where a Prescriber may wish to use an ‘unlicensed drug’:
Page 85 of 108
•
•
5.31.1
A product awaiting a UK product license
A product that has been withdrawn from UK market
Trust Procedure for the prescribing of unlicensed medication
Unlicensed medicinal products are only to be used when no
pharmaceutically equivalent licensed product or suitable alternative licensed
product is available for use at the time the patient requires it.
Prescribers who carry overall clinical responsibility for patients may use
unlicensed medicines in the course of their practice. However by their nature
the effects of an unlicensed medicine may be less well known than a
licensed product. Health care professionals are reminded of their duty always
to act in the best interest of their patient. In the case of an unlicensed
medicine this may mean refusing to administer an unlicensed medicine
where they have grounds to believe it may be unsafe.
When prescribing two or more medicinal products together for the purpose of
administering them to meet the needs of a particular patient this product
becomes unlicensed. This is now legally allowed PROVIDING that controlled
drugs are not included. However, MHRA have issued a statement that nonmedical prescribers are unlikely to be prosecuted for the purposes of
palliation even though this product is not legal.
Should any Prescriber within the Trust wish to prescribe an ‘unlicensed drug’
they must firstly make an initial application to the Chair of the Medicines
Management Committee. If it is felt therapeutically justified then the proposal
should be taken to the Trust’s Medical Director, Director of Nursing and Chief
Executive for approval.
Authorised pharmacy staff will advise the Prescriber (and/or the assigned
practitioner in charge) of the unlicensed nature of the medicines. Where such
unlicensed use is not common practice, or is deemed to constitute a
significant risk, this must be recorded in the patient’s clinical record by the
Trust Prescriber or pharmacist.
Prescribers must consider carefully the use of unlicensed medicines and only
use this form of therapy when the benefits outweigh the risks.
Prescribers must obtain consent to treatment and inform the patient of the
medicines license status. The patient must also be informed that the effects
of an unlicensed product will be less well understood than those of a licensed
product.
Prescribers must inform their medical colleagues (especially General
Practitioners) of the medicine’s licence status prior to any transfer of the
patient.
Page 86 of 108
5.32
Definition of “Off -Label Medicines”
The Summary of Product Characteristics (SPC) lists: indications, dose
ranges, methods of administration and age restrictions as granted by the
marketing authorisation for each medicine licensed for use within the UK.
Any use not in accordance with the SPC is considered “off-label”, or an
unlicensed use. This policy also applies to products used outside their
product license “off label use”, or herbal or homeopathic products. Off label
prescribing should only be carried out by senior prescribers within their area
of competence, and should be supported either by trust or national guidance.
5.33
Medicines Safety
The Medicines and Healthcare products Regulatory Agency (MHRA) issue a
regular monthly electronic bulletin bringing information and clinical advice
about the safe use of medicines.
It is intended for all healthcare
professionals who work in the UK – doctors, pharmacists, nurses, dentists,
allied health professionals, and coroners. The MHRA is the government
agency which is responsible for ensuring that medicines and medical devises
work and are acceptably safe
In addition, the National Patients safety Agency (NPSA) issue regular patient
safety incident data and reports, with alerts, directives, tools and guidance, to
improve patient and medication safety.
Within service Provision, the Director of Service provision will be responsible
for ensuring that NPSA, NICE and other national alerts/guidance are
actioned appropriately.
All staff (including self-employed staff contracted to work within Trust
provided services) will follow best practice detailed in MHRA and NPSA
alerts and reports.
5.34
Clinical trials including pharmaceutical products
•
Anyone considering conducting a clinical trial must refer to the MHRA
guidelines Description of the Medicines for Human Use (Clinical Trials)
Regulations 2004
•
Any Clinical trial within the Trust can only be undertaken after careful
consideration and approval from the Medicines Management
Committee
•
If the trial is sponsored by a pharmaceutical company it must comply
with the guidelines on compensation issued by the Associated of the
British Pharmaceuticals Industry.
•
Any patient who is to be involved in the trial must give informed consent
in line with the Mental Capacity Act (2005)
Page 87 of 108
5.35
•
Supplies of the drug will be issued by pharmacy as agreed in the trial
protocol
•
Pharmacy will supervise the use of the medicine in the trial
Contact with Pharmaceutical Industry Representative
The Trust Medicines Management Committee (MMC) has decided that
RDaSH staff will not be permitted to meet with representatives or agents of
the pharmaceutical industry on Trust premises or during normal working
hours.
This decision has been made as the Medicines Management Committee
does not consider such meetings to be an appropriate use of Trust
resources. The MMC believes that it is important that Trust staff should
focus their NHS time on clinical and patient-focused activities as well as
planning and management activities designed to serve the Trust’s immediate
and long-term goals. The MMC do not consider that meeting with sales
representatives of the pharmaceutical industry service is in the interest of
patients, clinicians or the Trust.
It is recognised that there may be research opportunities or other
collaborative arrangements where interaction with the pharmaceutical
industry can be mutually beneficial to the NHS but this should be organized
in a planned way through the appropriate research governance procedures.
Also, the MMC recognizes that there may be opportunities for other planned
collaborative work with the pharmaceutical industry that specifically serves
the Trust’s educational, training or other goals. Such specific and planned
projects should be cleared with MMC on a case by case basis and the
representatives of the Pharmaceutical industry have strict codes (ABPI Code
of Practice) by which they must abide. In line with this code they should:
•
•
•
Not enter any patient areas
Never have access to patient’s clinical records
Never directly promote their products to patients or carers
Individual educational and CPD activities should continue to be discussed
and arranged through the usual channels of appraisal, supervision ad job
planning.
5.36
New medicine related documents
All new and updated polices, guidelines, protocols PGDs and PSDs relating
to medicines must go through the Medicines Management Committee and on
to the Clinical Effectiveness committee for approval, unless exempted by the
Chief Pharmacist.
6.
TRAINING IMPLICATIONS
The Training Needs Analysis (TNA) for this policy can be found in the
Page 88 of 108
Training Needs Analysis document which is part of the Trust’s Mandatory
Risk Management Training Policy located under policy section of the Trust
website.
7.
MONITORING ARRAGEMENTS
Area for monitoring
Monitoring
process
How
medicines
are Pharmacy
prescribed
10 point plan
How the trust make sure Pharmacy
all prescription charts are 10 point plan
accurate
How the side effects of
Pharmacy
medication are
10 point plan
monitored (inpatient)
How the organization
Review
learns from medication
medicines
errors
related serious
incidents
How Medication is
Pharmacy
administered, including
10 point plan
patient identification
Patient selfAudit of Policy
administration
Who by
Reported to
Pharmacy
Team
Pharmacy
Team
Medicines Management Monthly
Committee
Medicines Management Monthly
Committee
Pharmacy
Team
Medicines Management Monthly
Committee
Pharmacy
Team
Medicines Management Quarterly
committee/Organisation
Learning Forum
Pharmacy
Team
Medicines Management Monthly
Committee
Chief
Pharmacist
How a patients
medicines are managed
on handover between
care settings
How drugs are disposed
of safely
Pharmacy
10 point plan
Pharmacy
Team
Clinical Quality Group Annually
/Medicines Management
Committee
Medicines Management Monthly
Committee
Site visits,
Contract
monitoring
Clinical Audit
(POMH UK)
Pharmacy
Team
Compliance with national
standards for medicines
management
Chief Pharmacist
Frequency
Ongoing
Clinical
Quality As results
Group/Medicines
become
Management Committee available/
annually
Staff training as identified Report
Head
of HR & OD
Quarterly/
in the Training Needs
Learning and
Annually
analysis
Development
In addition, the Chief Pharmacist provides an annual report to the Board of Directors in their capacity
as Accountable Officer for Controlled Drugs.
8.
Chief
Pharmacist
EQUALITY IMPACT ASSESSMENT SCREENING
The completed Equality Impact Assessment for this Policy has been
published on the Equality and Diversity webpage of the RDaSH website
Page 89 of 108
8.1.
Privacy, Dignity and Respect
The NHS constitution states that all patients should feel
that their privacy and dignity are respected while they
are in hospital. High Quality Care for ALL (2008), Lord
Darzi’s review of the NHS, identifies the need to
organize are around the individual, ‘not just clinically but
in terms of dignity and respect’.
As a consequence the Trust is required to articulate its
intent to deliver care with privacy and dignity that treats
all service uses with respect. Therefore, all procedural
documents will be considered, if relevant, to reflect the
requirement to treat everyone with privacy, dignity and
respect, (when appropriate this should also include how
same sex accommodation is provided).
8.2.
No
issues
have
been
identified in
relation
to
this policy
See attached
EIA
statement.
Mental Capacity Act
Central to any aspect of care delivered to adults and
young people aged 16 years or over will be the
consideration of the individuals capacity to participate
in the decision making process. Consequently, no
intervention should be carried out without either the
individuals informed consent, or the powers included
in a legal framework, or by order of the Court
Therefore, the Trust is required to make sure that all
staff working with individuals who use our service are
familiar with the provisions within the Mental Capacity
Act. For this reason all procedural documents will be
considered, if relevant to reflect the provisions of the
Mental Capacity Act 2005 to ensure that the interest
of an individual whose capacity is in question can
continue to make as many decisions for themselves
as possible
9.
Indicate how
this will be
met
Indicate How
this will be
Achieved.
All
individuals
involved in the
implementation
of this policy
should do so in
accordance with
the
Guiding
Principles of the
Mental Capacity
Act
2005
(Section 1)
LINKS TO ANY ASSOCIATED DOCUMENTS
•
Risk Management Strategy
•
Patient Safety Strategy
•
Medicines Management Strategy
•
Guidelines for nursing staff on the use of Section 62 Procedure for the
searching of a person or their property
•
Controlled Drugs procedure
Page 90 of 108
10.
•
Rapid tranquilisation policy and guidelines for inpatients
•
Patient Identification Policy
•
PGDS – a list of authorised PGD’s can be found on the Trust Intranet
under clinical policies
•
Procedure for the administration of long acting injections
•
Non-Medical Prescribing Policy (Supplementary Prescribing) and Trust
authorisation and sign off protocol
•
Policy and Procedure for the Safe and Secure Handling of Medicines in
Trust day care settings
•
Incident Reporting Policy
•
Policy for the Management of Serious Incidents
•
Policy and Procedure Relating to the Handling of Formal Complaints
•
Policy on the Development of Information For Patients
•
Guidance for nursing staff when incidents of drug misuse are
encountered on Trust premises
•
Policy for Health Record Keeping Standards and Health Records
Management
•
Safe Haven Policy (from October 2012)
•
Standards Operating Procedures, a list of authorised supporting SOP’s
can be found on the Clinical policies section of the Trust website
REFERENCES
Care Quality Commission (2010) Essential standards of quality and safety.
Audit Commission Report (2001) A Spoonful of Sugar – Medicines
Management in NHS Hospitals.
British Medical Association, Royal Pharmaceutical Society of Great Britain
(most recent edition) British National Formulary.
Consumer Protection Act of 1987.
Control of Substances Hazardous to Health Regulations (2002) Crown
Report 1998
Department of Health (1999) Review of
Prescribing, Supply and
Administration of Medicines.
Page 91 of 108
Department of Health (2004) Mechanisms for Nurse and Pharmacist
Prescribing and Supply of Medicines.
Department of Health (2007) Safer Management of Controlled Drugs: A
Guide to Good Practice in Secondary Care.
Department of Health (2015) Code of Practice Mental Health Act 1983.
Department of Health (2015) Reference Guide to the Mental Health Act
1983.
The Duthie Report (1988).
General Medical Council (2013) Good Practice in managing medicines and
devices
Manchester Mental Health and Social Care Trust (2008) Medicines Policy
4th Edition
Medicines for Human Use (Clinical Trials) Regulations 2004.
Mental Capacity Act 2005.
Misuse of Drugs Regulations 2001.
National Institute for Health and Clinical Excellence 2015 NG5 Medicines
Optimisation.
National Institute for Health and Clinical Excellence 2014 CG183 Allergy.
National Institute for Health and Clinical Excellence 2015 NG15 Antimicrobial
Stewardship.
National Institute for Health and Clinical Excellence 2013 MPG 2 Patient
Group directions.
National Patient Safety Agency (2007) Promoting Safer Use of Injectable
Medicines.
Nursing and Midwifery Council 2015 Standards for Medicines Management.
Nursing and Midwifery Council (2015) The Code: standards of conduct,
performance and ethics for Nurses and Midwives.
Nursing and Midwifery Council (2015) Standards of Proficiency for Nurse and
Midwife Prescribers.
Nursing and Midwifery Council (2008) Mental Health Act Manual Eleventh
Edition.
Royal Pharmaceutical Society of Great Britain (2008) Medicines Ethics and
Practice, A Guide for Pharmacists and Pharmacy Technicians.
Page 92 of 108
The Medicines Act 1968.
The Misuse of Drugs Act 1971.
The Royal Marsden NHS Foundation Trust (2004) Clinical Nursing
Procedures 6th Edition.
The Association of the British Pharmaceutical Industry Code of Practice
(2006)
The Human Medicines Regulations 2012.
Royal College of Psychiatrists (2007) Use of Licensed Medicines for
Unlicensed applications in Psychiatric Practice.
The Stationery Office (2007) Mental Capacity Act 2005 Code of Practice.
Waddell L. and Taylor M. - A new self-rating scale for detecting atypical or
second- generation antipsychotic side effects - Psychopharmacol 2008; 22;
238 DOI: 10.1177/0269881107087976.
11.
APPENDICES
Page 93 of 108
Appendix 1
Guidance to staff on Medicines Reconciliation
Introduction
•
•
In 2015 NICE published guidance NG5 Medicines Optimisation that states
when patients move between care settings, and the receiving team have
prescribing/administration roles then Medicines reconciliation should occur.
Medicines reconciliation will help ensure that all intended medication is given,
all unintended medication is avoided and the information transferred is
accurate and contemporaneous
Aims of the Medicines Reconciliation Process
•
•
•
•
•
•
To obtain, and verify, an accurate medication history for all patients on
admission to a service.
To maintain a contemporaneous record of current medicines and the reasons
for addition, discontinuation or alteration of the patient’s medicines during the
inpatient stay.
To provide accurate information of current medicines prescribed, including
any changes, upon transfer of care e.g. to the GP upon discharge.
Definition of Medicines Reconciliation.
The National Prescribing Centre defines Medicines Reconciliation as:
o Collecting information on medication history (prior to admission) using
the most recent and accurate sources of information to create a full and
current list of medicines (for example, GP repeat prescribing record
supplemented by information from the patient and / or carer), and
o Checking or verifying this list against the current inpatient
prescription/summary care record and administration record in the
hospital, ensuring any discrepancies are accounted for and actioned
appropriately, and
o Communicating through appropriate documentation, any changes,
omissions and discrepancies
In the community the reconciliation process should also indicate clearly who is
responsible for prescribing the medication.
Summary of Roles and Responsibilities
Role of the prescriber (to include medical staff and Non-Medical Prescribers)
•
To take a full, accurate medication history at the point of assessment on
admission to the team.
•
To communicate with the patient/carer with regard to their usual medicines to
ensure there are no discrepancies between the information obtained from the
information sources and the patient/carer.
•
To establish an allergy status and record this on the medication chart and on
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the alert sheet in the medical notes as per Trust policy.
•
Only prescribe once the medication history is complete and accurate as doing
so without this information is potentially hazardous.
• To complete and document the Medication History with the information
obtained.
• To document the reason(s) for any alteration in dose/frequency or for
discontinuation of medication on admission on the Medication History.
•
To
maintain
an
accurate,
contemporaneous
record
for
the
addition/discontinuation/alteration of any medicines during the patient’s
inpatient stay.
•
To document any changes/discontinuations/additions of medicines on the
patient’s discharge summary sheet.
Role of the pharmacist
•
To verify that the Medicines Reconciliation Process has been undertaken by
the prescriber as soon as possible after the patient’s admission to hospital.
•
To ensure the medication history appears complete and clinically coherent.
•
To ensure the medication written on the current inpatient prescription and
administration record matches that of the medication history, where
appropriate.
•
To ensure any discrepancies are documented appropriately on the Treatment
Sheet.
•
To clarify any undocumented discrepancies with the prescriber.
•
To endorse the Treatment Sheet that the medication history is complete and
clinically coherent.
•
To confirm and document allergy status, where appropriate.
Role of the pharmacy technician
•
To facilitate the Medicines Reconciliation Process by establishing a
medication history using appropriate resources in collaboration with a
pharmacist.
•
To record any additional information obtained on the Treatment Sheet.
•
To inform the pharmacist, or prescriber where appropriate, of any
discrepancies detected.
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•
To confirm and document allergy status, where appropriate
Role of the Nursing Staff
•
To highlight to a member of the medical or pharmacy team if they recognise
any discrepancies between the inpatient prescription and administration
record or and the patient’s regular medication.
•
To ensure any information obtained is documented on the Treatment Sheet.
•
To ensure allergy status has been confirmed and documented on the front of
the inpatient prescription and administration record prior to administration of
any medicines (unless in an emergency situation).
•
To ensure any medicines prescribed are appropriate, after considering any
allergy status.
Role of Community Team members (Key Worker)
•
To take a full, accurate medication history at the point of assessment on
admission to the team, for the patients under their care.
•
To highlight to a member of the medical or pharmacy team if they recognise
any discrepancies between what the record shows and what the patient is
actually taking.
•
To ensure any information obtained is documented in the patient record.
•
To ensure allergy status has been confirmed and documented in the patient
record, prior to medication being administered.
•
To ensure any medicines prescribed are appropriate, after considering any
allergy status.
The Medicines Reconciliation Process
Allergy Status
•
The prescriber retains the principal responsibility for ascertaining allergy
status of any patient for whom they prescribe. However, it is the responsibility
of every person involved in the medication process – prescribing, dispensing
or administration – to take every practical step to establish the allergy status
of the patient. The only exception to this is in an emergency situation where
this information is unobtainable and the risk of not treating the patient
outweighs the risk of having the information needed to make a fully informed
decision. It must be recognised that prescribing / administering medicines
without establishing allergy status is potentially hazardous.
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Sources of information
• Obtaining a full, accurate medication history requires access to one or more of
the following sources:
o Referral letter from primary care
o Repeat prescription sheet from the patient
o Electronic medication record from the GP practice
o GP surgery
o Community pharmacy
o Nursing Home Medication Administration Record (MAR sheet) / care
home /residential home
o Patient’s relative / carer
o Transfer from another unit / hospital
o Recent hospital discharge letter / prescription chart
o Patient’s Own Drugs
o Patient
•
In addition to using the sources listed above to identify prescribed medicines,
the patient, relative or carer should be questioned with regards to over the
counter medicines and alternative therapies they may be taking.
•
It is important to establish if there are any discrepancies between the
information obtained independently to the patient and the information that the
patient delivers. Ideally, more than one information source should be used to
obtain an accurate medication history.
Recording the Medication History
•
Once the medication history has been established, all of this information must
be transferred onto the Trusts approved medicines reconciliation document,
irrespective of whether the medicine will be continued during the admission.
This document will form part of the patient’s notes to record any changes in
medication therapy during the inpatient stay. Where the patient has an
electronic prescription, the Medication History should be filed in the
appropriate place in the medical notes.
Recording the Medication History on admission
•
Complete the Medication History with:
o Date of admission
o Source of information using appropriate codes
o Full name of the medicine and the formulation (e.g. tablet, capsule,
modified release preparation)
o Dose, frequency and route
o Sign and date the entry.
o If any of the patient’s current medication is to be discontinued or
altered on admission (for example, if the reason for admission is
medication related), this should be documented with the reason for
discontinuation / alteration and the entry signed and dated.
o Who is responsible for prescribing the medication
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Recording the Medication changes during a patient episode
• Patients who have a written Medicine Prescription and Administration record:
• All medicines that are started on the admission must also be entered onto the
Medication History Sheet and the indication for treatment should be indicated.
• All medicines that are discontinued / altered during the course of the patient’s
episode should have the reason for this recorded either on the Drug
Treatment Sheet adjacent to the Medication in question, and the entry signed
and dated, or recorded in the patients clinical record.
Communicating Medication changes at discharge or transfer
• All significant changes to the medication that has occurred during a period of
care, this includes outpatients settings, including medicines stopped on
admission, must be recorded on the discharge summary, including allergy and
sensitivity status, with reasons for those changes. This information is obtained
from the Medication History Sheet and, where applicable, the electronic
prescribing system
• The Medication History Sheet will be filed in the patient’s medical record.
• A discussion about sending a copy of the discharge letter, to the patients
community pharmacy, should be had with the patient
Frequency of review
This should occur on admission to teams and wards, and in the case of
community teams this should be updated each time medication is changed,
and at least annually at the point of their annual review.
Reference
NG 5 Medicines Optimisation
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Appendix 2
Crushing Tablets and Opening Capsules
Crushing tablets, opening capsules and altering the preparation of the medication
falls outside the Drug Product Licence. In these circumstances the Prescriber and
Practitioner are liable for any adverse effects resulting from administering of
medication in this manner.
Tablets you must never crush:
•
Enteric Coated Tables (also abbreviated to EC) are formulated to pass
through the stomach intact before they begin to dissolve. The enteric coating
may be being used to protect the stomach against local toxicity e.g. aspirin
EC, or it may be being used to ensure the medicine is released at the correct
site for absorption or action e.g. Bisacodyl¹.
Therefore, crushing enteric coated tablets may increase toxicity or reduce
effectiveness.
•
Modified Release Tablets (M/R) are designed to release their contents over
an extended period, typically 12 to 24 hours. If the tablets are crushed the
medicines will be absorbed in a much shorter period, perhaps 1-2 hours. This
may lead to increased toxicity as a full day’s dose is absorbed in that 1-2
hours period. Modified release tablets are also described as:
o
o
o
o
o
o
Slow Release or SR
Extended Release or XL
Long Acting or LA
Retard
Slow or Slo
Perlonget
•
Buccal or Sublingual tablets are designed to avoid the gastro intestinal
tract. Consequently crushing tablets and administering orally may be
counterproductive, as the drug may not be absorbed effectively.
•
Tablets that may be toxic when crushed. When crushing tablets, powder will
always be generated. A number of drugs will be potentially toxic to the person
crushing the tablets by inhalation of the powder. In addition there is always
the risk of sensitisation or anaphylaxis in susceptible individuals. Furthermore,
if the device used for crushing is not properly cleaned the potential to
contaminate other preparations exists.
Therefore the following must never be crushed:
•
•
•
•
Cytotoxic drugs such as melphalan, busulphan, methotrexate
Antibiotics such as penicillin’s, erythromycins
Prostaglandin analogues such as misoprostol (which is part of Arthrotec)
Hormone preparations
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¹ Enteral Feeding tubes include Nasogastric (NG), Percutaneous Gastrostomy
(PEG), and Percutaneous Jejunal (PEJ) tubes.
The medicines listed are common examples and do not constitute an exhaustive list.
You should consult the relevant section of the current BNF. If you are in any doubt
consult a Pharmacist.
In addition, some medicines have a bitter taste; these may or may not be coated.
Crushed medication may therefore produce an unpleasant product for the patient to
take orally for example.
In the event of any medication being administered using a different method e.g.
crushing, splitting capsules as advised by the Pharmacist or Medical Practitioner,
Must be recorded in the Patient’s Clinical records. Information should include date,
person advising change, drug name and reasons for administering medication not in
accordance with its summary of product characteristic and name and designation of
person administering the medication.
Page 100 of 108
Appendix 3
Adverse Drug Reporting
Adverse Drug Reaction Reporting and Yellow Card Scheme
The Yellow Card Scheme for spontaneous reporting of suspected adverse drug
reactions (ADRs) was introduced in 1964 after the thalidomide tragedy highlighted
the urgent need for routine monitoring of medicines. Adverse Drug Reactions should
be reported to the Medicines and Healthcare products Regulatory Agency (MHRA)
by completing a yellow card.
Who Can Report?
Until recently adverse drug reaction reporting using the yellow card scheme was only
available to healthcare professionals such as doctors, pharmacists, coroners and
nurses. In October 2005 the Yellow Card Scheme was opened up to patients and
their carers.
What should be reported?
An adverse drug reaction (ADR) is an unwanted or harmful reaction experienced
following the administration of a drug or combination of drugs under normal
conditions of use that is suspected to be related to the drug.
For intensively monitored medicines (identified by ▼) report all suspected reactions.
For established drugs and herbal remedies report all serious adverse reactions in
adults; report all serious and minor reactions in children (under 18).
Serious reactions include those that are:
• fatal
• life threatening
• disabling
• incapacitating
• result in or prolonged hospitalisation
• and / or are medically significant requiring intervention
• congenital abnormalities
If in doubt about the seriousness of a reaction please report it.
Areas of Special Interest
Although all adverse reactions with medicines are monitored there are a number of
areas of particular interest, as listed below:
•
•
•
•
•
Children
The elderly
Delayed drug effects
Congenital abnormalities
Herbal remedies – it is important to monitor all herbal products to ensure their
safety.
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It would be helpful to report the ingredients, source or supplier.
Where to find a Yellow Card
A paper version of the Yellow Card is included in:
•
•
•
British National Formulary
Nurse Prescriber Formulary
Monthly Index of Medical Specialties (MIMS)
Alternatively
down
load
http://medicines.mhra.gov.uk
a
copy
from
the
MHRA
web
site
Patient Details
Provide one of the following, patient’s initials, age, sex, weight if known, local
identifier.
Do not identify the patient by date of birth or name of patient. In order to help identify
the Patient in any future correspondence also include their initials and a local
identification number, which will identify them in the case of any future
correspondence. This does not breach any confidentiality agreements between the
health care professional and the patient.
Copy of Yellow Card in Patients Notes
It is vital that a copy of the Yellow Card Report is included in the patients clinical
record. It is also recommended that a copy be sent to the GP for future
Drug Alerts
Medicines and Healthcare Products Regulatory Agency (MHRA) Drug Alerts are
cascaded directly to the Trust Pharmacists and they are responsible for ensuring that
the advised action is taken, which may necessitate the removal of the affected
pharmaceuticals from pharmacy stock.
Page 102 of 108
Appendix 4
Guidance on High Dose Antipsychotic Prescribing*
Current evidence does not justify the routine use of high-dose antipsychotic medication in
general adult mental health services, either with a single agent or combined antipsychotics.
Calculating the level of antipsychotic dose*
The Consensus Working Group recommends the following definition for high dose: a total daily dose of
a single antipsychotic which exceeds the upper limit stated in the British National Formulary or a total
daily dose of two or more antipsychotics which exceeds the BNF maximum using the percentage
method, including PRN medication.
i.e. Olanzapine 15mg plus Aripiprazole 20mg
((15/20) x 100) + (( 20/30)x100) = ~142%
*recommendations adapted from CR 138 (RCPSYCH 2006)
Considering prescribing
Use of high dose of antipsychotics should only be considered in individual cases
•
•
•
•
as a carefully monitored therapeutic trial and where evidence-based strategies have failed
involve an individual risk–benefit assessment by a fully trained psychiatrist. (Consultant only)
in consultation with the wider clinical team and the patient and a patient advocate, if available,
and if the patient wishes their presence
taking full account of possible contraindications and drug interactions to high dose, for the drug(s)
in the patient
Having decided to prescribe
Having decided explicitly to prescribe high dose of antipsychotics
•
•
•
•
•
•
•
the decision should be documented in the case notes to include as a minimum
risks and benefits of the strategy
define the length of trial, not less than 6 weeks but not more than 3 months.
expected outcome and schedule for monitoring
Conduct baseline ECG to exclude cardiac contraindications, including long QT syndromes. This
must be repeated after a few days and then every 1–3 months in the early stages of high-dose
treatment (the frequency being determined as clinically indicated).
Baseline U&E’s, repeated after a week are required as abnormal electrolyte levels can pre
dispose patients to ECG abnormalities.
The use of PRN medication should be kept under regular review. Staff administering PRN should
be aware of its potential to raise the total daily dose of antipsychotic above the high-dose
threshold.
Prescribers should be able to readily identify patients on high dose antipsychotics within the team
Page 103 of 108
When used in the context or Rapid Tranquilisation.
•
•
•
If high-dose antipsychotic treatment has been used, it is particularly important that the routine
monitoring of a sedated patient is carried out, with particular attention to regular checks of pulse,
blood pressure, respiration, temperature and hydration, in line with the rapid tranquilisation policy.
ECGs should be carried out frequently during dose escalation, if and when possible, if unable due
to patient factors this should be documented and a risk benefit assessment carried out.
During acute violence or emergency tranquilisation avoid parenteral antipsychotics if possible, but
if used, ECG monitoring or regular ECGs should be performed, but see above
Patients subject to T2 or T3 regulations
•
In line with CQC guidance high dose prescribing must be explicitly acknowledged on the form,
with a cumulative maximum dose of antipsychotic stated
* These Guidance notes must be read in conjunction with other Trust guidance on medicines, and along with
NICE guidance, including guidance on the use of ECG’s.
Andrew Houston, On behalf of the Medicines Management Committee
Page 104 of 108
Appendix 5
Pharmacy Medication Card Assurance Verification Record
Ward:
Name:
D.O.B:
Silverlink No /Hospital No:
Date of admission:
Points (details are indicative of review but not exhaustive)
Yes/No
Allergy status
(patient’s allergy status is consistently and legibly recorded on all drug charts)
Medicines reconciliation
(medicines reconciliation has been completed and forms part of the patient record)
Dose
(all prescribed doses and routes of administration are unambiguous and congruent with SPC)
Time of does
(timings for doses are unambiguous and congruent with SPC)
Side effects
(there is evidence of baseline and periodic ADR assessment/enquiry consistent with changes to medication)
Interactions
(all significant drug interactions have been considered and co-prescribing is intentional with a clear rational recorded)
Form T2/T3
(MHA documentation is complete, in date and supports current prescribing)
PGD
(administration of medicine under PGD is clearly recorded and has been without risk
Monitoring
(Monitoring arrangements are in place to support safe use of medicines and establish their effectiveness
Indication for prescribing each drug
(it should be clear from the clinical record or care plan the purpose of prescribing each medication)
Patient information
(it should be clear that the patient has had the opportunity
PRN instructions & maximum dose
(all psychotropic medicines prescribed prn should have clear directions to include rational for administration admin route,
minimum time lapse between doses, maximum single and daily dose.
Medicines card complete
(all drug cards must be a complete record of prescribing and administration of medicines, all prescriptions to be signed, there
should be no gaps in the administration record)
Patient seen: Y/N
Interventions/outcomes:
Verification:
Yes
Reviewer’s
Name…………………………………………...
No
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Signature/date/time…………………………………………
Standard Operating Procedure for filling in assurance form
This is the SOP for filling in this form or spreadsheet, not for the checking and
intervention process as a whole.
1. For each patient a form must be filled in, for each visit, alternatively enter the
information directly in to the data collection tool spreadsheet, stored on the K
Drive
2. Attach patient PID sticker or fill in patient details
3. For each point indicate that you have verified it either yes or no.
4. If all 10 points are verified then:
a. Sign date and time form.
b. Apply green sticker to all cards for that patient.
c. Make entry in medical records that card is verified.
5. If unable to verify:
a. Give details of any interventions you have carried out in the free
b.
c.
d.
e.
6.
text box, including outcomes (if this then allows you to verify,
see 4)
Apply red sticker to all appropriate cards
Make entry in the notes, including what is required to be done to
verify that prescription card
Make note to follow up as appropriate.
Sign Date and Time Form
Upload details from each reviewed record to ‘Pharmacist 10 point plan’
database on Pharmacy K drive
Antibiotic 5 point plan





Clinical Indication and compliance with local guidance
Swab/culture (if indicated). Sample taken prior to initiation or in response to
empirical 1st line failure as per guideline
Review at 48/72 hour
Duration/review date/stop date and indication stated these are clearly stated
either on the drug card
Record of administered doses.
Drug cards will be checked against the 5 standards, the results entered on the
spreadsheet on the K Drive.
Page 106 of 108
Appendix 6
Allergy Assessment
When assessing a potential allergy the following tool should be used (NICE CG183)
Page 107 of 108
Appendix 7
Covert Administration Care Plan
Authority to Administer 1
MHA2
MCA2
MCA1/2 completed:
Review Date:
Name:
DOB:
Unit Number
1.
2.
See table for authority to administer for individual drugs
MHA – Mental Health Act MCA - Mental Capacity Act
Ward
Drug Name
Form
Frequency
MCA/MHA Agreed Method of Administration
Pharmacist Name and Signature:
1.
2.
Attach Copy to Medication Card
File Original in Notes
Page 108 of 108
Date and
Signature