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                              Medicines Policy



  Rev      Date       Purpose of Issue/Description of    Planned Review
                      Change                             Date
  2002j    July       Revised version of 1997 document   1/11/2003
           2002



  2004     Dec        Updated document                   31/12/2006
           2004




     Responsible Officer             Approved by              Date

  Head of Pharmacy          Prescribing and
                            Therapeutic Committee
  Kevin Smith
                            Clinical Governance
                            Committee

                           PROPRIETARY INFORMATION-

This document contains proprietary information belonging to the Powys Local
   Health Board. Do not produce all or any part of this document without
           written permission from the Powys Local Health Board.
                     POWYS LOCAL HEALTH BOARD


MEDICINES POLICIES

The safe and secure handling of medicines, incorporating Prescribing, Administering,
Ordering, and Storage


PURPOSE


This document is designed to help ensure the safe use of medicines within Powys LHB
Hospitals, and Community Nursing, and to safeguard patients and staff.


SCOPE


All staff who handle medicines, including clinical staff, transport, hotel services, and
managers.
Staff are reminded that they must adhere to these policies.



Author/Editor

Kevin Smith 2004
Head of Pharmacy
Powys Local Health Board
For Drugs and Therapeutics Committee




Page2 of 3      Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                 POWYS LOCAL HEALTH BOARD


                                    CONTENTS

       Section                                  Title
       1         Prescribing for Inpatients
       2         Unlicensed Medicines
       3         Prescribing at a distance
       4         Legibility of prescriptions
       5         Re-use of prescription charts for planned re-admission
       6         Clinical Trials involving Pharmaceutical Products
       7         Supply and Administration by practitioners without
                 authorisation to prescribe
       9         Administering medicines
       10        Emergency Drugs
       11        Medication related incidents
       12        Defective medicines - Adverse incident reporting
       13        Medicines Supply and Storage - Ordering
       14        Medicines Supply and Storage - Supply of medicines from
                 pharmacy departments
       15        Medicines Supply and Storage - Storage of medicines
       16        Hazard Warnings and Urgent Drug information
       17        Contact with Pharmaceutical and Wound Management
                 Company Representatives and Commercial Sponsorship
       18        Closure of Ward or Department
       19        Flammable Liquids Gases Aerosols
       20        Community Nursing
       22        Payment of prescription charges
       23        Waste medicines        - collated policies
       24        Controlled Drugs       - collated policies
       25        Midwives



Please check that your policy contains all the indicated sections and in
case of omission, inform Kevin Smith, 01874 712641 (internal extension
2641) immediately. Note that some section numbers are not used.


Page3 of 3   Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                    POWYS LOCAL HEALTH BOARD

SECTION 1             PRESCRIBING FOR HOSPITAL PATIENTS


      1.1. The Prescription Sheet

      Prescribing should be done only on approved documentation.
      (see list below)
      1.2. FUNCTION OF THE PRESCRIPTION SHEET
         To provide a permanent record of the patient's treatment with medicines.
         To indicate the patients' sensitivity to medicines.
         To facilitate the provision of the correct medicine from the pharmacy.
         To direct the administration of the medicine to the patient.


The prescription sheet is a legal record, and must be retained with patients'
notes when not in use.


      1.3. GUIDANCE TO MEDICAL OFFICERS
      1.3.1. All prescriptions must be clearly written by the prescribing Medical Officer,
      and each prescription must bear the prescriber’s signature. Full signature is
      mandatory for controlled drug prescriptions.


      1.3.2.   Writing must be in black ink to facilitate legible faxing


      1.3.3.   Medicines may only be prescribed on approved prescription documents. The
      following details must appear on each sheet:-
                      In-patient : Use preprinted ‘addressographs’ wherever possible
                      a)     The patients' name in full
                      b)     Age and date of birth.
                      c)     Ward or department (name or number)
                      d)     The patients' hospital number
                      e)     Whether patient is pregnant




      1.3.4.   Known medicine sensitivities must be included on the patient’s prescription


Page1 of 8     Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                      POWYS LOCAL HEALTH BOARD

        sheet by the prescribing Medical Officer.

      It is the medical officers responsibility to complete the allergies box, but,
Nurses and other practitioners should assist in identifying medicine sensitivities, and
ensuring that the record on the prescription chart, is kept up to date, and must not be left
blank


        1.3.5.   All details must be printed, clearly and legibly. Block capitals may improve
        legibility for some handwriting styles. Nurses MUST question any ambiguous or
        illegible prescription. The following information must be written on the prescription
        sheet by the prescribing Medical Officer:-
                       a)      Approved name for the medicines. If the medicine has unique
                       release properties or bioavailability, then the brand name should be
                       used. The form of a medicine must be specified; solid dose is
                       understood unless otherwise stated. Non-approved abbreviations of the
                       name of the medicine, eg CBZ for carbamazepine, must not be used.
                       Chemical formulae e.g. FeSO4 must not be used.


                       b)      Define dose in the metric system. If the medicine is one for
                       which the potency is expressed in terms of units then the word UNITS
                       must be written in full. Quantities less than one gram should be given
                       in milligrams and quantities less than one milligram should be given in
                       micrograms. ‘Micrograms’, ‘nanograms’ and ‘units’ should be written
                       in full, avoiding the use of a decimal point wherever possible, e.g.
                       100micrgrams NOT 0.1mg, do not use 3.0mg, use 3mg and 0.5ml
                       not.5ml. The word "Unit" must be written in full rather than
                       abbreviated to "U" or blood unit symbol "O", which can frequently be
                       confused with a "0" (zero) and may lead to 10 times the dose of insulin
                       or heparin being administered in error. Roman numerals (eg ii) are also
                       a potential cause of medication errors and should not be used.

                       c)      Times of administration – 24 hours clock. The times of
                       administration must be specified by the prescriber (eg by ticking in the
                       appropriate column on the in-patient prescription sheets). The



Page2 of 8       Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                   POWYS LOCAL HEALTH BOARD

                     following or clearly outlined on other documentation abbreviations are
                     standard means of indicating a dose regimen or for discharge or
                     outpatient prescriptions:
                      OD              Once a day
                      OM              Each morning
                      ON              Each night
                      BD              Twice daily
                      TDS             Three times daily
                      QDS             Four times daily
                      Mane            Morning
                      Nocte           At bedtime
                      Protocol        As per protocol
                      PRN             As required (with indication and interval stated).

      Note that PRN on its own is not sufficient. A maximum dose or dose frequency
      must be stated plus some indication of why the drug should be used (for nausea, for
      pain etc.). For safety purposes other directions may be appropriate, e.g. CO-
      PROXAMOL – PRN for strong analgesia, PARACETAMOL – regular lg QDS, do
      not use concomitantly. All other dose regimens must be written out in full.
      Depot injections should be prescribed with the time interval expressed using the term
      "every" (eg “every 3 weeks” rather than “3 weekly” which can be misinterpreted. This
      can be abbreviated as 3/52.)
                     d)      Start date. To indicate the start of treatment initiated during this
                     hospital stay - not the start of the chart


                     e)      Route of administration. The following abbreviations are
                     standard means of indicating the routes:
                      Ext            External use                 PR        Per Rectum
                      IM             Intramuscular                PV        Per Vagina
                      Inh            Inhalation                   SC        Subcutaneous
                      IV             Intravenous                  SL        Sublingual
                      Neb            Nebulisation                 Top       Topical
                      O              By Mouth
                      PO             By Mouth

                     f)      All other routes of administration, e.g. intranasal must be
                     written out in full. Only one route to be specified (ie IV/O is not




Page3 of 8    Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                    POWYS LOCAL HEALTH BOARD

                     acceptable). Once only or variable dose regimens should be written in
                     the section provided.


                     g)      Each entry on the prescription sheet, either for the
                     commencements of discontinuation of the medicine must be signed
                     and dated by the prescribing Medical Officer. Each prescription item
                     must be validated by unambiguous signature of a registered medical
                     practitioner or authorised prescriber. If the signature is not legible the
                     printed name of the prescriber should be written next to the signature.
                     Initials or abbreviated signatures are not an adequate means of
                     identification or authorisation.


                     h)      When the medicine is discontinued, a bold line should be
                     drawn diagonally across the prescription. The cancellation must be
                     dated and signed in full. Cancellation of areas of the medicine
                     administration record by the prescriber is also another permitted
                     method of indicating when the medicine should be administered and
                     when it should be discontinued.


                     i)      For Controlled Drugs, the dose and form and where appropriate
                     strength and frequency to be given must be indicated on the
                     prescription.


      1.3.6. Once a prescription has been written it should not be altered. If it is necessary
      to correct an entry the incorrect entry should be cancelled as above and a new
      prescription written. This applies to changes in route of administration and dosage as
      well as change in drug. Correcting fluid should not be used. No prescription should
      be altered; changes in medication should involve complete cancellation of the existing
      prescriptions and the writing of a new one. An altered prescription may not be
      administered: such a prescription is not valid. It is the prescribers responsibility at all
      times, to ensure that prescriptions are valid (see also section 24).




Page4 of 8    Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                     POWYS LOCAL HEALTH BOARD

      1.3.7. Pharmacists are authorised to make annotations on prescription record sheets,
      eg to clarify the meaning of a prescription or to include an approved name, or provide
      special instructions for nurses. Any such annotations should be in a colour which will
      show up after photocopying. Pharmacists must not affix post-it notes to charts to
      inform prescriber of non-urgent interventions – i.e. notes to doctors must be securely
      fixed to charts (e.g. stapled).


      1.3.8    If a nurse has reasonable ground to question the accuracy or completion of a
      prescription he/she has a duty to do so and must communicate with the prescriber
      before treatment if administered. If still not satisfied he/she must communicate with
      the Pharmacist and the Senior Nurse before treatment is administered (see also section
      9).
      1.3.9.   Patients who are admitted to hospital and who arrive with their own
      medication can, by agreement with the medical staff, continue on that medication until
      further supplies have arrived from pharmacy (provided the medication is written on
      the medication chart). They can continue using up the supplies that they have brought
      in with them provided this is written up on the prescription sheet (annotated “patients
      own drugs”), and provided agreement to do so has been received from the visiting
      pharmacist, or another practitioner accredited by The Powys Local Health
      Board to assess the medication. At the time of writing, no policy for accrediting
      other practitioners is in place.


      1.3.10. Patients may, under the direction of the doctor concerned, vary their own
      medication(s) within agreed (and documented) dose limits. Administration records
      should reflect the actual dose administered.


      1.3.11. A prescription must be reviewed and re-prescribed as appropriate at a
      maximum of three monthly intervals.


      1.3.12. Antibiotics Courses of antibiotics should have a bar inserted on the chart to
      indicate the end of the course of treatment or if the length of treatment is not known a
      review date should be stated. The duration of treatment can also be indicated in the
      prescription box.




Page5 of 8     Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                     POWYS LOCAL HEALTH BOARD


       1.3.13. Unlicensed use of licensed medicines

       As a general rule, licensed medicines should always be prescribed and administered in
       accordance with their data sheet recommendations. The following situations involve
       the prescription and administration of licensed medicines outside their manufacturer’s
       intended usage:


                  The administration of a medicine by its licensed route, to treat a disease
                   not included in its licensed indications.


                  The administration of a medicine by an unlicensed route, whether to treat a
                   disease included in its licensed or unlicensed indications.


       In these situations, the prescriber should be aware that he/she is using the
       medication on his/her own responsibility. The prescriber is advised to fully inform
       the patient of this course of action and, where appropriate, obtain their informed
       consent. Advice on use of medicines in such circumstances can be obtained from
       pharmacy departments and/or the Medicines Information Service.
       Pharmacists will check with the prescriber to ascertain that prescriber is aware that
       he has prescribed a licensed medicine for an unlicensed use.

       See below for use of depot injections in unlicensed sites, and Section 2 for use of
medicines which do not have a UK product license.


       REFERENCES

       Duthie Report 1988

       Medicines Act 1968

       Misuse of Drugs Act 1971 and regulations 2001




Page6 of 8      Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                     POWYS LOCAL HEALTH BOARD

       Medicines used in an unlicensed way – Depot injections by unlicensed route

NURSING PROTOCOL FOR THE ADMINISTRATION OF LICENSED MEDICINE
BY INJECTION INTO UNLICENSED SITES


                                          PURPOSE

This protocol outlines the standards to be followed by a qualified nurse when requested by a
patient and a prescriber to administer an injection into an unlicensed site, to ensure that, when
a licensed (or unlicensed) medication is administered via an unlicensed site, the patient is
aware of the possible consequences.

                                            SCOPE

This protocol applies to all nurses practising within the Directorate for Mental Health and
Learning Disability.


      An unlicensed medicine is the term used to refer to a medicine that has no product
       license. If an unlicensed medicine is administered to a patient, the manufacturer has
       no liability for any harm that ensues.

      The same issues apply to a licensed medicine used in an unlicensed way- ie outside its
       licensed indications.

                                 PROTOCOL STANDARDS

      A patient specific prescription must exist for unlicensed medicines, or for licensed
       medicines used in an unlicensed way.

      The manufacturer must be contacted to ascertain any available information on
       administration of the medication into the chosen site.

      The decision to utilise unlicensed sites can only be made in extremely exceptional
       circumstances. Every effort must be made to explore alternatives. Only when other
       possibilities have been exhausted should this course of action be followed.

      The prescriber and the nurse administering the injection should be satisfied that there
       is sufficient information to administer the drug safely and, wherever possible, that
       there is acceptable evidence for the use of that product for the intended indication.

      The decision to administer an injection outside of a licensed site must be made
       between the responsible medical officer, the patient and named nurse, in consultation
       with a pharmacist and entered into the patient's care plan. At each care plan review
       session an IR1 should be completed.




Page7 of 8      Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                     POWYS LOCAL HEALTH BOARD

      Every effort must be made to educate the patient about the benefits of administration
       of the injection into the licensed site.

      The responsible medical officer and named nurse must be assured that the chosen site
       is acceptable for administration. Administration will not take place into an unsuitable
       site.

      The prescription sheet must state the unlicensed site/sites that the medication is to be
       administered.

      The patient will be required to complete with the named nurse/responsible medical
       officer, Generic Consent Form (no. 1) Powys Local Health Board (2003).

      In obtaining consent it will be recorded in the client's notes that:

       - Information has been discussed with the client on the known/possible harmful
       effects of administration into an unlicensed site, and that using the licensed route is
       safer

       - It is in the best interests of the patient that the injection is administered into an
       unlicensed site.

       - The case plan contains a date for review of administration into the unlicensed site.

      The patient's General Practitioner must be notified of the use of an unlicensed site and
       the patient asked to report any difficulties.
                                                                 Compiled by Sally Simmonds
                                                                  Head of Nursing (MH & LD)
                                                                                        19/4/02

                                                                  Updated (for new organisation)
                                                                                   Kevin Smith
                                                                    Head of Pharmacy and R&D
                                                                                         3/1/05


Nursing and Midwifery Council (2002). Guidelines for the Administration of Medicine.
London: NMC
Powys Local Health Board (2003). Policy and Procedure for Consent: Wales




Page8 of 8      Created 28.8.2002 Reviewed 1.11.2003, 20.12.2004
                 POWYS LOCAL HEALTH BOARD

Medicines Policies – Section 2
Revision              Date                Purpose of                    Planned
                                          Issue/Desciption              Review Date
                                          of Change
2002-2a               August              Addition to 2002              1/9/2004
                      2002                Medicines Policies
                                          document
2004-1                December            Minor Update                  1.12.2006
                      2005




Responsible Officer                       Approved By                   Date
Head of Pharmacy                          Clinical Audit


                                          Prescribing &
                                          Therapeutics                  18.2.2005
                                          Committee



PROPRIETARY INFORMATION
This document contains proprietary information belonging to the Powys Local Health
Board. Do not produce all or any part of this
document without written permission from The Powys Local Health Board.


Medicines Policies
The safe and secure handling of medicines, incorporating Prescribing, Administering,
Ordering, and Storage

Purpose
This document is designed to help ensure the safe use of medicines within Powys.

Scope
All staff who handle medicines, including clinical staff, transport, hotel services, and
managers.
All staff are reminded that they must adhere to these policies.

Please advise of any errors omissions, amplifications, suggestions etc – for inclusion
or alteration. Thank you.
Kevin Smith 2002
Head of Pharmacy
Powys Local Health Board
For Drugs and Therapeutics Committee



Page 1 of 3                                                                                1
                 POWYS LOCAL HEALTH BOARD

Medicines Policy Section 2

USE OF UNLICENSED MEDICINES

2.1 In the UK no medicine can be marketed for human use without a Product
    Licence (PL) granted by the Licensing Authority (Ministry of Health). The PL
    specifies the indications for which a product may be used and also the dose, route
    of administration etc. Licensing arrangements are determined by the Medicines
    Act 1968 and implemented through the Medicines and Health Care products
    regulatory Agency (MHRA).



2.2 Unlicensed medicines fall into 4 broad categories:

   1. Products derived from licensed medicines and prepared by the NHS or
      commercial unit with a "specials" manufacturing licence or prepared in a
      hospital pharmacy under a Medicines Act exemption.
Eg liquids for patients with swallowing difficulties
low dose formulations for children
intravenous preparations
   2. Products for which a NHS pre-packed medicines licence has yet to be given,
      but available and licensed outside the UK.

   3. Clinical Trial medicines.

   4. Medicines used outside the terms of the Product Licence eg unlicensed
      indication, dose, route.

2.3 Negligence Liability
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.

2.4 Strict Product Liability (or liability without fault)
The Product Liability Directive (EEC/85/374) and the Consumer Protection Act 1987,
makes the producer or supplier liable for damage caused by a defect in the product.
The product can be considered defective on the basis of what the patient is entitled to
expect. This may be affected by the verbal and written information and warnings
given to the patient.

2.5 Practical Implications

The responsibility for use of unlicensed medicines lies with the prescriber. The
supplying pharmacy department will indicate that a medicine supplied has no UK
license (but will not normally know when a medicine is being used in an unlicensed
way). Visiting pharmacists will note use of unlicensed dosages and routes. Unlicensed
indications will also be identified to prescribers where a pharmacist is part of a multi-


Page 2 of 3                                                                             2
                 POWYS LOCAL HEALTH BOARD

disciplinary team meeting or ward round, but where this does not happen doctors are
advised to ascertain whether they are using medicines in a licensed way, before
prescribing.
Unlicensed medicines should only be used to fulfill the special needs of an individual
patient (MHRA). Use of an unlicensed medicine on a wider scale eg for routine stock
use, must be approved by the Prescribing and Therapeutics Committee.

2.6 Trust Procedure
      The DGH pharmacy department will advise prescribers of the unlicensed
       nature of the medicine at the time of dispensing.

      Prescribers should consider carefully the use of unlicensed medicines and only
       use this form of therapy when the benefits outweigh the risks and where there
       is no licensed alternative available.

      Prescribers must obtain properly informed consent to treatment.

      Prescribers should inform their medical colleagues (especially General
       Practitioners) of the medicine's licence status when advising them to use
       unlicensed medicines.




Page 3 of 3                                                                          3
                              Medicines Policies
                             Section 3 Cover sheet

  Rev      Date       Purpose of Issue/Description of       Planned Review
                      Change                                Date
  2002-    Aug 2002   Revised version of 1997 document      1/10/ 2004
  3A                  Section 3 Prescribing at a distance



  2004-1   Nov 2004   Updated Document                      1/10/2006




     Responsible Officer              Approved by                 Date


  Head of Pharmacy          Prescribing &
                            Therapeutics Committee

                            Management Team

                           PROPRIETARY INFORMATION-

This document contains proprietary information belonging to the Powys Local
   Health Board. Do not produce all or any part of this document without
          written permission from The Powys Local Health Board.
                    POWYS LOCAL HEALTH BOARD

MEDICINES POLICIES
     The safe and secure handling of medicines, incorporating prescribing, administering,
     ordering, and storage

PURPOSE
    This policy is a section of the Powys LHB Medicines Policy, designed to ensure the
    safe use of medicines within Powys.
    Staff are reminded that they must adhere to these policies.

SCOPE
     The policy applies to all Medical and Nursing staff, who prescribe, administer and
     supply medication.


AUTHOR: Kevin Smith reviewed with minor updates, December 2004
Update due November 2006




Page 2 of 5
                     POWYS LOCAL HEALTH BOARD


SECTION 3 PRESCRIBING AT A DISTANCE

3.1    POLICY STATEMENT

It is the responsibility of the prescriber to ensure that the patients anticipated medication
needs are written up on a prescription sheet, e.g. using “as required” medication, and
treatment plans. This is particularly important where medical attendance is not standard on a
daily basis.

Prescribing at a distance has been shown to be more risky, for patients, than prescribing by
the patient’s bedside, and should not be routinely undertaken.

Instruction by telephone to a qualified nurse to administer unprescribed medication is deemed
by The Nursing and Midwifery Council to be unacceptable. In exceptional circumstances
where the medication has been previously prescribed and the prescriber is unable to issue a
new prescription but where changes to the dose are considered necessary, the preferred
method is fax or e-mail. This should be the primary method used when the presence of a
doctor to write on the administration chart is not possible. Rarely, in Powys, prescribing at a
distance will have to be by telephone.
Powys Local Health Board will support staff in enforcing this policy.

Only in emergency situations should fax, email, or telephone orders for items not previously
prescribed, be given, or accepted.

The protocol below must be followed.


REFERENCES:
     Milam T. (2001) Written communication regarding verbal orders/ Professional
     Advisory Service. London. UKCC
     The Nursing and Midwifery Council (2002). Guidelines for the Administration of
     Medicines. London
     Duthie Report DoH 1988




Page 3 of 5
                     POWYS LOCAL HEALTH BOARD

PRESCRIBING AT A DISTANCE

3.2 PROTOCOL FOR CHANGE OF DOSAGE OF PREVIOUSLY PRESCRIBED
MEDICATION

PURPOSE: The protocol outlines the standards to be followed by qualified nursing staff
when dosage alterations are required for currently prescribed medication. It should only be
used in exceptional circumstances where a patients condition deteriorates and it would be
detrimental to the patients health to await a medical examination, or where there is likely to
be a significant delay in obtaining a medical examination. The preferred method is by fax or
e-mail but changes to dosage can be accepted by telephone if the required technology is not
available
                         Standard                                      Rationale
The qualified nurse will fully describe the patient’s     To ensure the medical
condition and current medication to the medical           practitioner has adequate and
practitioner. The information should include the          current information
patients full name address date of birth and registration
number
All information given will be recorded in the patient’s To meet The N&MC record
record                                                    keeping requirements
A faxed prescription sheet should be sent to the nurse    To minimise the risk of
in charge. The nurses will only administer the            medication error
medication if the fax is legible and all the patients
details (name, address, date of birth registration
number) are included
    If technology is not available and a change of dose To minimise risk of
    is undertaken via telephone the nurse, who has        misinterpretation
    given patient details and history, should take steps
    to minimize risk of mishearing, or
    misunderstanding instructions, eg
            a. by repeating back the instructions to the
                prescriber (after writing them down).
            b. by asking for the instructions to be
                repeated in full to another qualified
                nurse, where fax, email, or other means
                are not available.
            c. spell out drug names
            d. for numbers in the teens, (for example
                14), say “one – four units”, not
                “fourteen units” which can be
                misinterpreted as “forty units”
            e. for “ten” say “one – zero” to avoid
                confusion with “two”
            f.
The standard checking procedure for the safe              To comply with Powys Local
administration of medicines will be followed              Health Board medicines policy
The doctor or designated deputy will counter sign the     Good practice as recommended
medical record as soon as possible, and in any case       by the N&MC, Duthie Report.



Page 4 of 5
                     POWYS LOCAL HEALTH BOARD

within 12 hours for injectable preparations, or within
24 hours for other medicines.
Failure of the prescriber to counter sign the medical    To ensure good practice, and to
record should be reported to the senior nurse and        ensure we can learn from
intermediate care manager. Further unwritten orders in   incidents.
any form will not be accepted until the issue is
resolved. An IR 1 form should be completed if this
situation occurs


3.3 Emergency Situations

In emergency situations, when medication has not previously been prescribed, but a

nurse considers that it is in the patient’s best interest to administer, because there is a

duty of care, and because not acting would be detrimental to the patient, he or she

should be aware:

       The LHB cannot remove or assume the nurses' professional accountability.

       HOWEVER The LHB would support the nurse in any legal action, providing

       the nurse complied with the principles of the above "protocol for change of

       dose"

       An IR1 form must be completed

It is not acceptable for any nurse employed by Powys Local Health Board to be

requested to administer medication without a written prescription unless the criteria

within the policy and protocol are met

"LIFE THREATENING CIRCUMSTANCES" SEE ALSO SECTION 7

Created 11.10.2002 Reviewed 1.12.2004




Page 5 of 5
Powys Local Health Board
Medicines Policies – Section 4 Legibility of
prescriptions
Revision              Date                Purpose of                    Planned
                                          Issue/Desciption of           Review Date
                                          Change
2002-4a               August 2002         Revised version of 1997       1/9/2004
                                          document

2004-1                Jan 2005            Update                        1/12/2006

Responsible Officer                       Approved By                   Date
Head of Pharmacy                          Management Team

                                          Prescribing &
                                          Therapeutics
                                          Committee


PROPRIETARY INFORMATION
This document contains proprietary information belonging to the Powys Local Health
Board. Do not produce all or any part of this
document without written permission from The Powys Local Health Board.


Medicines Policies
The safe and secure handling of medicines, incorporating Prescribing, Administering,
Ordering, and Storage

Purpose
This document is designed to help ensure the safe use of medicines within Powys.

Scope
All staff who handle medicines, including clinical staff, transport, hotel services, and
managers.
All staff are reminded that they must adhere to these policies.


Please advise of any errors omissions, amplifications, suggestions etc – for inclusion
or alteration. Thank you.

Kevin Smith 2004
Head of Pharmacy
Powys Local Health Board
For Prescribing and Therapeutics Committee
                POWYS LOCAL HEALTH BOARD

Section 4 Legibility of Prescriptions

  4.1. The implications of the N&MC Standards for the Administration of Medicines
       are that a qualified nurse, acting in the interests of the patient, should (among
       other activities)


      4.1.1. Question the medical practitioner or pharmacist, as appropriate, if the
           prescription or container information is illegible, unclear or unambiguous
           or incomplete, or where it is believed that the dosage or route of
           administration falls outside the product licence for a particular substance,
           and where believed necessary, refuse to administer the prescribed
           substance. This should be reported as a near miss on IR1 form / Datix
           System.


  4.2. Within Powys Local Health Board, nurses should not administer medicines
       where the prescription record is illegible or incomplete.


  4.3. A prescription should be considered illegible or incomplete if
    it is not immediately clear what the prescriber has written.
    if the administrating practitioner feels it is necessary to seek confirmation or
       clarification , from another colleague, or other health professional, of what is
       written on the prescription card
    the practitioner feels there is a need check in patient’s medical or nursing notes
       to confirm their interpretation
    the practitioner feels there is a need check the medicines within the medicines
       trolley or cupboard for confirmation
   In any of these circumstances it is potentially dangerous to administer a
   medicine.

   4.4 The medical practitioner should be advised immediately so that the chart can
       be amended. The medicine should not be administered until the prescription
       has been rewritten, using the appropriate approved name for the medicine.

   4.5 Nurses should not write or rewrite prescription charts, or items on prescription
       charts, unless they are qualified to do so for specific named medicines, for
       which they should then sign.


Created 11.10.2002 Reviewed 1.12.2004




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                 POWYS LOCAL HEALTH BOARD


Medicines Policies – Section 5
Revision              Date                Purpose of                    Planned Review
                                          Issue/Desciption of           Date
                                          Change
2002-5a               August 2002         Addition to 2002              1/9/2004
                                          document
                                          Update
2004-1                December
                      2004
Responsible Officer                       Approved By                   Date
Head of Pharmacy                          Management Team

                                          Prescribing &
                                          Therapeutics Committee        18.2.05 (update)
                                                                        11/10/2002


PROPRIETARY INFORMATION
This document contains proprietary information belonging to the Powys Local Health
Board. Do not produce all or any part of this
document without written permission from The Powys Local Health Board.


Medicines Policies
The safe and secure handling of medicines, incorporating Prescribing, Administering,
Ordering, and Storage

Purpose
This document is designed to help ensure the safe use of medicines within Powys.

Scope
All staff who handle medicines, including clinical staff, transport, hotel services, and
managers.
All staff are reminded that they must adhere to these policies.

Please advise of any errors omissions, amplifications, suggestions etc – for inclusion
or alteration. Thank you.
Kevin Smith 2004
Head of Pharmacy
Powys Local Health Board
For Prescribing and Therapeutics Committee
.Update December 2004




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                 POWYS LOCAL HEALTH BOARD

SECTION 5 Re-use of patients drug charts for planned re-
admission

   5.      Re-Use of patients drug charts on planned admission for respite care

   5.1     Except for stable planned admissions (eg respite care patients) a new chart
           must be written for each admission of a patient.

   5.2     For repeated planned admission of stable patients, the drawbacks of re-use
           of medication charts are probably outweighed by the benefits.


   5.3     The admitting medical officer must make all alterations to the chart as
           described below.


   5.3.1   The chart must be clearly marked “For planned admission”

   5.3.2   At each discharge, a double line must be drawn down the chart.

   5.3.3   At each re-admission, a two-column gap, in the administration record,
           should be created, where the admitting doctor must sign each item, to
           authorise administration.


   5.3.4   Where a dosage, dose timing, or formulation is changed, the item must be
           cancelled and re-written, not altered. (A single solid diagonal line should
           be put through the item, and through remaining administration recording
           space.)

   5.3.5   Where a new, or revised item is written, administration recording space up
           to the current administration date column should be lined through


   5.4     All administration records must be in the same column, for the same date,
           and it must be unambiguous on which date a medicine was provided

   5.5     Continuation sheets must not be used, in Powys.

   5.6     The smallest number of charts possible should be in use at one time. This
           will mean rewriting onto new charts when cancellations would mean an
           extra chart would otherwise need to be used.




Created 11.10.2002 Reviewed 1.11.2004




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                     POWYS LOCAL HEALTH BOARD

SECTION 6             Clinical Trials Involving Pharmaceutical Products


   Liability issues relating to clinical trial medicines - Drugs for Clinical Trial

      6.1. Approval and pre Drug trial requirements

      6.1.1. All clinical trials must be approved by the Dyfed Powys Research Ethics
      Committee.

      6.1.2. Unless there is approval by this Committee: -

               The pharmacy (Nevill Hall, Bronglais, as appropriate) will not stock or
               supply any clinical trial drugs and Nurses must not administer a drug as
               part of a clinical trial

      If there is any doubt regarding the approval then a Nurse must contact a Senior
      Nurse/Doctor or the Pharmacy Department.

      6.1.3. All drugs for clinical trials conducted within The Powys Local Health Board
      are stored in and supplied by the hospital Pharmacy. Under no circumstances must
      clinical trial drugs be allowed on the wards without the approval of the relevant
      Pharmacy Department. The clinical trialists must make provision for re-imbursing
      pharmacy costs of involvement.

      6.1.4    When a prescriber takes part in a study initiated by a pharmaceutical
      company, it is for the company to obtain a Clinical Trials Certificate or Clinical Trials
      Exemption. Any research study must have been previously identified to the Powys
      Research and Development committee

      6.1.5. Before starting the trial and only when the study has been approved by the
      local ethical committee, prescribers must seek no fault compensation cover from their
      employer for the research subject, ensure that their medical defence organization
      membership permits the proposed activity, and if the study is sponsored by a
      pharmaceutical company, that it will comply with the ABPI's guidelines on
      compensation.



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                    POWYS LOCAL HEALTH BOARD

      6.2.     Procedural requirements during the clinical phase of the drug trial

      6.2.1. Any supplies of medicines must be made by the relevant supplying hospital
      pharmacy department. Clinical trial drugs (and placebos) must not be stored on Powys
      Local Health Board sites. Where drugs for use in a clinical trial must be immediately
      available at the point of use (ie before a patient is identified) the appropriate pharmacy
      department must be contacted for advice (eg on safe and secure storage, and any
      labelling requirements).

      6.2.2. When a prescriber initiates a medicine study using an unlicenced medicine he
      or she must notify the Licencing Authority giving details of the trial and the method of
      supply of the medicines to be used. The Licencing Authority has 21 days to raise
      objections, although the Authority may extend this upto 63 days if required. If no
      objections are forthcoming the trial can start (normally required for ethical approval)

      6.2.3. At the end of a study a prescriber may wish to continue to prescribe the trial
      medicine for those patients who have benefited, but such a provision must be included
      in the original protocol. If there is no such provision it would be possible to continue
      using the medicine on a "named patient" basis but in this event the ethical committee
      must be consulted, as must the Licensing Authority and the manufacturer. The legal
      standing of the medicine or animal safety data may make a longer period of human
      exposure unjustified.

      6.2.     Responsibilities of the Pharmacy Department

      The legal and indemnity issues surrounding supply of clinical trial materials are
      complex. Once a medicine trial has received ethical committee approval, the trialist
      must approach the relevant Principle Pharmacist and seek agreement for the clinical
      trial supplies to be made to patients via the relevant supplying pharmacy department.
      The Principle Pharmacist must ensure that all legal, indemnity and professional issues
      are adequately covered before agreeing to the trial proceeding.


      References

      Duthie Report 1988


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                   POWYS LOCAL HEALTH BOARD


 Rev    Date           Purpose of Issue/Description of      Planned Review
                       Change                               Date
 B      14/10/04      Medicine Policy: SECTION 7:           01/08/06
                      Supply or Administration of
                      Medicines by Practitioners without
                      authority to prescribe-Review
   Responsible                     Approved by                      Date
       Officer
 Head of Pharmacy      Drugs & Therapeutics Committee       05/12/03
 Kevin Smith
                       Clinical Governance, Audit and
                       Medical Team



                       Clinical Governance Risk
                       Management Committee
                        PROPRIETARY INFORMATION
This document contains proprietary information belonging to the Powys Local Health
 Board. Do not produce all or any part of this document without written permission
                                 from the Board.




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                        POWYS LOCAL HEALTH BOARD

         SECTION 7                 SUPPLY OR ADMINISTRATION OF MEDICINES BY
                                      PRACTITIONERS WITHOUT AUTHORITY TO
                                                        PRESCRIBE.


            7.1.   Supply of medicines



                   "Supply" refers to the provision of medicines for a patient to take away
                   (such as Take home medication, outpatient medication, or MIU pre-
                   packs - see also section on Dispensing" in section 14).



            7.2.   Administration of medicines
                   "Administration" refers to the immediate use of medicines for a patient
                   in a ward, outpatient, or MIU.
0.   ,




            7.3. Legal considerations for supply and administration
            7.3.1. Prescription Only Medicines (POMs) can only be administered to
            patients in Powys hospitals where there is a patient specific written direction
            (in Powys hospitals this means an entry on an approved prescription
            document, i.e. prescription chart, TTO form, MIU card, etc), or where there is
            an agreed patient group direction (PGD) in place. Providing that the
            administering practitioner has been trained, and has agreed to its use.


                   7.3.2. Similarly Prescription Only Medicines, and pharmacy only
                   medicines (P) may only be supplied against a direction written on an
                   approved prescription document, or against an agreed PGD, as above.


                   7.3.3. Nurses, (for example), cannot supply or administer POM
                   medicines where no pre-existing, valid, prescription (or patient specific
                   written direction), or PGD exists.




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                    POWYS LOCAL HEALTH BOARD

      7.3.4. This principle also applies to medicines, which are not prescription only
      medicines. In this case it is Powys LHB policy (rather than law), based on
      advice on good practice by NMC, and the Welsh Assembly, that there will be
      a Powys approved protocol supporting administration or supply. Note that
      oxygen and Entonox (nitrous-oxide/oxygen gas mixture) are classed as
      medicines, when used to treat patients.


               7.3.5. Any administration of medicine must be noted on the
               prescription
      administration chart. In this case the nurse is not prescribing, but recording
      the fact of administration. The entry must therefore be on the "once only"
      section

      7.4. Life Threatening Emergencies


      7.4.1. In life threatening emergency situations, practitioners will need to use
      their professional judgement in determining whether it is appropriate to wait
      for medical attendance before administration of any medication, where there
      is no prior prescription, and no appropriate PGD, taking into account their own
      knowledge and experience, and the risks to the patient. (Refer to section 3:
      Prescribing at a Distance)



      7.4.2. Legally, any practitioner, without a prescription, may administer the
      following drugs, in a life-threatening emergency. However, any nurse, who
      expects to be in a position where he or she may need to use these drugs,
      should be appropriately trained and be accredited to use an appropriate
      patient group direction, where available.

                     Adrenaline ( epinephrine) injection
                     Atropine injection
                     Chlorpheniramine injection (Chlorphenamine injection)
                     Dextrose injection (strong)
                     Glucagon injection




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                    POWYS LOCAL HEALTH BOARD

                      Hydrocortisone injection


               An IRI form must always be completed where administration of a
               POM was carried out without prior prescription or PGD .



      7.5. Patient Group Directions (PGD). Use and Development.

               7.5.1 Background
      The majority of clinical care should be provided on an individual, patient-
      specific basis. The supply and administration of medicines under patient
      group directions should be reserved for those limited situations where this
      offers an advantage for patient care (without compromising patient safety),
      and where it is consistent with appropriate professional relationships and
      accountability.


               7.5.2 Policy statement

      There are only two legal ways for a practitioner, without prescribing authority,
      to provide medicines.

               1) Where there is a patient specific written direction, usually, but not
                  exclusively, a prescription written on a prescription sheet or an MIU
                  prescription form, or outpatient prescription, or ward take home
                  medication prescription. The crucial part here is that it must be
                  specific to the patient being treated - i.e. they have to be named in
                  the written direction, or the direction must be on documentation
                  specific to that patient.

               2) Where there is a patient group direction in place, approved by the
                  LHB, and to which the nurse is trained to use, and has signed
                  agreement to use.


      There is an exception for supply/administration of GSL medicines, and
      administration of P medicines, but the N&MC advice, (and Powys LHB




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                    POWYS LOCAL HEALTH BOARD

      supports this in Powys), is that they should also have PGD equivalent
      protocols to support their use.

      Practitioners need to ensure that their practice is covered by one of these two
      alternatives when supplying or administering medicines to patients. If in
      doubt, please contact the relevant nursing manager, Head of Pharmacy, or
      the medicine management team.


      7.5.3 Patient Group Direction Development
      The development of patient group directions will be co-ordinated by the Head
      of Pharmacy.


      Development of each PGD should include a senior pharmacist, a senior
      medical clinician,

      (a legal requirement), and a member of the group of staff who will use the
      PGD.

      Documents will be drawn up using research/good practice based evidence
      that is current, All documents must include references of evidence used

      A consultation period will be undertaken with clinicians that will operate the
      PGD, medical staff working within the areas where the PGD will be operated,
      and appropriate specialist opinion will be sought. Comments received during
      the consultation period will be retained while the document remains
      operational


               A patient group direction must be reviewed at least every two years.

      The latest WHC circular on PGDs should be referred to when deciding
      whether a PGD is appropriate, and in determining what should be
      included in the document

               7.5.4 Items which must be included in a PGD

      The legislation specifies that each patient group direction must contain the
      following information:




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                     POWYS LOCAL HEALTH BOARD

                  the name and address of the business to which the direction
                   applies;
                  the date the direction comes into force and the date it expires;
                  a description of the medicine(s) to which the direction applies;
                  class of health professional who may supply or administer the
                   medicine;
                  signature of a doctor or dentist, as appropriate, and a pharmacist;
                  signature by an appropriate health organisation;

                  the clinical condition or situation to which the direction applies;
                  a description of those patients excluded from treatment under the
                   direction;
                  a description of the circumstances in which further advice should be
                   sought from a doctor (or dentist, as appropriate) and arrangements
                   for referral;
                  details of appropriate dosage and maximum total dosage, quantity,
                   pharmaceutical
                  form and strength, route and frequency of administration, and
                   minimum or maximum period over which the medicine should be
                   administered;
                  relevant warnings, including potential adverse reactions;
                  details of necessary follow-up action and the circumstances;
                  a statement of the records to be kept for audit purposes



      A template is available to help ensure that all this information is included, and
      to set a standard format for PGDs in Powys


               7.5.5 Patient Group Direction Authorisation
               The patient group direction must be signed by a senior doctor (or, if
               appropriate, a dentist) and a senior pharmacist, both of whom should
               have been involved in developing the patient group direction. The
               Director responsible for Clinical Governance, or their nominated
               deputy, should also sign documentation on behalf of the LHB. It is a


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                     POWYS LOCAL HEALTH BOARD

               legal requirement that each PGD is authorised by the LHB. The
               person signing on behalf of the LHB should not be the author of the
               document.


      In Powys PGDs should be approved by the D&T committee before presenting
      the document to the clinical governance lead for signature. The D&T
      committee may delegate this function to a consultant serving on the
      committee, to allow documents to become operational to meet the needs of
      the service. The nominated consultant may also be the lead doctor in the
      development of the PGD. . If the doctor nominated by the D&T committee is
      not the lead doctor for the development of the document, the name and
      signature of the doctor developing the PGD and the name and signature of
      the nominated consultant should appear on the document.


      The name of the consultant delegated this responsibility should be recorded
      in the minutes of the D&T committee and should be reviewed annually.


               When all those who are required to sign the document to meet legal
               and organisational requirements have done so it will become
               operational.


      Where a PGD has not already been presented to the D&T committee,
      new/revised PGDs should be notified to the first D&T committee meeting
      following adoption by the nominated consultant. Documents will then be
      forwarded to the Clinical Governance Risk Management committee for
      reporting


      The medicine management team will retain a signed master copy of each
      document


      7.5.6 Distribution of new/revised documents

      Operational documents will be posted on the Intranet and a member of the
      medicine management team will notify staff by e-mail that they are
      operational.


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                      POWYS LOCAL HEALTH BOARD

      7.5.7 Staff who can use a PGD

      The qualified health professionals who may supply or administer medicines
      under a patient group direction are nurses; midwives; health visitors;
      optometrists; pharmacists; podiatrists; radiographers; orthoptists;
      physiotherapists and ambulance paramedics. They can only do so as named
      individuals and must be issued with a personal copy of each PGD they
      operate which should be signed by the member of staff wishing to operate the
      PGD and the authorising clinician/manager

      The Head of Podiatry, Head of Radiography, and the Director of Nursing are
      designated with the responsibility to ensure that only fully competent, qualified
      and trained professionals operate within directions. (See policies for each
      discipline)


                   All professions must act within their appropriate Code of
                    Professional Conduct.


                   The LHB will maintain a register of PGDs that it authorises this will
                    include the review date. This will be held in the medicines
                    management office


                   There will be a database of PGDs and practitioners authorised
                    to use them held in the medicines management office

             Any supply (or administration) under a PGD must comply with the
             Powys medicines policy, and any relevant legislation that supersedes
             those policies.



             7.5.8. Process for the authorisation of patient group directions (PGDs)
                                             Purpose

             To implement a standard process for the authorisation of PGDS, which
             will maintain patient safety and allow practitioners to expand and
             develop practice within, agreed parameters




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                  POWYS LOCAL HEALTH BOARD

            Scope

               To ensure patient safety when practitioners operate PGDS
               To ensure practitioners use evidence based information to practice.
               To ensure that practitioners recognise their limitations and remain
                within their realm of competency
               To identify practitioners training needs and develop appropriate
                training programmes to meet these needs.

            The Process

                    1. Notification that a PGD is operational will be by written or
                       electronic confirmation by a Pharmacist or Practice
                       Development Nurse from the Medicine Management Team

                    2. Operational PGDS will be notified to the appropriate Head of
                       Nursing, The MIU Lead Nurse, Head of Allied Health
                       Professionals and The Clinical Governance Facilitator and
                       Shire Quality & Performance Managers

                    3. Each time a PGD is developed or amended the practitioner
                       will need to be authorised to operate the PGD.

                    4. Copies of the operational PGDS will be held within each
                       clinical departments (Purple folder) that they pertain to,
                       together with a list of practitioners that are authorised to
                       operate the PGD. The appropriate Head of Service will
                       retain a copy of the list of authorised practitioner’s and a
                       copy will be sent to the Medicines Management Team.

                    5. Authorisation of fully competent, qualified and trained
                       practitioners to operate a PGD is the responsibility of the
                       Head of Service. (NAW 2003) This task should only be
                       delegated to competent clinical managers. (minimum
                       nursing grade G to authorise the use of a PGD) A list of
                       managers authorising PGDS will be held by the Head of
                       Service and a copy will be sent to the Medicines
                       Management Team
                          SEE CHECK LIST AT THE END OF THIS SECTION

                    6. A clinical manager who has been delegated the task of
                       authorising the use of PGDS cannot authorise themselves to
                       use PGDS. Authorisation for these practitioners should be
                       undertaken by the appropriate Head of Service



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                  POWYS LOCAL HEALTH BOARD


   Authorisation of a practitioner to operate a PGD

                   1.       Once a PGD is operational, each practitioner identified as
                        able to use the PGD will need an individual interview with the
                        authorising manager. The interview should be by
                        appointment and the practitioner should be supplied with the
                        relevant copy of the PGD beforehand and should be
                        requested to bring to the interview their professional portfolio.
                        The checklist will be used during the interview to identify the
                        practitioner is competent and understands their responsibility
                        and accountability when using a PGD.

                   2.       If the practitioner meets the training requirements and has
                        demonstrated knowledge of the PGD, the authorising
                        manager should then sign two copies of the PGD. The
                        practitioner should retain a personal copy and the Head of
                        Service should retain a copy. A photocopy of the
                        authorisation page should also be held in the practitioners
                        clinical department and a copy should be forwarded to The
                        Medicines Management Team.

                   3.      The action of signing both copies of the PGD document
                        authorises the practitioner to begin using the PGD

                   4.       If, during the interview, the practitioner or the Authorising
                        manager expresses concern about using the PGD, or if the
                        practitioner has not demonstrated an understanding of the
                        PGD, the interview should be terminated and rearranged at a
                        later date. During this period, issues of concern should be
                        discussed and any identified training needs should be
                        addressed. A PGD should not be authorised for operation
                        unless both parties agree.


      7.6.   Protocols for the administration and supply of GSL medication
         and administration of pharmacy only medication


             7.6.1Development and authorisation of the protocol document for
             medication will use the same process as for PGD development A
             signed master copy of each document will be retained by the
             medicines management team




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                   POWYS LOCAL HEALTH BOARD

      There is a template available to help ensure that all information is included,
      and to set a standard format for protocols for medication in Powys


             7.6.2 Each member of staff wishing to use a document must sign the
             list attached to each protocol indicating they have read the document
             and accept accountability and responsibility for meeting the
             requirements of the document


             7.6.3. It is the responsibility of the ward manager/team leader to
             ensure all members of staff are made aware of new/reviewed
             protocols, as they become operational. It is the responsibility of the
             ward manager/team leader to forward the completed lists to the
             medicines management office


                The LHB will maintain a register of protocols that it authorises
                 including a review date. This will be held in the medicine
                 management office


                There will be a database of protocols and practitioners using
                 them held in the medicine management office

                All professions must act within their appropriate Code of
                 Professional Conduct


      7.7.   Patient Specific Directions-PSD


      Development and authorisation of the PSD document for medication will use
      the same process as for PGD development. The additional requirements are:

                    1) Where the document is used in GP premises in the primary
                   care setting. The document must be signed by the lead GP of
                   the specific practice and carry the practice stamp.


                    2) To be patient specific the document must include the patients
                    name, address and/or date of birth and are signed by a doctor.



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                  POWYS LOCAL HEALTH BOARD

                    For immunisation programmes a list with the appropriate
                    information may be attached to one document, but a doctor
                    should sign each page of the patient list.


                    3) All GP’s who may authorise use of the PSD for groups of
                    patients should provide a specimen signature on the appropriate
                    list in the document.


      There is a template available to help ensure that all information is included,
      and to set a standard format for PSDs for medication in Powys


      The Practice will retain a signed master copy of each document and the
      medicine management team will retain a copy of each document that will be
      operated by LHB staff.


             7.7.2. Each member of staff wishing to use a document must sign the
             appropriate list attached to each PSD indicating they have read the
             document and accept accountability and responsibility for meeting the
             requirements of the document. A copy of the list should be retained by
             the practice and a copy forwarded to the LHB medicine management
             team if LHB employees are included on the list.




References


Welsh Health Circular




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                    POWYS LOCAL HEALTH BOARD

SECTION 9            `        ADMINISTRATION OF MEDICINES


      NB When Doctors are administering drugs by the intravenous route where
      calculations are involved, it is theLHB’s policy to have the details checked by a
      second person either a Registered Nurse, another Doctor (or a Pharmacist, where
      available), and the second practitioner should also sign the prescription
      administration chart.

      9.1 The Prescription
      The practitioner administering medicine against a prescription written by a registered
      medical practitioner, can reasonably expect that the prescription satisfies the
      following criteria.


      9.1.1. That it is based, whenever possible, on the patient’s awareness of the purpose
      of the treatment and consent (commonly implicit).


      9.1.2. That the prescription is clearly written and that the entry is indelible and dated
      and signed. (see also “Legibility of prescriptions” above.) Any allergies known are
      recorded, or ‘no known allergies’ is recorded, on the chart.


      9.1.3. That where the new prescription replaces an earlier prescription, the latter has
      been cancelled clearly and the cancellation signed and cancellation date appropriately
      indicated by an authorised registered medical practitioner. Check that entries for more
      than one does of the same medicines are intentional, not due to non cancellation


      9.1.4. that the prescription provides clear identification of the patient (preferably an
              addressograph) hospital number, name, address, date of birth.


      9.1.5. That the substance to be administered is clearly specified, and where
      appropriate, its form (eg tablet, capsule, suppository) stated, together with the
      strength, dosage, frequency and route of administration




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                    POWYS LOCAL HEALTH BOARD

      9.1.6. That the registered medical practitioner understands that the exceptional
      administration of medicines (eg faxed instructions) strictly follows LHB medicines
      policy on “prescribing at a distance”.


      9.2.    Responsibility and Accountability


      “The Administration of medicines is an important aspect of the professional practice
      of persons whose names are on the nursing and Midwifes Council Register. It is not
      solely a mechanistic task to be performed in strict compliance with the written
      prescription of a medical practitioner. It requires thought and exercise of professional
      judgement …” (N&MC 2002)


      9.3.    Principles for the Administration of Medicines


      The most up to date version of the N&MC guidance on the administration of drugs
      must be adhered to.

      "A registered nurse is accountable for his/her actions and omissions. In administering
      any medication, or assisting or overseeing any self-administration of medication
      he/she must exercise professional judgement and apply his/her knowledge and skill in
      the given situation."


      9.4.    Professional Accountability


      In exercising professional accountability in the best interests of patients the
      practitioner must


                 Know the therapeutic uses of the medicine to be administered, its normal
              dosage, side effects and contra-indications


                 Be certain of the identity of the patient to whom the medicine is to be
              administered




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                    POWYS LOCAL HEALTH BOARD

                 Be aware of the patient’s care plan


                 Check that the prescription, or the label on the medicine dispensed by a
              pharmacy, is clearly written and unambiguous and matches the product to
              which it is attached.


                 Check carefully, the prescription sheet, and the information provided on
              and in the relevant containers that they comply with each other.


               Have considered the dosage, method of administration, route and timing of
              the administration in the context of the condition of the patient and co-existing
              therapies

                 Check the expiry date of the medication to be administered

               Check that the patient is not allergic to the medication before
              administering it

                 Contact the prescriber or another prescriber without delay where contra-
              indications to the prescribed medication are discovered, where the patient
              develops a reaction to the medication, or assessment of the patient indicates
              that the medication is no longer suitable, or where it is believed the dose or
              route fall outside the product licence indications, or where interactions with
              other prescribed medicines may occur, or where a patient refuses medication
              and where that refusal may compromise their condition.


                 Refuse to prepare substances for injection in advance of their immediate
              use, and refuse to administer a medicine not placed in a container, or drawn
              up, by him/her, or in his/her presence


                 Make a clear accurate and immediate record of all medication
              administered, intentionally withheld or refused by the patient, ensuring any
              written entries and the signature are clear and legible




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                    POWYS LOCAL HEALTH BOARD

                 Where supervising a student nurse or midwife in the administration
              medicines clearly countersign the signature of the student


                 Be able to justify any actions taken

                 Be prepared to be accountable for the action taken

               Seek immediate medical aid if an error is made in the administration of a
              drug.

      9.5.    Other principles to consider

                 Controlling access to the ward medicine cupboards and Trolley (by keys or
              other means) is the responsibility of appointed nurse in charge of the ward (see
              section 13)


                 The responsibility remains with the appointed nurse in charge even if
              she/he decides to delegate the duty.


                 Any apparent loss or misuse of drugs must be reported immediately to the
              senior nurse. Pharmacy should also be contacted. In the case of controlled
              drugs the Powys LHB Head of Pharmacy must be informed immediately.


                 Nurses must not use medicines from the ward for themselves or other
              members of staff.


                 Cupboards must be locked at all times, except for access.


                 Medicine Trolleys must be locked and immobilised when not in use.


              When undertaking a ward drug round the trolley must never be left
              unattended in the ward area. If a nurse is interrupted during the drug
              administration round, the Trolley must be supervised by another authorised
              nurse or locked and immobilised.




Page 4 of 9
                    POWYS LOCAL HEALTH BOARD

              *A record of all registered nurses/midwives initials and full signature with
              printed name must be kept locally and it is the responsibility of the appointed
              nurse in charge of a designated clinical area to update this periodically


              In Powys LHB a system of one-nurse administration is used in community
              hospitals. To support safe practice and minimise risk Powys LHB Procedure
              for Single nurse drug administration will be adhered to.


              However there are some situations where a second authorised nurse (first
              or second level) must check all aspects of medication administration. These
              include:


                        calculation of a drug dosage is required
                     some drug administrations require complex calculations to ensure the
                     correct volume or quantity of medication. To minimise risk of error, in
                     these situations a second nurse is required to check all aspects of
                     administration and advice from pharmacists can be obtained where
                     there is any doubt.


                        Administration of medication to those under 16 years of age


                        Weight related dosage Calculation


                        Controlled drugs Security


                        Intravenous drugs ( including fluids) - follow Powys IVI Policy.


                        Where a bank nurse/agency nurse is employed to cover a shift,
                     unless the nurse involved is also employed to work on the ward under a
                     normal contract




Page 5 of 9
                    POWYS LOCAL HEALTH BOARD

                        Where there are two patients with same name on a particular ward
                     or where a patient is unable to verify his/her identity (e.g EMI patient )
                     – to minimise risk of drug administration error it is recommended that
                     administration procedure involves a second authorised nurse


                        Where a second nurse checks the administration of a medicine , the
                     identity of the checking nurse will also be recorded, however the
                     ultimate responsibility remains with the administering nurse.


                        For continuous administration (e.g. via intravenous infusion or via
                     driven syringe) record of nurses involved in setting-up the infusion will
                     be recorded in the multi-disciplinary notes, including a signature of the
                     second nurse involved. The first nurse should sign the drug
                     administration record. The bag or syringe should be labelled and
                     signed by both nurses involved.


      Note that advice from a pharmacist can be obtained at any time, if required.

      9.6.    Procedure for Single nurse Drug Administration

              Wash hands prior to administration of medicines


              Remove and unlock the drug trolley and take to the patients’ bedside. (The
              trolley must always be visible and is the sole responsibility of the nurse
              undertaking the drug administration.)


              Review the Patient’s prescription sheet and confirm identity of patient verbally
              (name and date of birth) and by checking patient number on identity wrist
              band with that recorded on the prescription sheet.

              When administering a medication against a prescription the nurse must ensure
              that the prescription is based whenever possible upon patient’s informed
              consent and awareness of the purpose of the treatment




Page 6 of 9
                    POWYS LOCAL HEALTH BOARD

              the prescription must


                 Be clearly written in indelible black ink, signed and dated.


                 Clearly identify the patient for whom the medication is intended Prior to
              undertaking the drug administration the nurse must ensure that the patients
              name, date of birth and hospital number are also recorded in the appropriate
              sections on the front cover and on the inside sheet of the prescription chart,
              where applicable.


                 Record the current weight of the patient on the prescription chart where
              dosage of medication is related to weight


                 Record any known allergy for the patient. Where there is no known allergy
              this section must be completed stating “NO KNOWN ALLERGY”. “None”,
              or “Nil” would also be acceptable. Where the section is blank confirmation
              should be obtained from the responsible medical officer, of allergy status.


                 Clearly specify the substance to be administered using its approved or
              brand name where appropriate and its stated form along with the strength,
              dosage, timing, frequency of administration, start and finish dates and route of
              administration.


                 Be signed and dated by the authorised prescriber


                 Not be for a substance to which the patient is known to be allergic or
              otherwise unable to tolerate


                 Check the expiry date of the medication to be administered and check box
              and label match.




Page 7 of 9
                    POWYS LOCAL HEALTH BOARD

      The nurse should have considered the dosage, method of administration, route and
      timing of the administration in the context of the condition of the patient and co-
      existing therapies, including the patient’s weight, especially if it is changing.


                 Follow good hygiene and hand washing practice


               After carefully checking the dosage, time and frequency of the prescribed
              drug, remove medication from its container without touching.


                 Where medication is dispensed as a liquid mixture or solution the bottle
              must be clearly labelled with date of opening /use by date. This also applies to
              use of multi-dose solution eye drops, ear drops and other multi-dose solutions.


                 When administering liquid medication, shake vigorously prior to pouring,
              unless informed otherwise. Holding at eye level, measure the required amount
              from the bottle ensuring correct dosage in millilitres.


                 Always check that the patient is not allergic to the medication before
              administering it


                 Remain with patient until medication has been swallowed, offering fluids
              or food where appropriate. If this activity is delegated (eg to an HCA), the
              nurse is reminded that the responsibility remains with the registered nurse.


                 Make a clear, accurate and immediate record of all medication
              administered, intentionally withheld or refused by the patient, ensuring any
              written entries are made in black ink and the signatures are clear and legible


                 On completing the drug round consider any special drug storage
              requirements that must be adhered to. e.g. some products may require to be
              stored at low temperatures/away from light, CD’s etc.




Page 8 of 9
                     POWYS LOCAL HEALTH BOARD

                Staff administering medicines should also be aware of the contents of other
                sections of this document particularly relating to medicine prescribing, and
                disposal


   References

   Milam. T (2001) Written communication regarding verbal orders/Professional Advisory Service.
   London: UKCC.

   Nursing and Midwifery Council (2002). Guidelines for the Administration of Medicines.
   London.

   The Royal Marsden Hospital Manual of Clinical Nursing Procedures 2000 (Fifth Edition)
   Blackwell Science

   Jacinta Meighan Davies
    February 2002

   Updated
   Kevin Smith
   December 2004




Page 9 of 9
                    POWYS LOCAL HEALTH BOARD

SECTION 9B                           LEGAL IMPLICATIONS IN
                                     ADMINISTERING DRUGS TO MENTAL
                                     HEALTH PATIENTS

              It is illegal to administer psychotropic drugs to a patient beyond those agreed
              on (mental health act) Form 38, or defined on Form 39 one of which should be
              attached to the prescription chart.
              Form 38 is filled in when a patient consents to treatment with the medicines
              included on the form 38. If the patient has not consented, for example when
              midway through a (MHA) Section 3 process, a second opinion must be sought
              from a doctor assigned by the Mental Health Act Commission. This doctor
              then fills in a form 39, a photocopy of which should be secured to the
              prescription chart. When a patient has consented to psychotropic medication
              being administered, a Form 38 should be completed (by the RMO) and
              attached to the prescription chart. Note that hypnotics and anxiolytics would
              be classed as psychotropic drugs.
              Where a practitioner is unsure of the legal position they should contact a
              member of the mental health team before administering any psychotropic
              medicines to a mental health patient.

Updated December 2004
K Smith
Head of Pharmacy




Page 1 of 1
                   POWYS LOCAL HEALTH BOARD

SECTION 9D                  MEDICINE ADMINISTRATION –
                            COMMUNITY NURSING

See separate section on community nursing




Page 1 of 1
                    POWYS LOCAL HEALTH BOARD

SECTION 9E                   CYTOTOXIC DRUGS ADMINISTRATION

      Cytotoxic drugs must be handled in accordance with Welsh Office “Guidance on the
      Safe Handling of Cytotoxic Drugs”, September 1998. Gloves / Do Not Touch
      No cytotoxic drugs should be administered intra-thecally by Powys Local Health
      Board staff in Powys hospitals
      Nurses asked to administer cytotoxic drugs are advised to seek advice from a
      specialist pharmacist, before doing so.


      Note that different cytotoxics / anticancer agents have different hazards.
      Product information should be checked carefully before handling or administration or
      disposal.
      For certain agents, cytotoxic spill kits should be easily accessible, but administration
      should then be by appropriately trained staff only.




      Kevin Smith
      Head of Pharmacy
      Updated December 2004




Page 1 of 1
SECTION 9F                          DISPOSAL OF UNUSED DRUGS

      Drugs prepared for administration, which are subsequently not used, must be
      returned to the pharmacy. For Intravenous fluids and antiseptic fluids which are
      not conveniently returned to pharmacy, the Ward COSHH procedures must be
      checked to ascertain the correct method of disposal. No pharmaceutical fluid
      must be disposed of via the hospital drainage system without checking the
      COSHH data or pharmacy for advice.


      All cytotoxic drugs must be returned to the pharmacy by a visiting member
      of pharmacy staff and not disposed of by any other method.


      For community staff using injections, any remaining quantities not appropriate to
      return for destruction (eg in the syringe, or ampoule) should be disposed of in the
      portable sharps box.


      Controlled drugs must be returned via the visiting pharmacist and recorded in the
      ward CD book.




Updated K Smith

Head of Pharmacy
December 2004
SECTION 10
                             Mansion House
                             Bronllys Hospital
                            Brecon
                            LD3 0LS


  Rev       Date         Purpose of Issue/Description     Planned Review
                                   of Change                    Date
         02/08/04    Medicine Policy :SECTION 10          01/09/06
                     Initial issue

                     The management of Emergency
                     Drugs




   Responsible                  Approved by                      Date
     Officer
                     Prescribing & Therapeutics                25/06.04
 Head of Pharmacy    Committee
   Kevin Smith
                     Clinical Governance, Audit and
                     Medical Group.
                     Clinical Governance Risk
                     Management Committee

                     PROPRIETARY INFORMATION-

This document contains proprietary information belonging to the Powys Local
Health Board. Do not produce all or any part of this document without written
                        permission from the Board.




                                   2 0f 9
Section 10 The Management of Emergency Drugs

Purpose

        To ensure that all Powys staff are aware of:

        1) The provision of emergency drugs to wards and departments in
           Powys LHB Community Hospitals as laid down in the resuscitation
           policy.
        2) The provision of emergency drugs to Dental Clinics.
        3) The roles and responsibilities of the supplying Pharmacies. (Bronglais
           & Nevill Hall)

All 1ST line Emergency drugs will be supplied in black Medical Emergency
boxes or blue Cardiac Arrest boxes. (See appendix 1 for lists of drugs
contained in these boxes)

NOTE: Dental clinic emergency drugs are not supplied within these
boxes

Scope

All qualified clinical staff (Nursing, Midwifery, Medical and Dental) should be
aware of emergency drug requirements for their clinical areas:

    The contents of Medical Emergency boxes (Black) and Cardiac Arrest
     (Blue) boxes

    The location of these drugs boxes.

    Their responsibility in the process of replacing these drugs boxes.

    The location of other essential drugs to be held on all hospital sites. (See
     appendix 2 for list)

    Drugs required to be available in dental clinics (See appendix 3 )

    How availability of the drugs to be held on all hospital sites is to be
     ensured in Powys Hospitals.

   All other clinical staff should be aware in their clinical area of:

    The location of the emergency drugs boxes and the resuscitation trolleys
     on which they are stored.

    The location of the essential drugs to be held on all hospital sites

    The location of emergency drugs in dental clinics

                                        3 0f 9
Location of Medical Emergency boxes and Cardiac Arrest boxes

All resuscitation trolleys will carry:
    1) One cardiac arrest box (Blue) & one medical emergency box (Black)
    2) Laminated location maps for the site.
    3) Lists of drugs included in each box.
    4) The list of drugs to be available at each hospital site and their location.

The checking of the resuscitation trolley should include ensuring these
laminates are in place. If they are missing the hospital manager should be
informed immediately between 9-5 or as soon as possible if they are found to
be missing outside those hours

It will be the responsibility of Hospital Managers to:

        Inform medical staff and visiting consultants of the location and
         contents of Medical Emergency boxes Cardiac Arrest boxes and the
         location of other emergency drugs held on the hospital site.
        Ensure all information laminates on the trolleys are replaced should
         they become damaged or lost

It will be the responsibility of Ward Managers to inform all qualified staff
of

        The location and contents of Medical Emergency boxes and Cardiac
         Arrest boxes.
        How these drugs boxes are to be replaced.
        The location of the drugs to be held on all hospital sites, and how
         availability of these drugs is to be ensured in Powys Community
         Hospitals.
        No change to these locations should be made without discussing with
         the Resuscitation Officer and the Powys LHB Medicine Management
         Team

It will be the responsibility of the Resuscitation officer.

        To notify the appropriate supplying pharmacy if the location of any of
         the emergency drug boxes changes.

Management of Medical Emergency boxes and Cardiac Arrest boxes

Responsibilities

The supplying pharmacies (Nevill Hall & Bronglais)

The supplying pharmacies will supply the appropriate drugs within each box in a
plastic roll, where possible drugs will be supplied in original packs. All boxes will
                                        4 0f 9
be individually numbered and a database for the location, batch numbers and
expiry dates of each box will be maintained by the pharmacy. It will be the
responsibility of the supplying pharmacies to exchange all boxes prior to the
shortest expiry date of any drug within the box. A minimum of four spare
cardiac arrest and medical emergency boxes will be retained in each supplying
pharmacy.

Powys Local Health Board Staff

Once the seal has been broken a box must be returned to the supplying
pharmacy

 It is the responsibility of the person breaking the seal on the box to inform
  the senior member of nursing staff on duty as soon as possible that the box
  needs replacing.

 It is then the senior member of staff’s responsibility to

              a) Replace the emergency box used with the spare box retained
                 on the hospital site.

              b) Inform the supplying pharmacy (verbally and then by fax), of
                 the number and location of the box opened the number of the
                 box used to replace it and the location it was obtained from.
                 See Procedure for the replacement of emergency boxes.

              c) Ensure that the opened box is stored in a secure location and
                 to arrange with the supplying pharmacy how the box is going
                 to be returned.

PROCEDURE FOR THE REPLACEMENT OF CARDIAC ARREST AND
MEDICAL EMERGENCY DRUG BOXES
OBJECTIVE

   To ensure all Powys LHB staff are aware of how to order replacement
   emergency boxes:
   A) Within pharmacy opening hours.
   B) Outside normal pharmacy working hours. (e.g. weekends and night
      time).
   C) To ensure that the replacement of these boxes takes place in as short a
      time span as possible.

ORDERING REPLACEMENT BOXES: -
WITHIN PHARMACY OPENING HOURS.

   The senior member of staff will need to verbally inform the supplying
   pharmacy of the following information, which should also be confirmed by
   fax:


                                      5 0f 9
      A box has been opened and will need replacing.

      The secure location of the opened box

      The reference number of the box opened, and location of the trolley from
       which it was taken.

      The reference number of the spare box and position of the trolley to
       which the box has been placed.

      The senior member of staff should also discuss with the supplying
       pharmacy whether the opened box will:-

                a)Be sent back with the visiting pharmacist (or transport
                  Bronglais only)

                b) Or will be re-checked and sealed by the visiting
                 pharmacist while visiting the hospital*

   *Option b) should only be used if it can be completed in less time
   than it would take to get a replacement box from the supplying
   pharmacy.

OUTSIDE PHARMACY HOURS: -

The senior member of staff should follow the same procedure of
informing the supplying pharmacy that a box has been opened as soon as
the pharmacy is opened (including Saturdays/Bank Holidays & Sundays)

It is the responsibility of senior member of staff on duty when the box is opened
to ensure this happens, even if they are not on duty when the pharmacy is next
open. If the replacement ordering of the box is delegated there must be a
hospital system in place to ensure this process happens


THE SPARE BOX

   If the spare box is used then: -

    The person in charge should be notified.

    It is their responsibility to ensure that the supplying pharmacy is
   informed as soon as they are open, that a box is needed.

    The procedure should then be followed as for replacement during
   pharmacy hours.

    If a further box is used before the spare box is replaced then the on
   call pharmacist should be contacted to discuss arrangement for the
   provision of a replacement box .
                                    6 0f 9
    It should be noted out of daytime working hours, on some hospital sites
   there are boxes available in departments that are not in use e.g. OPD (if not
   attached to MIU’s). It may be appropriate to use this box instead of calling
   the on call pharmacist. A change of location of any box must be notified to
   the supplying pharmacy, as soon as is practically possible.




MANAGEMENT OF OTHER ESSENTIAL DRUGS HELD ON THE HOSPITAL
SITE. (Appendix 2 list of drugs)
Responsibilities

The supplying pharmacies

    Minimum stock levels of these drugs will be highlighted on ward/unit
     stock lists expected to keep these drugs. These items will remain on the
     stock list regardless of usage.

Powys Local Health Board Staff

   It will be the responsibility of ward/unit on which the drugs are stored to
    carry out a monthly check of expiry dates and replace stock as necessary.

   Any member of staff using stock designated as “Other Essential Drugs”
    and highlighted as so on the stock list should ensure replacement is
    ordered as soon as pharmacy opens during normal hours.

   If the whole stock is used and the nurse in charge has established there is
    no stock available in the hospital, the pharmacist should be contacted to
    discuss whether urgent replacement is needed.

   In the unlikely event of one of these drugs not being available any doctor
    requesting an admission of a patient into the hospital should be informed
    which drug is not available. The Doctor responsible for the patients
    already admitted should also be informed.
EMERGENCY DRUGS HELD IN POWYS LHB DENTAL CLINICS
There is a requirement for all Dental Practices to carry a list of medical
emergency drugs (See appendix 3 for list). Dentists are responsible for
managing common medical emergencies in the dental practice, including the
administration of the recommended list of drugs.
Responsibilities

Supplying Pharmacy-Nevill Hall only


                                      7 0f 9
       Dental clinics in Llandrindod Wells and the south receive the Dental
       emergency drugs from the Pharmacy at Nevill Hall.
       Nevill Hall will automatically recall and renew these drugs.

Powys Local Health Board Staff
       The Dental Officer is responsible for ensuring that the drugs are in date
       and changed prior to their expiry dates at the clinics in Newtown and
       Welshpool, this is recorded on the monthly check sheet. (Appendix 3 )
       The dental emergency drugs are obtained from the pharmacy at
       Bronglais Hospital.
       In Llandrindod Wells and the south the dental officer is responsible for
       monitoring the automatic recall by recording on the monthly check sheet

The Resuscitation Officer will deliver a 2½ hour practical and theoretical training
session for the whole dental team approximately annually.




                                      8 0f 9
                                Appendix 1


Contents of Medical Emergency Box (Large Black Box)

Drug                                          Minimum Quantity
                                             2 pfs
Adrenaline 1: 10,000 1mg/10ml
Aminophylline 250mg/ 10ml                    2 amps*
Furosemide 50mg (10mg/ml) 5ml                6 amps*
Adrenaline 1:1000 1mg/ml                     5 amps*
Chlorphenamine (10mg/ml) 1ml                 2 amps*
Glucose (dextrose) 25% 50ml                  1
Diazepam 10mg/2ml                            2 amps*
Diazepam rectal tubes 10mg                   2
Hydrocortisone 100mg/ml (Efcortesol®) 1ml    2 amps *
Naloxone 400mcg/ml                           5 amps
Glucagon 1mg                                 1 kit
Atropine sulphate 600mcg/1ml                 5 amps *
Amiodarone 150mg/ml 3ml                      4 amps*
Magnesium sulphate 50% 2ml                   2 amps*
Adenosine injection 3mg/ml 2ml               4 amps*
Midazolam 10mg/2ml                           2 amps*
Sodium chloride 0.9% 10ml (for flushing)     2 amps
Disposable syringes                          1 x 30ml
                                             2 x 10ml
                                             2 x 5ml
                                             2 x 3ml
                                             1 x 1ml
Disposable needles                           10 x green (21 gauge/38mm
                                             long)
                                             5 x blue (23 gauge/25mm
                                             long)
                                             5 x orange (25 gauge/16mm
                                             long)
*Drugs to be supplied in original packs where possible.

Cardiac Arrest Boxes (Standard Blue Box)

Drug                                         Quantity
Adrenaline 1: 10,000 1mg/10ml                8 pfs
Atropine sulphate 1mg/10ml                   3 pfs
Calcium chloride 10% 10ml                    1 pfs
Sodium bicarbonate 8.4% 50ml                 1 pfs
Amiodarone 300mg/10ml                        1 pfs
Magnesium sulphate 50% 10ml                  1 pfs
      Pfs-pre-filled syringe
                      Appendix 2 Essential Drugs


        DRUGS                              LOCATION
Benzylpenicillin 600 mg vial
Calcium Gluconate 10% 10mlx2
Cefotaxime 500 mg vial
Cyclizine injection 50mg/ml
Dexamethasone injection 4 mg/ml
Diclofenac sodium injection 25 mg/ml
Haloperidol injection 5mg/ml
Insulin Actrapid 10mlx1
Hyoscine Hydrobromide
400microgramm/mlx4
Metoclopramide injection 5mg/ml
Phytomenadione injection 2mg/ml
(Vitamin K)
Prochlorperazine injection 12.5mg/ml
(Stemetil)
Procyclidine injection 5mg/ml (Kemadrin)
Promethazine hydrochloride injection
25mg/ml
Propranolol hydrochloride injection
1mg/ml
Tetanus Immunoglobulin injection
Adsorbed Diptheria [low dose] & Tetanus
Vaccine for adults & adolescents
Verapamil 2.5mg/ml 5 x 2ml
Folic acid tabs 5mg
Phenytoin 25/50mg tablets /caps
Carbamazepine tablets 100mg
Glyceryl trinitrate sl spray
Salbutamol inhaler 100mcg/puff
Salbutamol nebules 2.5mg/2.5ml
Volumatic
Glucose syrup (Hypostop gel) x 1
Lidocaine (lignocaine) 100mg x 2
                                                     Appendix 2

                          Appendix 3 Dental Clinic Emergency Drugs and check list
                                         Dental clinic Emergency Drug list
Adrenaline 1:1000
GTN Sublingual Spray
Salbutamol Inhaler
Hypostop Gel 10g/23g
Glucagon Injection BP 1 unit
Rectal Tube Diazepam 10mgs
Rectal Tube Diazepam 5mg x 2

 Dental Clinic-Name                                               For
                                                                  year
 Dental clinic Emergency Drug                Jan   Feb Mar   Apr    May   Jun   Jul   Aug   Sept   Oct   Nov   Dec
                                Expiratory
 list
                                Date
 Adrenaline 1:1000
 GTN Sublingual Spray

 Salbutamol Inhaler

 Hypostop Gel 10g/23g
 Glucagon Injection BP 1 unit
 Rectal Tube Diazepam 10mgs

 Rectal Tube Diazepam 5mg x
 2



                                                    Page 8 of 9
                                       Appendix 2

                   SECTION 11 Medication Related Incidents
11.1   All incidents and near misses must be reported as per the Adverse Incident, Hazard
       and Near Miss Reporting Policy

11.1.1 All medication related incidents will be forwarded to the Head of Pharmacy, from the
       health and safety department.

11.1.2 Anonymised summaries of the reported incidents will be taken to the Drugs and
       Therapeutics committee for discussion and feedback of any identifiable learning
       points



11.2    “Must be recorded” incidents


The following incidents must always be reported via the IR1 system (to comply with the
Medicines Management Welsh Risk Pools standards).

1      Disappearance of medicines without explanation e.g. CD. Note CD disappearance
       must be dealt with promptly – see section 24.

2      Supply / administer without prescription, outside of any Prescribing &Therapeutics
       agreed protocol.

3      Administration errors – wrong patient, wrong drug, overdose, missed administration
       (see 11.3 below).

4      Prescribing errors including near miss (i.e. where identified prior to administration).

5      Labelling errors/dispensing errors.

6      Non supply of ordered medicine within 1 working day unless previously notified.



11.3          Errors of administration

       Errors in administration are those situations when a mistake actually did occur and
       may include: -


              • A drug given to the wrong patient
              • The wrong drug given to a patient
              • An incorrect dose of drug given to a patient
              • A drug given by the incorrect route



                                      Page 8 of 9
                                 Appendix 2



11.3.1 If at any time during or following the administration of a drug the Nurse
suspects that an error has occurred then he/she must immediately report it to the Nurse
in Charge, the duty Doctor in charge of the patient and formally report to the Director
of Nursing or her Deputy who will then make a decision as to whether an
investigation is required.


11.3.2 A record of the error will be made in the medical and the nursing notes
Administration incidents are those situations when an error in administration almost
occurred but did not actually do so. They can be considered as near misses. It is
important that both incidents (near misses) and errors (actual mistakes) are reported.
In all cases an incident form (IR1) will be completed and forwarded to the line
manager within 24 hours.


11.3.3 In cases where the error involves a member of the Nursing staff, the Director of
Nursing, her Deputy and Directorate Manager must be informed immediately. Where
the error involves a member of the Medical staff, the Medical Director and Clinical
Director will be informed. In cases where Pharmacy staff are involved the Head of
Pharmacy will be informed.


11.3.4 Importance of reporting
Note that errors are inevitable in a human based system, but policies and systems can
minimise the risk, Reporting errors, and particularly near miss incidents means we can
learn from them and help prevent future harm to patients and stress for staff members.



Updated December 2004
K Smith
Head of Pharmacy and R&D
Powys LHB




                                 Page 8 of 9
                                      Appendix 2

SECTION 12                  DEFECTIVE MEDICINES - ADVERSE
                            INCIDENT REPORTING

    REPORTING ADVERSE INCIDENTS, REACTIONS AND DEFECTIVE
    PRODUCTS RELATING TO MEDICAL AND NON MEDICAL EQUIPMENT
    AND SUPPLIES, FOOD, BUILDINGS AND PLANT, AND MEDICINAL
    PRODUCTS (WHC(97)28)


    12.1        Welsh Circular (WHC(97)28) provides detailed advice on the NHS
    procedure for the reporting of adverse incidents, reactions and defective products
    relating to medical and non-medical equipment and supplies, food buildings and
    plant. The purpose of the reporting procedure is to ensure a centrally coordinated
    response, which will prevent risk to other patients and staff. Every Member of NHS
    staff has a duty, therefore, to see that all safety related defects are notified even if
    there is only the suspicion of a problem.


    12.2.       At ward level nursing staff must ensure that all such incidents involving
    medicinal products are promptly brought to the attention of the Pharmacy Department
    and Directorate Manager, either directly or through the appropriate Senior Nurse.
    Outside normal pharmacy hours the On-Call Pharmacist must be contacted.


    12.3.       The LHB procedure for dealing with incident reporting must be followed.
    The Pharmacist will take the appropriate action according to local pharmacy
    procedures based on current Welsh Assembly Guidance.


    12.4.       Where patient care has been compromised by the administration of a
    defective pharmaceutical product the Nurse in Charge must be contacted and
    appropriate Medical Staff informed. In the community all such incidents must be
    reported to the patient’s General Practitioner and the Community Pharmacist.


    The LHB policy on reporting of adverse incidents must be followed.




                                     Page 8 of 9
                                      Appendix 2

SECTION 13                      SUPPLY AND STORAGE

    13.1.     Accountability for medicines management (safety and security) in Powys
    Local Health Board Hospitals.

    13.1.1.    Staff in Powys should work to Powys approved policies on medicines
    management. These in turn should follow national guidance where ever possible.
    Policies will be developed in consultation with DGH suppliers

    13.1.2.    DGH staff working in Powys should ensure that polices are being followed,
    and that medicines management (as defined in the controlled assurance standards)
    follows good practice, where specific policies do not exist. Any anomalies
    discrepancies or digression from this should be corrected, if possible, and the Powys
    Head of Pharmacy informed.

    13.1.3.    Accountability for the quality of medicines, staff, and pharmacy services
    (clinical pharmacy, medicines information, etc) from supplying DGH pharmacies, rest
    with the supplying pharmacy.

    13.1.4.    Powys LHB are accountable for the determination of the contract terms of
    the SLA with the supplying DGHs, based on advice from the Powys Head of
    Pharmacy, (and finance director, etc)

    13.1.5.    Accountability for medicines policies approved in Powys (agreed by the
    Prescribing & Therapeutics committee) rest with Powys LHB.

    13.1.6.    Accountability for actions of Powys staff regarding medicines use, rests with
               Powys LHB. Lines of accountability follow normal procedures for each staff
               group

    13.1.7.    Accountability for the secure transport of medicines is a shared one. The
               system must be agreed by both parties, and contain a suitable audit trail.
               Responsibility rests with the organisation in possession at the time. In the
               case of use of Taxis, it remains the responsibility of the supplier until the
               taxi delivers.




                                     Page 8 of 9
                                  Appendix 2

13.1.8.    Nurse in charge of wards and departments are responsible for the safety and
security of medicines in their area, following the principles laid out below.


13.2.      ORDERING

13.2.1.    Normal Requisitions

Requisitions may be made according to the relevant Bronglais or Nevill Hall
procedure on a ward or departmental requisition pad. The requisition must be dated
and the name written in capitals and signed by the nurse, midwife or practitioner in
charge of the ward or department. (NB while on duty, a ward sister cannot delegate
this signing to a subordinate nurse, but during those periods when the latter is left in
charge of the ward, he/she has full authority to sign requisitions). Orders may be sent
or faxed to the pharmacy (except for controlled drugs – see section 24).


13.2.2.    Telephone requests MAY NOT be accepted as recommended by the internal
auditor. Similarly, requests for discharge medication or controlled drugs will NOT be
accepted verbally over the telephone, only by way of faxing the completed TTO. CD
orders must be sent, or handed to a member of the supplying pharmacy staff
(technician or pharmacist).


13.2.3.    Some wards receive a technician topping up service.           In this case a
technician from the supplying hospital will check stocks against the agreed stock lists
and order accordingly. Although a delivery note is supplied at present there is no
order generated which can be kept in the ward. This system is under review.



13.3.     Controlled Drug Requisitions

See Section 24 .

13.4.     Controlled Stationery

13.4.1.    Controlled stationery is any stationery, which has the potential to be misused
           to obtain drugs fraudulently and includes controlled drug order book and
           register, and FP10(HP) prescription forms. Appropriate arrangements must



                                  Page 8 of 9
                                   Appendix 2

          be made by the Nurse in Charge to ensure the security of Controlled
          Stationery at all times.




13.4.2.   FP10 (HP) forms are serially numbered. If a form is spoiled the form must
not be destroyed. It must be crossed through and retained with the pad. Pads or forms
shall be kept in a secure location in the ward or department and shall be the
responsibility of the Nurse in Charge.


13.4.3.   Drug prescription and administration charts or other forms used for ordering
medicines; These are not treated as controlled stationery. However the following
precautions shall be observed :- Unused forms shall be kept securely in wards and
departments and issued only to staff who have authority to prescribe. Used forms shall
be retained as part of the patient’s medical records. A file of specimen signatures of
all staff authorised to prescribe will be kept in the pharmacy department. No
stationery used for ordering or prescribing medicines shall be taken away from NHS
premises except in the custody of an authorised member of staff who shall be
responsible for its safekeeping.

13.4.4.   Ward order requisitions must be kept securely stored when not in use, and
          accessible only to staff who have authority to order medicines. A file of
          specimen signatures of all staff authorised to order will be kept in the
          pharmacy departments.




Updated December 2004
K Smith
Head of Pharmacy and R&D
Powys LHB




                                Page 8 of 9
                                  Appendix 2

   Section 14 Issue and Delivery
14.1.      Issue by pharmacy


   Drugs issued on weekly/fortnightly orders by the pharmacy will be
   accompanied by a delivery note. In the case of Controlled Drugs; the quantity
   will be specified. The delivery notes must be stored in a suitable lever arch
   file, and be available for examination on the ward. CD delivery notes should
   be faxed back to the supplying pharmacy on receipt.

   14.2      Dispensing

   14.2.1.    All medicines dispensed by the supplying DGH pharmacies will
   comply with relevant regulations on labelling, patient information leaflets, and
   containers.
   14.2.2.       Note that the supply of pre-packs whether for MIU or any other
   part of the business of the hospital, is considered to be dispensing.
   Practitioners supplying pre-packs must therefore ensure that the supply
   conforms to the requirements of the relevant regulations, on labelling, patient
   information, and containers. Pre-packs provided by our supplying hospitals
   will comply with these regulations, providing the patient’s name and the date
   of dispensing (and the completion of any dosage regimen instructions) are
   added by the practitioner supplying to the patient. The expiry date of any pre-
   pack must be checked before supply.

   14.3.     Drugs in Transit – security

   14.3.1.       Drugs in transit are particularly vulnerable to theft. All deliveries
   should be taken straight to the receiving ward or department. Boxes should
   not be left with reception staff. Once in the ward or department they should be
   kept under continual surveillance until they can be unpacked, checked by
   nursing staff and transferred to appropriate drug cupboards.




                                 Page 8 of 9
                              Appendix 2

14.3.2.      Staff involved in transferring drug boxes must always ensure their
prompt onward delivery. Drug boxes which have to be stored outside their
destination ward or department, while awaiting onward delivery constitute a
risk. An incident report form (IR1) should be completed any time that this
happens, stating where they are left, for how long and stating the reason, where
known.


14.4.     Receipt by wards and departments


14.4.1.    Supplies of drugs received by Wards, Departments and Hospitals,
           should be checked against the accompanying delivery note, as soon
           as possible. The supplying pharmacy department should be notified
           immediately of any apparent discrepancies. The delivery notes must
           be stored in a suitable lever arch file, and be available for
           examination on the ward, for two years from date of receipt. CD
           delivery notes should be faxed back to the supplying pharmacy on
           receipt.
14.4.2.          As noted above, drugs in transit are particularly vulnerable to
           theft. Once in the ward or department they should be kept under
           continual surveillance until they can be unpacked, checked and
           transferred to appropriate drug cupboards.
14.4.3.    Where applicable, receipts should be signed by the receiving officer,
           and stored ready to be collected by the pharmacy or delivering
           officer, as appropriate.




14.5.     Where an emergency stock is available


14.5.1.    A record must be made of all items taken from any “emergency stock
cupboard”, booked out on the provided forms and signed by the person taking
the medicine from the cupboard. Borrowing of medicines from other wards is
discouraged and should only be undertaken after consultation with the
appropriate Senior Nurse or with the ‘on-call’ Pharmacist. Any such


                             Page 8 of 9
                             Appendix 2

borrowing must be recorded on appropriate forms. Controlled Drugs may not
be borrowed, it would be a criminal offence to do so.


14.5.2.   If a medicine which is required urgently is not available, and there is
not a suitable alternative available, then the on-call pharmacist should be
contacted for advice and/or supply


Updated December 2004
K Smith
Head of Pharmacy and R&D
Powys LHB




                            Page 8 of 9
                                Appendix 2

Section 15 Storage of Medicines
15.1.      Storage on wards


15.1.1. The design and location of all ward or department medicine storage
          cupboards must be approved by the Head of Pharmacy. This function
          is normally delegated to the supplying visiting Pharmacy and regularly
          monitored, by them.


15.1.2.    All internal and external medicines, disinfectants, and reagents must
be stored in locked cupboards, trolleys or other secure cabinets - all reserved
solely for medicinal products. The only exceptions to this requirement are
medicines for clinical emergencies, intravenous fluids, sterile topical fluids
and nutritional products and some bulky medicated dressings which, because
of their bulk, are stored in a clean area (as agreed between the Practitioner in
Charge and Pharmacy Staff).

15.1.3.    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, or locked, container.


15.1.4.    Only items requiring storage between 2 and 8C should be stored in a
refrigerator. The LHB Drug Refrigerator Policy must be followed.


15.2.       Siting of Cupboards and Trolleys.

Cupboards and trolleys must be sited where most convenient for staff,
allowing adequate space and permitting surveillance to afford maximum
security against unauthorised entry. Medicine cupboards must generally be
sited in a clean utility room to which the general public does not have access.
Cupboards must not be sited where they may be subjected to higher than
average humidity or temperature. Reagent cabinets must be sited in areas
where testing is carried out.



                            Page 8 of 9
                                   Appendix 2


15.3.      Review of Storage of Medicines

   The quantities, range and storage of medicines to be stocked will be reviewed
   regularly (at least annually) by the Pharmacy Staff and the Practitioner in
   Charge.




   15.4.      Controlled Drugs

   15.4.1. No ward or department must store Controlled Drugs unless there is a
   Practitioner in Charge responsible for their storage and use. The labels on
   containers will identify:"Controlled Drugs". These will continue to be
   stored in appropriate Ward Controlled Drug Cupboards, reserved solely for
   drugs of this class.

   15.4.2. Containers not bearing the above label, will be stored elsewhere,
   according to the good nursing practice developed from the Aitken Report
   1958. The details depend on ward function, but normally separate locked
   storage is used for:-

                 a) Drugs for internal use, e.g. tablets, capsules, mixtures,
                 ampoules


                   b) Drugs for external use e.g. lotions, antiseptics, eye/ear
                          drops, suppositories, irrigation fluids

                   c) urine and other testing reagents. Depending on the type of
                          hospital and location, not all such cupboards need to be kept
                          locked (see (d) below).

                   d) Disinfectants. These may be stored with cleaning materials.
                          In paediatric, mental illness and learning difficulties wards,
                          these cupboards will be kept locked, but in other wards the
                          lock is a matter of discretion by the nurse in charge.



                                  Page 8 of 9
                               Appendix 2


                  e) Infusion fluids. Because of the bulk, it may be impractical
                      to store these in locked cupboards. In such cases they may
                      be kept in a clean designated area. Fluids containing
                      potassium should be stored separately and clearly labelled.
                      Concentrated potassium solution (ampoules) must not be
                      stored, or ordered by wards.
                  f) Thermolabile substances. These are drugs which
                      deteriorate rapidly at room temperature. They will be
                      labelled “Store in refrigerator” and should be kept in the
                      lockable ward refrigerators.

   15.4.3.   It is the responsibility of the nurse in charge of the ward to ensure
   that medicines are stored securely, in accordance with these principles.

15.5.   Medicines Trolleys

   Medication (other than Controlled Drugs) in current use, may be kept in the
   trolley between rounds, provided the lid is locked closed, and the trolley
   immobilised by being padlocked to a permanent fixture, or by being parked
   inside a locked room.

15.6.   Custody of Keys


   15.6.1.   The Misuse of Drugs Act 1971 requires the key of the Controlled
   Drug cupboard to be kept “on the person of the nurse in charge, or acting nurse
   in charge for the time being, of the ward or department”.


   15.6.2.   All other keys should be kept under the control of the nurse in
   charge, and never be available to unauthorised persons.

15.7.   Security of Drugs & Medicines.

   15.7.4. The security of all medicines on the ward or department is the
   responsibility of the nurse in charge of the ward or department.


                               Page 8 of 9
                             Appendix 2


15.7.5. Details of any missing medicines must be reported immediately the
loss is discovered to the Senior Nurse responsible for the ward and also
reported to the Pharmacy. Every effort must be made to determine the reason
for the loss. Report using the IR1 form .

15.7.6. The quantity of a Controlled Drug remaining in stock must be checked
daily and preferably at each shift change, at each point of dispensing (i.e. CD
register and stock count must tally) and receipt of delivery of stock.

15.7.7. Drugs must not be transferred from one container to another or left in
unlabelled medicine pots. If a label is damaged or cannot be read the container
must be returned to the pharmacy.

15.7.8. Out of date medicines should be returned to pharmacy (after recording
on the appropriate audit forms). Any unwanted or date expired Controlled
Drugs must be entered in the Controlled Drugs Record Book by the pharmacist
and witnessed by the nurse in charge as having been returned. On no account
should Controlled Drugs be returned to the Pharmacy other than by being
handed to a pharmacist (not a pharmacy technician) on the ward. Ampoules
broken accidentally should be retained until entered into the ward CD record
book and accounted for.

15.7.9. Similarly, any medicines returned to pharmacy because it is no longer
required, or is excess stock should be recorded on the appropriate forms, and
returned according to the policy of the supplying pharmacy.

15.7.10. Return medicines to Pharmacy according to the procedure set by your
supplying pharmacy. For Nevill Hall, i.e. for Llandrindod Wells, Knighton,
Builth Wells, Brecon, Bronllys and Ystradgynlais, items should be returned
via the pharmacy staff only. For hospitals served by Bronglais, with lockable
boxes, pharmacy items (except controlled drugs) can be returned securely
locked inside the box.




                            Page 8 of 9
                        Appendix 2

15.7.11. Breach of Security Any incident must be reported
immediately and investigated by the nurse in charge together with an
authorised member of the Pharmacy Staff.


Updated December 2004
K Smith
Head of Pharmacy and R&D
Powys LHB




                        Page 8 of 9
                                        Appendix 2

Medicines Policies – Section 16
Revision              Date                Purpose of                    Planned Review
                                          Issue/Desciption of           Date
                                          Change
2002-a                August 2002         Addition to 2002              1/9/2004
                                          Medicines Policies            (approved
                                          document                      13/11/2002)
2004-1                December            Update                        1/9/2006
                      2004
Responsible Officer                       Approved By                   Date
Head of Pharmacy                          Management Team

                                          Drugs & Therapeutics
                                          Committee
                                          Update


PROPRIETARY INFORMATION
This document contains proprietary information belonging to the Powys Local Health Board.
Do not produce all or any part of this
document without written permission from The Powys Local Health Board.


Medicines Policies
The safe and secure handling of medicines, incorporating Prescribing, Administering,
Ordering, and Storage

Purpose
This document is designed to help ensure the safe use of medicines within Powys.

Scope
All staff who handle medicines, including clinical staff, transport, hotel services, and
managers.
All staff are reminded that they must adhere to these policies.

Please advise of any errors omissions, amplifications, suggestions etc – for inclusion or
alteration. Thank you.
Kevin Smith 2004
Head of Pharmacy
Powys Local Health Board
For Prescribing and Therapeutics Committee




                                       Page 8 of 9
                                        Appendix 2

Section 16 Hazard Notice (Pharmaceutical) and Urgent Pharmaceutical
Drug Information

16.1   Where product recalls or defects are highlighted, it is the responsibility of the
       supplying pharmacies to action these warnings and recalls within Powys. Wards and
       departments are asked to co-operate fully, to safeguard patients.

16.1.1 Out of hours, the hospital switchboard will be able to give the contact details for the
       senior nurse in charge.

16.1.2 Any difficulties should be reported to the Head of Pharmacy as soon as possible.

16.2   Within Powys LHB, copies of the hazard notices and urgent information will be
       received by the Head of Pharmacy PA, who will distribute to all matrons, consultants,
       chief executive, medical director, clinical governance lead, and Head of Pharmacy. In
       her absence, this duty will be undertaken by the clinical governance department.




       Updated December 2004
       K Smith
       Head of Pharmacy and R&D
       Powys LHB




                                       Page 8 of 9
                             Mansion House
                             Bronllys Hospital
                             Brecon
                             LD3 0LS

      Policy for Contact with Pharmaceutical and Wound
    Management Company Representatives and Commercial
                         Sponsorship

 Rev       Date         Purpose of Issue/Description Planned Review
                                of Change                  Date
A       16/12/03      Medicine Policy :SECTION 17    01/01/06
                      Review




    Responsible                 Approved by                     Date
      Officer
                      Drugs & Therapeutics Committee          19/09/03
  Head of
 Pharmacy
                      Clinical Governance                     28/10/03
   Kevin Smith
                      Management Team
                      Clinical Governance Risk                16/12/03
                      Management Committee

                     PROPRIETARY INFORMATION-

This document contains proprietary information belonging to the Powys Local
Health Board. Do not produce all or any part of this document without written
                       permission from the Board.
                      Powys Local Health Board


     Policy on Contact with Pharmaceutical and Wound
   Management Company Representatives and Commercial
                       Sponsorship

   PURPOSE

       To provide a legal and ethical framework for Powys LHB staff to work
       within in situations where they are either in contact with company
       representatives, or receiving commercial sponsorship from
       pharmaceutical companies.

   SCOPE

      The policy applies to all staff employed by Powys LHB.

      The policy covers all types of contact with company representatives
       where an individual is acting in their professional capacity for the LHB.

      The policy relates to all locations both within the LHB and at external
        events or venues (e.g. study days).

  1.   MAIN PRINCIPLES

       1.1. It is recognised that contact with company representatives may be
            necessary for a variety of reasons. All contact should be
            appropriate to the individual LHB employees’ role within the
            organisation

       1.2. All contact should be undertaken in accordance with any ethical
            and professional standards relevant to the individual employee,
            e.g. the NMC Code of Professional Conduct.

       1.3. Company representatives should only visit LHB premises by prior
            appointment

       1.4. Representatives are not permitted in clinical areas of the
            organisation, to ensure that staff are not distracted from their
            usual duties. Meetings should be held in non-patient areas.

       1.5. Company representatives must not undertake any activities that
            are in conflict with the aims or decisions of the LHB Drugs and
            Therapeutics Committee.

       1.6. Patient confidentiality must be maintained at all times.

       1.7. The LHB appreciates that the use of commercial sponsorship
            from pharmaceutical companies may be either necessary or
            beneficial to its staff and patients.

14/03/2012                   Medicines Policy Section 17 Date ratified 16/12/03
                                    Page 4 of 8          Review date 01/01/06
                       Powys Local Health Board

2. MEETING WITH REPRESENTATIVES.

       2.1. Staff should consider whether a meeting with a representative is
            necessary. If basic product information is required, it may be more
            appropriate to obtain it direct from the company without seeing a
            representative.

       2.2. Before arranging a meeting staff should consider whether to meet
            with the representative individually or as a team.

       2.3. When arranging a meeting with a company representative, LHB
            staff should state the purpose of the meeting and the time that will
            be available for the meeting.

       2.4. . Staff should request information from a company before seeing a
            representative. This will allow time to critically appraise the
            information and decide relevant questions to ask during the
            meeting.

       2.5. Staff should consider whether meeting a group of representatives,
            who promote a similar group of products, on a regular basis (e.g.
            every three to six months) may be a practical solution to obtaining
            balanced information from pharmaceutical companies.

       2.6. To allow the LHB to monitor the activities of company
            representatives within the organisation, the attached proforma
            (Appendix 1) should be completed each time a meeting takes
            place with a company representative. A copy of this proforma
            should be returned to the Medicines Management Department,
            Mansion House, Bronllys.

 3. ASSESSING INFORMATION AND PRODUCTS FROM COMPANIES.

       This section covers:
      Verbal and written information for either new or existing products (e.g.
       routes, doses, product range, alternatives etc).
      Patient information leaflets
      Educational materials for patients or staff, e.g. videos, CD Roms,
       devices for demonstration purposes only. Documentation- patient
       diaries

   3.1. Product information

       3.1.1. Staff should be aware that company data might not be presented in an
       unbiased manner, and that companies may use non-robust evidence as a
       marketing tool. It is important to ensure that there is access to balanced
       information from more than one source and to use critical appraisal skills in
       assessing the information.



14/03/2012                    Medicines Policy Section 17 Date ratified 16/12/03
                                     Page 5 of 8          Review date 01/01/06
                     Powys Local Health Board

      3.1.2. Staff should consider seeking independent validation of
      information received e.g. journals, reference texts, peer discussion,
      specialist web sites, Medicines Information Centre.


   3.2. Product Samples

      3.2.1. No samples (of medicines or dressings) may be left on wards or
      departments or with community staff. Samples must not be used to treat
      patients. Representatives of pharmaceutical companies wishing to leave
      samples must be referred to the Medicines Management Department,
      Mansion House, Bronllys.

   3.3. Obtaining Equipment from Companies.

      3.3.1. The LHB recognises that some equipment is only available from
      company representatives (e.g. reusable insulin pens),
      Also that it may be most appropriate to obtain certain equipment from
      company representatives (e.g. blood glucose monitors). However,
      such products should only be accepted if the LHB Medical Devices
      Group have approved them, or if they are to be used to evaluate a
      device.

      3.3.2. When obtaining equipment from company representatives, staff
      should be aware that equipment is classed as a type of commercial
      sponsorship, and the procedure for obtaining commercial sponsorship
      must be followed.

      3.3.3. Staff who use educational equipment should ensure that they
      have access to an appropriate range of products to allow a range of
      treatment options to be considered by the patient.

    3.4. Giving Equipment or Written Information obtained from
       Representatives to Patients / Carers

      3.4.1. Any written information, equipment or documentation given to
      patients must be assessed to ensure that it has no unnecessary
      promotional content.

      3.4.2. Staff should be aware that in situations where they are
      recommending products to patients they might be perceived to be
      endorsing the product. Staff should obtain sufficient evidence based
      information on all the suitable alternatives and fully explain the
      advantages or disadvantages of alternative products so that the
      patient can make an informed choice. The reasons for a specific
      choice should be documented in the patient’s records.




14/03/2012                  Medicines Policy Section 17 Date ratified 16/12/03
                                   Page 6 of 8          Review date 01/01/06
                      Powys Local Health Board

   4. COMMERCIAL SPONSORSHIP

      4.1. The Department of Health document “Commercial Sponsorship- Ethical
      Standards for the NHS” defines commercial sponsorship as

      “NHS funding from an external source, including funding all or part of
      the costs of a member of staff, NHS research, staff training,
      pharmaceuticals, equipment, meeting rooms, costs associated with
      meetings, meals, gifts, hotel and transport costs (including trips
      abroad), provision of free services (speakers), buildings and
      premises”.

      4.2. The document also states that:

         Sponsorship should be publicly declared (it suggests that
          sponsorship is recorded in a centrally held ledger)
         NHS staff and organisations can be held to account for it.
         Sponsorship arrangements must comply with the Medicines
          (Advertising) Regulations 1994. Contravention of these regulations
          is an offence and can lead to a fine or imprisonment.

      4.3.    Personal gifts of less than £25 per gift (or less than £100 per year
          from the same source) do not count as commercial sponsorship.

      4.4.  Staff should consider whether the use of sponsorship is
         necessary, or if suitable alternatives are available within the LHB.

      4.5.   All hospitality provided by pharmaceutical companies should be
         appropriate to the situation in which it is offered, and secondary to
         the main purpose of the meeting.

      4.6.   Staff undertaking company funded and provided training must
         be aware of the potential for bias in this situation. Sponsorship
         must not be conditional upon inappropriate use of the sponsor’s
         product.

      4.7.   When LHB staff are seeking sponsorship for educational
         events provided within the organisation, where feasible
         sponsorship should be split between at least three companies with
         products in competition with each other. This will help any staff
         attending the event to obtain balanced information. If this is not
         feasible, staff must ensure that there is not undue bias towards any
         one company.

      4.8. Any staff undertaking company sponsored research must be
         aware that authorisation within the organisation via the LHB
         Research and Development Committee is necessary, and that the
         sponsorship is reported when seeking authorisation.




14/03/2012                   Medicines Policy Section 17 Date ratified 16/12/03
                                    Page 7 of 8          Review date 01/01/06
                    Powys Local Health Board

      4.9. To allow the LHB to keep a central record of commercial
         sponsorship, (as suggested by the DOH), all commercial
         sponsorship obtained (including equipment) should be recorded on
         the attached commercial sponsorship reporting form (Appendix 2)
         and returned to the Medicines Management Department at
         Mansion House, Bronllys.

    REFERENCES
    Trust Policy on the Activity of Pharmaceutical Company Representatives-
    North Glamorgan NHS Trust.
    Guidance for Commercial Sponsorship- Carmarthenshire LHG (March
    2002).
    NMC Code of Professional Conduct 2002
    Commercial Sponsorship-Ethical Standards for the NHS- Department of
    Health (November 2000)
    Guidance for Pharmacists on Working with the Pharmaceutical Industry-
    Royal Pharmaceutical Society of Great Britain (January 2003).




14/03/2012                Medicines Policy Section 17 Date ratified 16/12/03
                                 Page 8 of 8          Review date 01/01/06
                                               POWYS LOCAL HEALTH BOARD

Appendix 1                                                               Proforma for a Session with Pharmaceutical
Proforma for a Session with Pharmaceutical                               Representatives
Representatives                                                          Please return completed form to the Medicines Management
Please return completed form to the Medicines Management                 Team, Mansion House, Bronllys
Team, Mansion House, Bronllys
                                                                         Hospital/Community____________________             Date ______
Hospital/Community____________________                 Date _____
                                                                         Clinicians present     Name                    Designation
Clinicians present      Name                       Designation




Company represented ________________________                             Company represented ________________________

Name of Representative ________________________                          Name of Representative ________________________


Nature of session e.g. Training/information/new products                 Nature of session e.g. Training/information/new products


             Training               Content of session                               Training           Content of session



             Information left       Product information                              Information left   Product information

                                    Patient leaflets                                                     Patient leaflets

                                    Other                                                               Other

                                    Please state                                                         Please state
14/03/2012                      Medicines Policy Section 17 Date ratified 16/12/03
                                       Page 9 of 8          Review date 01/01/06
                                           POWYS LOCAL HEALTH BOARD

Appendix 2

Record of Commercial Sponsorship Obtained From Pharmaceutical or Wound Management Companies
Please return completed form to the Medicines Management Team, Mansion House, Bronllys.

Personal Details

Date______________________              Name of Person Obtaining Sponsorship _____________________________


Designation________________________          Base Hospital or Community Unit__________________________________


Type of Commercial Sponsorship Obtained

Funding for independent external training course                      Funding to attend company run external training course

Sponsorship for LHB run training courses                              Hospitality / Travel /Accommodation Costs

Costs associated with meetings                                Research Costs

Equipment                                                     Other
                                                              (Please specify below)

Details of Company sponsorship obtained from



Details of sponsorship obtained (including reason for seeking external sponsorship, value of sponsorship and number of
patients / staff this will benefit). Please continue overleaf if necessary.


14/03/2012                 Medicines Policy Section 17 Date ratified 16/12/03
                                  Page 1 of 8          Review date 01/01/06
SECTION 18                CLOSURE OF A WARD OR DEPARTMENT


    18.1   If a ward or department is due to close, the Controlled Drugs must be handed
           over by the Practitioner in Charge to an authorised member of the Pharmacy
           Staff who will sign the appropriate section of the register and return the
           Controlled Drugs to the pharmacy.
    18.2   If a ward or department is to close for more than a few days, all other
           medicines must be returned to the pharmacy. However, if a ward is to close for
           only a few days, the medicines (other than Controlled Drugs) may, with the
           agreement of an authorised member of the Pharmacy Staff and the Practitioner
           in Charge, stay on the ward, provided there is adequate security to prevent
           unauthorised access to the cupboards.




    Updated December 2004
    K Smith
    Head of Pharmacy and R&D
    Powys LHB
                 POWYS LOCAL HEALTH BOARD

SECTION 19                FLAMMABLE LIQUIDS, GASES, AEROSOLS -


    Advice is obtainable from your local Fire and Safety Officer. Also ensure that you
    have appropriate COSHH data sheets filed on the ward. Sheets for pharmaceutical
    products (including disinfectants etc) can be obtained from your supplying pharmacy.




    Reviewed December 2004
    K Smith
    Head of Pharmacy and R&D
    Powys LHB
                  POWYS LOCAL HEALTH BOARD


SECTION 20                 COMMUNITY NURSING

    The principles laid out in the medicines policy documents should be followed by
    community nurses. There are some specific issues related to community nursing,
    however.

    20.1.   Medicines -Community Nursing

    The community nurse’s role in relation to medicines is similar to that of the hospital
    nurse. The hospital nurse must ensure that the community nurse has a comprehensive
    report of the patients nursing care whilst in hospital, which will include any special
    requirements regarding medicines. The community nurse will reciprocate, if a patient
    is required to be admitted to hospital.

    20.2.      Safe Custody – Community Nursing

    Medicines prescribed and supplied to a patient are in the patient’s charge (or carer).
    The nurse is required to:-

                   a) Check that the patient (or carer) fully understands his/her medicine
                   regimen

                   b) Be prepared to offer advice on the storage of medicines at home

                   c) Advise on the need to keep medicines out of the reach of children

                   d) Recognise side effects of medication.

    20.3.Administration – Community Nursing

    20.3.1. .A record of medicines prescribed by a General Practitioner to patients should
    be kept in nursing notes, and will include:-

                   a)      Name of medicine
                   b)      Date supplied
                   c)      Quantity
               POWYS LOCAL HEALTH BOARD

               d)     Strength
               e)     Patients name and address
               f)     D.O.B (Patient identifier)


       20.3.2. If the nurse is responsible for administering any medicine, including
       Controlled Drugs, he/she must record on the nursing record:




               a)     Medicine
               b)     Date
               c)     Dose and time given
               d)     Route of administration




Note that medicines (and dressings) can only be given to those for whom they have
been prescribed. Returned medicines should not be re-used for other patients




20.4.Conveyancing


Medicines being carried by practitioners should be carried securely and safely. They
should never be left unattended. Pockets are not a suitable means of carrying drugs.
Ideally drugs should not be kept in the practitioners home overnight. They should
never be left in a vehicle overnight, nor in extreme weather conditions during the day.
Where it is necessary to keep drugs overnight in the practitioners home, they should
be kept out of sight in a locked container. See also nursing policy below (Appendix 1
Section 20).


20.5.Immunisation – carrying adrenaline


The POM order section 12a(2) allows a nurse to carry adrenaline 1:1000 to use in an
emergency situation, where the nurse has been trained in its use, and has signed
                POWYS LOCAL HEALTH BOARD

agreement to use the adrenaline in accordance with the “adrenaline in anaphylaxis”
PGD




20.6.     Controlled Drugs – Community Nursing
See also section 24


20.6.1. Conveyance of controlled drugs – Community Nursing
A community nurse who has agreed to collect a Controlled Drug, which has been
prescribed in accordance with the requirements set out above, from the community
pharmacist or the patient in his own home, is authorised to have the controlled drug in
her/his possession for conveyance purposes only. She/he may in some circumstances
carry controlled drugs prior to administration where these are prescribed specifically
for clients and provided they have appropriate written authority for doing so.
Shipman guidelines are likely to require that a nurse involved in this must present
identification evidence at community pharmacy prior to CD release and to sign the
register.


For Midwives, see N&MC Code of Practice.


20.6.1.     Unused Controlled Drugs which are no longer required by the patient / or
where the patient has died at home where relatives / other people are present.


                 a)     These may be returned by the patient / relative to the Pharmacy
                 which originally supplied the drug, or to any other pharmacy. The
                 patient’s notes must be endorsed with details (quantity, strength, name)
                 of the drug, the reasons for its discontinuation and the arrangements
                 which have been made for its disposal, signed by the nurse and
                 witnessed. Where the nurse is working alone, the patient can witness
                 the record.


                 b)     If the patient / relative is unable to return Controlled Drugs to
                 the pharmacy, the Community Nurse can do this on their behalf, with
             POWYS LOCAL HEALTH BOARD

               the patient’s authority if this is practicable. The Community Nurse
               will be acting as an agent and is not legally in possession. It would be
               courteous to contact the pharmacy first to ensure they have the
               necessary controlled drug destruction kit available.


Relatives or patients must sign if they do not wish controlled drugs to be
destroyed. It is good practice for the disposal to be witnessed with both parties
signing the Patient’s Nursing Records, stating the name and quantity of the
discarded medicines.
Note that although prescribed CDs become part of the deceased estate, relatives
have no authority to possess them


Other drugs may be taken for disposal if permission is obtained from the patient.


               c) Disposal of Controlled Drugs when a patient dies alone at home
               The Community Nurse has no legal authority to ‘possess’ but may
               proceed, as an agent, as described above.


               d)      A community nurse who is asked for advice on the disposal of
               a Controlled Drug, after the death of patient, should instruct the family
               to dispose of it by returning it to a community pharmacy.


               e)      Where the Community Nurse acts as an agent, she should
               document in the Patient’s Nursing Notes the quantity and strength of
               the Controlled Drugs being returned and sign the Notes after this entry.
               The receiving Pharmacist should also be asked to sign in the Notes on
               receipt of the Controlled Drugs.
                     POWYS LOCAL HEALTH BOARD

                        Appendix 1 (Section 20)

                      POWYS NURSING PROCEDURE
Protocol for the transportation and administration of depot medication in a community
                                       setting

                                        Introduction

This protocol is intended to outline the process whereby injectable medicines are transported
to a venue away from the designated base and then administered to the patient.

                                            Scope

This protocol applies to all Mental Health and Learning Disability qualified nurses working
within the community.


                                     Policy Statement

   -   It is the nurses responsibility to adhere to the principles for the administration of
       medicines as identified by the NMC (2002).

   -   It is essential that medication and associated equipment is stored and transported in a
       safe and secure manner both for the protection of the nurse and public.

                                    Protocol Standards

Transportation

   -   The nurse must ensure that the patient’s medication sheet is valid (Mallet &
       Doughtery 2000).

   -   All equipment necessary to administer the medication should be collected and
       checked to make sure it is in date. This would include appropriate needles, syringes,
       swabs, cotton wool, plasters, gloves, sharps box, rubbish vessel, receiver.

   -   The medication ampoule/ampoules should be checked against the prescription
       sheet/sheets. Where possible a second qualified nurse should check the ampoule
       against the medication sheet.

   -   The prescription sheet, ampoules and equipment should be placed within a lockable
       transportation box.

   -   Where a transportation box may cause unnecessary stigma to the patient, it is essential
       that a secure alternative solution is agreed with the team manager. This would only
       apply for transportation of a single depot where the nurse was able to return to base at
                     POWYS LOCAL HEALTH BOARD

       the end of the day. A secure alternative must also be able to house safe carrying of
       equipment.

   -   During transportation the box should be kept locked within a car boot, bearing in
       mind ambient temperature conditions

   -   All medication should be collected daily and returned at the end of the day to the
       stock cupboard.

   -   In the event of the nurse not being able to return to base and it is necessary for a nurse
       to keep medication under his/her control at home overnight, the medication must be
       kept within the locked transportation box and stored securely within the nurse’s home.

                                      Administration

   -   The nurse should check with the client their continuing consent and check the
       patient’s understanding of the drug to be administered.

   -   The nurse should wash his/her hands.

   -   The equipment, medication and prescription sheet should be laid out appropriately.

   -   The ampoule should be checked against the prescription sheet.

   -   The injection should be prepared and administered as prescribed. (Mallet &
       Dougherty 2000).

   -   The prescription sheet should be signed and dated and placed within the box along
       with the equipment and items for disposal.

   -   All medication, equipment and items for disposal should be returned to base.
                                                              Compiled by Sally Simmonds
                                                               Head of Nursing (MH & LD)
                                                                                    19/4/02

                                                                 Minor Update by Kevin Smith
                                                                           Head of Pharmacy
                                                                                     1/12/04
                                         References

DUTHIE. R.B. (1988) Guidelines for the Safe and Secure Handling of Medicines: A report
to the Secretary of State of Social Services. London : Department of Health.

MALLETT. J. DOUGHERTY. L. (Eds.) (2000). Manual of Clinical Nursing Procedures :
The Royal Marsden Hospital. (5th Ed). London : Blackwell Science.

Nursing and Midwifery Council (2002) Guidelines for the Administration of Medicines.
London.
                 MEDICINE POLICY SECTION 21
                             [
                  21a-Nurse Prescribing Policy
      District Nurse and Health Visitor Nurse Prescribers


Rev          Date       Purpose of                  Planned
                       Issue/Description of         Review Date
                       Change
A

B        March         Review-Section 21a:          March 2009
         2006          Community Nurse
                       Prescribing-
                       Health Visitors & District
                       Nurses


B




Responsible Officer           Approved by               Date

Head of Pharmacy       Drug and Therapeutic         3/3/06
Kevin Smith            Committee
                       Clinical Governance Risk     3/4/06
                       Management Committee
                                    CONTENTS

                                                                         Page No.
      Background                                                              4

1.    Policy Statement                                                        4

2.    Categories of Nurses who may prescribe                                  4

3.    Nurse Prescribers’ Formulary and Drug Tariff                            4

4.    Education and Training                                                  4

5.    Continuing Professional Development                                     5

6.    Notification of the Qualification to Prescribe                          6

7.    Notification of Nurse Prescribers leaving the employment of the LHB,    7
      or no longer eligible to prescribe

8.    Management of the Register of Nurse Prescribers                         8

            8.1 Accessing registers and providing information to other       8
                organisations

9.    Prescription Forms                                                      9
            9.1 Local Health Board nurses                                     9
            9.2 Completion of prescription forms                              9
            9.3 Wasted prescriptions                                         10
            9.4 Informing Patients                                           10
            9.5 Prescribing for Self, Family and Friends                     10
           9.6 Who to Write Prescriptions For                                11

10.   Record Keeping and Nurse Prescribing                                   11
           10.1 Documentation                                                11
            Nurse’s Patient Record                                           11
            GP Patient record                                                11
            What should be recorded                                          11


11 Controlled Stationary (Prescription pads) Ordering and security           12
            11.1 Ordering                                                    13
            11.2 Distribution                                                14
            11.3 Responsible Officer at Hospital sites                       14
            11.4 Nurse prescribers Responsibilities                          15

12.   Procedure for the Loss or suspected theft of FP10(N)                   16

13    Cross Boundary Prescribing                                             16
      13.1 Across GP Practices
      13.2 Across Health Authority Boundaries

                                                                                  2
14.   General Issues Relating to NHS LHB Nurse Prescribing               17

15.   Clinical Supervision                                               18

16.   Budget Setting & Monitoring                                        18
      16.1 Prescribing Costs                                             18
      16.2 Monitoring                                                    18

17.   Medical Representatives                                            18

18.   References                                                         19

Appendix 1                                                               20

      Form A1          Notification of Newly Qualified Community Nurse
                       Prescriber Change in Circumstances
      Form A2          Notification of Newly Qualified Practice Nurse
                       Prescriber Change in Circumstances
      Form A3          Register of Prescribers Specimen Signature List
      Form A4          Leavers Checklist
      Form CSDoc1      Order form for FP10(N)
      Form CSDoc2      Individual Record of Prescription Pad Orders
      Form CSDoc3      Checklist in Case of Loss or Suspected
                       Theft of Controlled Stationery
      Form NPDoc1      Record of Nurse Prescriber Items (for
                       inclusion in-patient records)
      Form NPDoc2      Personal Record of Staff Support


      (1) List of Responsible Persons for Receipt of
                       Controlled Stationery for each Hospital

      (2) List of GP Practice Codes




                                                                              3
Background

Nurse prescribing has been on the professional agenda since the Cumberledge
Report of 1986.

The current nurse prescribing scheme is based on recommendations contained in
the Report of the Advisory Group on Nurse Prescribing (1989) – The Crown Report
– which advised Ministers on how nursing care in the community might be improved
by the introduction of nurse prescribing. The report identified a number of clear
benefits, which could arise from nurse prescribing:

                    An improvement in patient care
                    Better use of “patients, nurses and GP’s time”
                    Clarification of professional responsibilities leading to improved
                     communications between team members.


1.     POLICY STATEMENT

Powys Local Health Board employs qualified Health Visitors and District Nurses who
are eligible in law to undertake the duties of Nurse Prescribers. It is recognised that,
where a District Nurse/Health Visitor or Nurses employed by the Local Health Board
in any setting when the role of nurse prescriber is included in the job description for
that post and is appropriately qualified by successfully completing the specific nurse
prescribing training programme, and prescribes as part of their nursing duties in
compliance with this document, the LHB accepts vicarious liability for their actions.

2.     CATEGORIES OF NURSES WHO MAY PRESCRIBE.

Staff employed by Powys LHB and in General Practice as Practice Nurses.
The nurse must hold the Health Visitor (HV) or District Nurse (DN) qualification (or
equivalent) and have successfully completed an approved prescribing training
course so that they are legally entitled to prescribe.
The nurse’s name must be held in the NMC professional register with an annotation
V100 signifying the nurse is qualified in this field

3.     NURSE PRESCRIBERS’ FORMULARY AND DRUG TARIFF

Nurses may only prescribe from the items listed in the Nurse Prescribers’ Formulary
for Community Practitioners Copies of the BNF and when available the NPF will be
provided by the LHB to its staff.
The Prescription Pricing Authority (PPA) produces the Drug Tariff monthly, nurse
prescribers should have access to an up to date copy. Pharmacists, dispensaries
and GP practices receive updates monthly.

4.     EDUCATION AND TRAINING

Nurse prescribing is now and integral part of Specialist Practitioner programmes in
District Nursing and Health Visiting
District Nurses and Health Visitors returning to work after a career brake and
therefore have not accessed the initial training programme will be able to undertake

                                                                                          4
the nurse prescribing module in the specialist practice course as long as they meet
the admission criteria of the higher education institute.
Nurse prescribers who have an extended period of leave/break in service may need
to update their skills and knowledge in certain areas in order to ensure that they are
safe and competent practitioners. (See Nursing Policy to ensure that qualified
nurse prescribers (Annotation V100) who return to work following extended
period of leave/break of service are competent to continue in their nurse
prescribing role. Powys LHB 2005)
5.     CONTINUING PROFESSIONAL DEVELOPMENT
The National Prescribing Centre has been commissioned to provide continuing
support in the form of educational information for nurse prescribers and can be
accessed through the website www.prescribing.info:
                    Prescribing bulletins
                    Product summary fact sheets.
The information will cover the following topics:
                    General principles of prescribing
                    Wound care
                    Infestation (head lice/threadworm/scabies)
                    Incontinence
                    Constipation
                    Pain relief
All nurses have a professional responsibility to keep themselves up to date with
nursing developments. Nurse prescribers will be expected to keep up to date with
best practice in the management of conditions for which they may prescribe, and of
the use of drugs, dressings and appliances in the nurse prescribing community
formulary.
Details of continual/additional training and updating will need to be incorporated into
the nurse’s personal and professional profile for the purpose of renewing their
registration with the NMC. It should also be included in Individual Performance
Review to provide information to team/Health Board training plans.
Nurse prescribing should be included in the framework of clinical supervision. Whilst
it is the individual nurses’ responsibility to ensure that her knowledge and skills in
relation to prescribing remain current, ongoing training/updating resources will be
identified and provided annually by the Local Health Board via the annual training
plan development process. Nurse Prescribing updating is currently provided by the
medicines management team in the form of quarterly one and a half hour training
sessions. The session will be held at a north and south site in the county and will
also offer video conferencing facilities.
Personal records of Staff Support sessions should be maintained. (Appendix 2
N/Pdoc 2 ). A note should be made in the nurse prescribers’ personnel file of when
these staff support sessions were held, who was involved and note any relevant
concerns or problems.




                                                                                      5
6      NOTIFICATION OF QUALIFICATION TO PRESCRIBE

            Nurse Prescriber newly qualified, newly employed or Change of
               Circumstances (Name or base) process of who to notify



      Newly qualified Nurse             Newly appointed DN/HV with a Nurse
      completes BSc, Higher             Prescribing Qualification NP completes
        Education Institute             form A1 and forwards to line manager
          notifies NMC                  Line Manager checks NMC register has
                                        V100 code and signs A1 form and
                                        forwards it to the DN/HV lead for Nurse
                                        Prescribing
    NMC                                   This can be completed when written
    Register annotated V100                acceptance of the post is received




    NP completes form A1 and                   DN/HV Lead for Nurse
    forwards to line manager                   Prescribing
    The Line manager checks the
    MNC register and forwards the
    form to the DN/HV prescribing
    lead                                     DN/HV lead for Nurse Prescribing sends
                                            a copy of the completed form to
                                             Health Solutions Wales (HSW),
    Form A1 is received by HSW
                                             LHB Person Responsible for
    and the database is updated
                                              Controlled Stationery (Supplies)
    The database is uploaded to
                                             Medicines Management Team
    Astron weekly
                                             Person Responsible for Controlled
                                              Stationery (local )
    (Please allow 2/52 for this
                                             Person Responsible for receiving
    process).
                                              controlled stationery at the BSC
    No pads will be issued unless
    the prescribers name appears
    on the LHB and HSW data
    base
                                           DN/HV Lead for Nurse Prescribing
     When this process has been
     completed prescribing pads
     can be ordered-
     FOR ORDERING
                                            NP changes his/her name or base
     PRESCRIPTION PADS
                                                Form A1 complete the appropriate
     SEE SECTION 9                             sections completed and signed and
    Nurse prescribers cannot                  forwarded to the line manager. The
    begin prescribing until they             line manager is not required to check
    have received their personalised                      NMC register
    prescription pads                       The Line Manager then forwards this
                                            form to the DN/HV Lead for Nurse
                                            Prescribing


                                                                                  6
 7.       NOTIFICATION OF NURSE PRESCRIBERS LEAVING THE EMPLOYMENT
          OF THE LHB, OR NO LONGER ELIGIBLE TO PRESCRIBE

 It is also important that when nurse prescribers leave their employment or cease to
 prescribe that prescription pads are returned and a formal notification is sent to
 HSW, a leaver’s check list should be completed

      Nurse Prescriber leaving the employment of the LHB notifies the D/N H/V
      prescribing lead in writing.
      If a nurse becomes ineligible to prescribe this should be recorded in the
      nurse personal file the Team Leader should notify the D/N H/V prescribing
      lead


       On receipt of written resignation or if the prescriber becomes ineligible to
       prescribe the D/N H/V prescribing lead completes appropriate sections of
       form A1 and sends a copy of the form to DN/HV lead for Nurse Prescribing.
       It will be the responsibility of DN/HV lead for Nurse Prescribing to notify the
       following



      Health Solutions Wales (HSW),
      LHB Person Responsible for Controlled Stationery (Supplies)
      Medicines Management Team
      Person Responsible for Controlled Stationery (local )
      Person Responsible for receiving controlled stationery at the BSC

   It will be the responsibility of the D/N H/V prescribing lead to inform the nurse
   prescriber in writing the date the prescribing pads are to be handed in a copy
         of this letter will be sent to the local person for controlled stationery.



By 12 mid-day on the last working day, or on the day designated for a nurse no longer
eligible to prescribe, the NP will return any unused or partially used prescription pads to
                     the Local person for controlled stationery (LPCS)
 The first and last numbers of all pads returned will be recorded in the supply of
   controlled stationery book The NP and the LPCS will sign the entry
 The LPCS will complete the check list and give this to the N/P
 If the pads are not returned by the specified time the LPCS will inform the line
   manager of the NP
 The NP pads will be returned to the supplies department for destruction



The NP will return the check list to the line manager before finishing duty on the last
working day or on the day designated for a nurse no longer eligible to prescribe
The line manager will:
 Complete the leavers form and send copies to (This must be done within 24 hours)
 LHB Person Responsible for Controlled Stationery (Supplies)
 Medicines Management Team
 Person Responsible for Controlled Stationery (local )
 DN/HV lead for Nurse Prescribing
 7.      Management of the Register of Nurse Prescribers
 File a copy of the check list in the NP personal file
                                                                                        7
8.     Management of the Register of Nurse Prescribers
8. MANAGEMENT OF THE REGISTER OF NURSE PRESCRIBERS
In order that pharmacists can check that a nurse prescription prescribed for
dispensing is bona fide, the Local Health Board will keep a register of all nurse
prescribers employed by them, it is referred to as the Register of Nurse Prescribers.

The Local Health Board should maintain an up to date register of nurse prescribers
in their employ.

The register needs to contain:

                    Nurse’s name
                    Community qualification
                    NMC PIN Number
                    Contact Number
                    Specimen Signature. These should be held separately if the
                     other details are held electronically

The following will hold a list of nurse prescribers and a specimen signature for
nurses employed in their administrative area:
At Local level
                    The Responsible officer for controlled stationary.
                    Line Manager for D/Ns and H/Vs.

At LHB level a list of all nurse prescribers within the LHB will be held
                    Supplies Department.
                    Medicines Management Team
                    Lead District Nurse/Health Visitor for Nurse Prescribing

At The Business Service Centre
                    Person responsible for receiving controlled stationery from
                     Astron
Nurses should be prepared to provide specimen signatures to pharmacists if
required. Pharmacists will also be able to confirm the status of a nurse prescriber
with the NMC Tel No-02076313200
  8.1.Accessing registers and providing information to other organisations.
      This will be done in compliance with the Freedom of Information Act
       Requests for information can be made in writing or by telephone and only
       information contained in the register can be given out.
   Access to the Register by telephone is restricted to the following personnel:
      Local Health Board (Director of Nursing).
      Community Pharmacists.
      Line managers.
      Human Resources.
      Support Services.
      Locality designated person for controlled stationery.


                                                                                      8
     Pharmacists should only access the register to check whether a nurse
     prescription handed in for dispensing is bona fide, to confirm any aspect of the
     prescription, return it for amendment, or even refrain from dispensing it.

     The NMC 24-hour telephone line (01716313200) can be assessed to confirm to
     any enquirer whether or not a nurse is eligible to prescribe. The enquirer must
     state they are checking prescriber status, if not the NMC operator will assume
     the caller is the employer and ask further questions to which the enquirer will not
     have the answers.


     Requests by personnel other than those listed above must be received in writing
     and comply with The Freedom of Information Act

     Misuse of any information will be dealt with under the appropriate Local Health
     Board procedure or reported to the appropriate authority.

9.      PRESCRIPTION FORMS

        9.1    Local Health Board nurses

        Nurse prescribers use specific types of prescription forms for prescribing
        which the dispenser can identify. This is an FP10(N) which is pre printed with
        the nurses name and PIN number. Prescription forms will be serially
        numbered and produced on specially printed, anti-fraud paper.

        Local Health Board nurses working across different practices can use one
        pad, but must complete the relevant practice number for the patient. (GP
        Practice Codes are in Appendix 2)

        A nurse prescriber may only prescribe items as specified in the Drug Tariff
        (Part XVIIB) and documented in the Nurse Prescribers Formulary for
        Community Practitioners.

        9.2 Completion of Prescription Forms

        Nurses qualified to prescribe should not issue prescriptions on behalf of a
        nurse who is not a qualified nurse prescriber. A nurse prescriber can only
        issue a prescription for a patient whom she herself /he himself has
        assessed for care and should only write prescriptions on a prescription pad
        bearing her/his own unique identifier number.

        1. Only qualified nurse prescribers employed by Powys Local Health Board
           are authorised to prescribe for patients of GPs responsible to Powys LHB

        2. The nurse prescriber must take into consideration any professional and/or
        ethical issues relevant to the prescribing needs of the patient. The nurse
        prescriber will be accountable for all prescriptions.

        3. It is unethical for nurses to recommend a particular pharmacist to
        patients since this is a matter of patient choice.



                                                                                        9
      4. A nurse prescription should generally provide treatment for no more
         than one month, although cost and clinical effectiveness should also
         be borne in mind for patients receiving long term treatments. Re-
         evaluation dates need to be clearly established. It is best practice to
         allow no more than six repeat prescriptions, or for no more than six
         months to elapse, whichever is the less without reassessing the
         patients needs

The nurse prescriber should complete all the details on the prescription form by
writing clearly and legibly using an indelible pen. The details required are:

                   Patient’s surname and first name, date of birth and full address
                   The name (plus quantity and strength, if any) of the prescribed
                    item, dosage and frequency. The quantity prescribed should be
                    appropriate to the patient’s treatment needs, bearing in mind the
                    need to avoid waste.
                   Medicine name should be written clearly using approved generic
                    titles as specified throughout the BNF and should not be
                    abbreviated. The only exception to this rule is for the
                    prescribing of dressings and appliances.
                   Directions, if for use or application by the patient or carer, which
                    should be in English and not abbreviated
                   Signature and date
                   Where there is more than one item on a form, a line should be
                    inserted between each item for clarity
                   Unused space in the prescription area of the form should be
                    blocked out with, for example, a diagonal line.

General information on prescription writing can be found at the beginning of the
BNF.

      9.3 Wasted prescriptions

      It is mandatory to record the number and reason for any wasted prescription
      sheets (Appendix 2 Form CSDoc 2) score through the prescription sheet and
      write cancelled. Destruction of these prescriptions must be witnessed by
      another clinician and both nurses should sign that this action has been taken


      9.4.   Informing Patients


      Nurse prescribers must ensure patients and clients are fully informed of the
      change in nursing responsibilities, items prescribed should be explained so
      there is no delay in obtaining supplies.

      9.5.   Prescribing for Self, Family and Friends.

      If the situation arises when the nurse prescriber or members of their family or
      friends are registered with the practice to which the nurse prescriber is


                                                                                      10
      attached, there will be an ethical question to be faced. Nurse Prescribers are
      advised not to prescribe for self, family or friends.
      Registered nurses are accountable for their practice, if the situation arises
      where they find themselves in a position to prescribe for themselves or their
      family, then they must accept accountability for that decision.



      9.6.    Who to Write Prescriptions For
      Powys LHB nurses may issue prescriptions for the patients of the GP
      practices under the administration of Powys local health Board.
      Nurses can prescribe for travelling patient’s families, provided that they have
      completed the appropriate residency forms.

      Nurses should only prescribe for visiting relatives of patients if they are
      temporarily registered with the doctor concerned.

10.   RECORD KEEPING AND NURSE PRESCRIBING
      All Nurses are required to keep contemporaneous records, which are
      unambiguous and legible in accordance with statute, NMC guidelines and the
      LHBs standards for record keeping.
      Good communication and teamwork are essential for effective nurse
      prescribing and patient safety, and patients' records should be made
      available to any nurse visiting a patient for the first time.

      10.1. Documentation:
              The Nurses Patients Record

              All nurse prescription items must be recorded on the appropriate
              patient documentation at the time of writing the prescription,
              For district nursing patients, prescription items should be recorded on
              the form NPDoc1. in the nursing notes which are left in the patient's
              home whilst care is being provided.
              For health visiting clients, prescription items should be recorded on the
              nurse's pink medication page in the parent held child record (PHCR)
              for children, and in the health visiting record. For adults a record
              should be made on NPDoc1.
              The GP Record
              Nurses should enter the information within 48 hours into the GP
              Record. The record should indicate that it was a nurse prescription
              with the name of the prescriber

             What should be recorded : The record should clearly indicate:
                the date and time
                the name of the prescriber
                 the name of the item prescribed
                                                                                     11
                the quantity prescribed
           For medical preparations (items to be ingested or inserted into the body)
            the dosage schedule and route of administration must be stated e.g.
            paracetamol, oral suspension 5 mls 4 hourly.
           For topical medicinal preparations, the quantity to be applied and
            frequency of application must be included.
           For dressings and appliances, details of how to be applied and how
            frequently changed.
             Note advice given on over the counter (OTC) items.
   Prescribed items must be entered into the General Practitioner's records as
   soon as possible within 48 hours maximum, indicating that it is a nurse
   prescription and who the prescriber was. This information must be entered
   into records directly by the nurse or communicated to the surgery by the
   nurse prescriber using an appropriate form.
             In some circumstances in the clinical judgement of the nurse, it may be
             necessary to advise the General Practitioner immediately of the
             prescription. This action should be recorded in the nurse's notes.
             In the event of an adverse reaction the nurse should record it in the
             patient's notes, GP records and report this by submitting a yellow card
             to the Medicines Control Agency Committee on Safety of Medicines.
            A LHB incident form should also be completed by the nurse prescriber.
11. CONTROLLED STATIONERY (PRESCRIPTION PADS) ORDERING AND
      SECURITY
The Nurse Prescribers name needs to appear on the LHB and HSW data base
before pads can be ordered
The prescription forms are controlled stationary and therefore need to be stored in a
locked environment, with one member of staff controlling the access at each local
centre. Your Line manager will notify your local point and staff member to you.
Local security arrangements for the receipt, storage and distribution of prescription
pads must be robust.
Local Health Board nurses order prescribing pads through the Support Services
Department.
To order prescription pads, nurse prescribers need to complete a written request
which must be completed in full. Verbal requests will not be accepted. (Appendix 2
Nurse prescribers order form for controlled stationary CSDoc 1),
      No nurse prescriber prescription pads will be stored long term in the Support
      Services Department. If prescription pads cannot be despatched immediately
      they should be stored with FP10 (H) in a secure cupboard overnight and be
      dispatched the next day

      An audit trail must be evident for all prescription pads passing through each
      department.


                                                                                      12
        11.1 Ordering of prescription pads.

The Nominated Person in Support Services Mansion House, Bronllys. Fax No:
01874711983 Ext.: 2626.) will receive a list of nurse prescribers and their
signatures. This list will be updated by the Nurse Prescribing Leads when any
staff changes occur.

                                               Local Person for Controlled
   Prescription pads will be ordered           Stationery receives the form
   in writing using                            and:
    CSDoc1 (App                                 Checks the data base to
   endix 2).                                      the nurse is a prescriber
   Forms must be fully completed                Counter-signs the form if
   by the nurse prescriber                        fully completed
   And forwarded to the D/N H/V                 Forwards form to the
   prescribing lead they will then                Supplies Dept for ordering
   be forwarded to Local Person                   (This form may be faxed in
                                                  exceptional circumstances
   for Controlled Stationery
                                                  but the original must also
                                                  be forwarded)
  No signature, form
  returned to person                        The nominated Person for
                                   NO       Controlled Stationery in Supplies will
  responsible for controlled
  stationery in local area                   Check authorised signature of
                                               designated person for controlled
                                               stationery before processing the
                                               order.
                                                        YES


                                             Central Supplies department
 Returns the form to the
                                   NO         checks the nurses name
 lead nurse for prescribing
                                              appears on the central data base
 DN- HV
                                                         YES


                                             Process the order with Astron
                                              within three working days from
   Astron informs Person                      receipt of the request form.
   Responsible for controlled
   stationery Supplies, who                 Asteron
                                       NO
   will in turn inform DN HV                 Checks the data base to ensure
   responsible for NP                          it contains the nurse prescribers
                                               name

 BSC receives prescription                              YES
 pads and forwards them to
 PLHB person responsible
 for controlled stationery in                If all details are correct prints the
 Powys LHB (Supplies) for                     prescription pads and sends
 distribution                                 them to the BSC in Carmarthen



                                                                                      13
       11.2 Distribution of Prescription Pads

       11.21 Before issuing the prescription pads to the post room staff the
             appropriate form must be signed by two members of Support Services
             Department.

       11.22 Transport driver must sign the appropriate documentation to accept for
             delivery before leaving the department.

      11.23 When there is any change over of transport staff the form must be
            signed by the new member of staff accepting the delivery

       11.24 On reaching destination, the prescription pads must be handed to the
             hospital’s Designated Responsible Person and the form signed
             accepting delivery. (In the event of late delivery the nurse in charge of
             the hospital should sign for the prescription pads.)

       11.25 The delivery document must be returned to Support Services
             Department within one working day by the transport driver with all
             sections completed.

All returned CSDoc1 forms should be filed and maintained for audit and legal purposes for
two years.

      11.3 Responsible Officer at hospital sites(See attached list for each
                        areas Responsible Officers)

       11.31 Receipt and Storage of Stock Prescription Pads

      Stock prescription pads are ordered and supplied from the Support Services
      Department using the requisition form CSDoc1(Appendix 2) against the name
      and P.l.N. number of individual nurse (and Welsh Nurse Identifier number).
      This is dated and signed by the Nurse Prescriber and countersigned by the
      locality designated responsible person for controlled stationary

      Supplies will send the prescription pads to the appropriate hospital, where the
      Responsible Officer will sign the original order form acknowledging receipt.
      The form is then taken back to Support Services by the driver.

      The pads are stored in a locked cupboard at in each hospital. The only
      officers with keys to the locked steel cupboard will be the people identified as
      Responsible Officers on the attached list. (There should be an identified
      deputy to cover periods of absences)

       11.32 Issuing of Prescription Pads

        Nurse prescribers are advised to order a new pad at least two weeks before
        they expect to need it. Maximum of two pads per prescriber should be held
        in stock at the issuing centre

      A register (CSDoc1 appendix 2) for each nurse prescribing pad will be
      maintained as a record of every issue of prescription pad, stock control and
      indicating in red ink any loss or theft of pad. This will be signed on each

                                                                                      14
occasion by the individual nurse and the issuing officer and should ensure
sequential use of pads.
If a nurse works for more than one employer an additional proforma will need
to be completed, as the nurse will require separate pads for each organisation



11.33 Destruction of Prescription Pads


If a nurse prescriber is no longer carrying out prescribing duties for whatever
reason, it is the responsibility of the Local Health Board to ensure no further
prescription pads are ordered for the nurse.

It will be the responsibility of the Nurse Prescriber to return all pads to the
Local Health Board’s nominated officer at the hospital site. The pads will be
returned to the central supplies department at Mansion House for destruction.

11.4 Nurse prescribers responsibilities for security of prescription pads

The prescription pad is the legal property of Powys Local Health Board The
Local Health Board will ensure the control and monitoring of the supply and
distribution of prescription pads, however once it has been allocated it is the
responsibility of the individual nurse prescriber to ensure the security of the
pad at all times.

11.41 Receipt of Prescription Pads

Prescription pads must be signed for on receipt.

Nurse prescribers must keep a record of the serial numbers of prescription
forms issued to them. It is important to record the first and last number on
each pad. (Appendix 2 CSDoc 2)

11.42 Ensuring Security of the Pad:

       Under no circumstances should prescription pads must left unattended
        whilst not in use but be placed in a locked drawer.

       Prescription forms should not be pre-signed before use

       The prescription pad should only be produced when required and
        never left unattended.

       When travelling between patients, the prescription pad should not be
        visible and must be locked in the car boot within the nursing bag/box.

       The nursing bag and prescription pad must always be removed from
        the car when the car is unattended.

       When leaving the employ of the LHB or on becoming ineligible to
        prescribe a nurse must return unused or part used pads to the person
        responsible for controlled stationery at the hospital (As per page 7)


                                                                               15
12. PROCEDURE FOR LOSS OR SUSPECTED THEFT OF FP10 (N) PADS

The security of the prescription pad is the responsibility of the receiving
member of staff at what ever stage the issuing process has reached

12.1   During Normal Working Hours

       Nurse prescriber is to inform identified individuals immediately a script is
       found to be lost or suspected stolen so HSW can be informed within 24 hours
       (with the exception of weekends).

       Procedure

       Nurse Prescriber

             Informs; D/N H/V prescribing lead, if not available the manager
             providing cover

              The nurse prescriber completes clinical incident report (Datix) and
             CSDoc3, giving details of the approximate number of scripts missing
             and where they went missing from, or last time they saw them.

       D/N H/V prescribing lead/manager providing cover

             Informs:   Police, GP. HSW, Medicine Management Team and
             BSC Person Responsible for Controlled Stationery

             Investigates the incident using root cause analysis

             Reports the incident and investigation findings to the Head of
             Pharmacy, Clinical Govenance and Director of Nursing. It is important
             that the manager’s investigation is of the circumstances of the loss or
             suspected theft as the police will also be investigating.

       BSC

             Informs:     Community Pharmacists.

             Out of Hours: As above with the Nurse Prescriber informing the
             operational person on call

             GP. HSW, Medicine Management Team and BSC Person
             Responsible for Controlled Stationery as soon as possible, e.g.
             Monday morning if the incident occurred at weekend.

              The Police should be informed immediately by the line manager
             responsible covering the weekend

   N.B.   NURSES TO BE ASKED TO PRESCRIBE IN RED INK FOR A
   PERIOD OF TWO MONTHS.

                                                                                    16
13.   CROSS BOUNDARY PRESCRIBING

      13.1   Across GP Practices

      Powys Local Health Board nurse prescribers can use the same pad across
      GP practice areas for all practice patients regardless of country of residence.
      However they must enter the patient’s practice code, i.e. the code of the
      practice with which the patient being prescribed for is registered.

      13.2   Across Local Health Board Boundaries

      Nurse prescribers who are likely to prescribe across Local Health Board
      boundaries should use the pad issued by Powys Local Health Board.
      However they must enter the patient’s practice code, i.e. the code of the
      practice with which the patient being prescribed for is registered. This also
      applies to practices administered by English PCT’s. Nurses employed by
      Welsh Health Boards will not need to apply to English PCT’s for prescribing
      pads.

14.   GENERAL ISSUES RELATING TO NHS LHB NURSE PRESCRIBING

                 Local Health Board nurses may prescribe in any setting as long
                  as nurse prescribing is included in the nurses duties and job
                  description. When a Local health Board nurse prescriber is
                  providing ‘cover’ for an absent colleague, who is also a qualified
                  to prescribe, the nurse providing cover may prescribe in their own
                  right following a patient assessment and they might write a
                  repeat prescription
                 Whoever signs the prescription assumes responsibility and the
                  clinical liability for it. In all cases, nurses must put themselves
                  in a position to assess the necessity for, and appropriate choice
                  of, drug, dressing or appliance before prescribing.
                 Patients needs should be continually assessed and prescriptions
                  issued should reflect assessed need.

                 Items for dispensing on the FP10(N) form must only be those
                  from the Community Nurse Prescribers Formulary.
                 When a nurse becomes aware that the patient intends having a
                  prescription dispensed by approaching an appliance contract, she
                  must ensure that the prescription does not contain medical
                  preparations.
                 Appliance contractors cannot dispense medicinal preparations.
                 Items that require a GP signature should not be entered on a
                  FP10(N), even if they are counter signed by a GP. The GP
                  prescription pad must be used at all times when a GP signature is
                  required.
              
It is advisable for nurses to obtain their own professional indemnity by means
of membership with a professional organisation or trade union.


                                                                                      17
15.   CLINICAL SUPERVISION

The Local health Board Clinical Supervision Policy defines how Powys LHB will
ensure clinical supervision will be implemented The Powys LGB clinical supervision
guideline should be used as a tool to support supervision sessions

16.   BUDGET SETTING AND MONITORING

For legal reasons, it is not possible for nurses employed by Local Health Boards to
prescribe directly against the prescribing amount allocated to a GP.

Practice nurses can prescribe against their GP employer-prescribing amount.

      16.1   Prescribing Costs

      The National Assembly for Wales, in discussion with HSW and Local Health
      Board professionals, has agreed the following:
                 Cost of drugs and appliances prescribed by the Local Health
                  Board nurses in Wales will remain within the primary care sector
                 Prescribing costs will be allocated to the responsible practice for
                  the patient, for information purposes only; it will not directly affect
                  the practice budget.
                 LHB will top slice participating practices’ prescribing budget. The
                  LHB sets the budget allocation for the nurse prescribing.
                 Practice nurse prescriptions will be charged against their
                  employer’s prescribing amount and accounted for as Part II
                  expenditure in the same way as GP prescribing.

      Nurse prescribing is substitute prescribing and there should therefore be no
      additional prescribing costs as a result of introducing nurse prescribing.

      16.2   Monitoring

      HSW will provide standard Prescribing Audit Reports to GP practices, LHB
      and Welsh Assembly, on a monthly basis with an analysis quarterly.

      Prescribing Catalogues are available on request to: individual prescribers, GP
      practices, and LHB.

17.   MEDICAL REPRESENTATIVES
Nurse Prescribers should refer to NMC Document “Guidelines for Professional
Practice” (1996) for guidance dealing with medical representatives.

Further guidance can be sought from:

                 Prescribing Lead for HV and DN
                 Local Health Board Medicines Management Team
                 Local Pharmacist

                                                                                       18
18.   REFERENCES

Nurse Prescribing         HSC 1998/232
                          December 1998


Nurse Prescribing         A Guide for Implementation
                          NHS Executive
                          December 1998


Nurse Prescribing         A Guide for Implementation
                          National Assembly for Wales
                          May 2000


Nurse Prescribing         Open Learning Pack
                          WNB July 2000


Record Keeping            Guidelines for Record and Record Keeping
                          NMC 2005


Practice                  The NMC code of professional conduct
                          NMC 2004


Nurse Prescribing: A guide for implementation (1998) NHS Executive London

Nurse Prescribing: A guide for implementation (2000) National Assembly for Wales
Cardiff

Practice                  Powys LHB Clinical Supervision Policy 2006
                          Powys LHB Clinical supervision Guidelines 2006


N.B. - Nurse is a generic term referring to male or female, the feminine has
been used throughout this document for consistency.




                                                                               19
Content

     Form A1        Notification of Newly Qualified Community Nurse
                    Prescriber Change in Circumstances


     Form A2        Notification of Newly Qualified Practice Nurse
                    Prescriber Change in Circumstances


     Form A3        Register of Prescribers Specimen
                    Signature List


     Form A4        Leavers Checklist


     Form CSDoc1    Order form for FP10(N)


     Form CSDoc2    Individual Record of Prescription Pad Orders


     Form CSDoc3    Checklist in Case of Loss Or Suspected
                    Theft of Controlled Stationery

     Form NPDoc 1    Record of Nurse Prescriber Items (for
                    inclusion in-patient records)


     Form NPDoc 2   Personal Record of Staff Support


     List 1         List of Responsible Persons for Receipt of
                    Controlled Stationery for each Hospital


     List 2         GP Practice Code




                                                                      20
Notification of Newly Qualified Community Nurse
                    Prescriber Change in Circumstances
Form A1
Use this form to advise details relating to Community NHS Trusts Nurse
prescribers

To:    Health Solutions Wales               From: ……………………………………
       Unit 14/15                           ……………………………………
       Swift Business Centre                ……………………………………
       Keen Road                     ……………………………………
       East Moors
       CARDIFF                                      ……………………………………
       CF24 5JR                                     ……………………………………

PLEASE TICK                     TYPE OF CHANGE               NOTES ON
                                                             COMPLETION
                                Newly qualified nurse        Complete sections A and B
                                prescriber                   and Part C1
                                Nurse working for an   Please complete parts A1
                                additional organisationand A2 Section B and part
                                                       C2
                        Nurse’s employment ends at Complete as a minimum,
                        a specific unit                Parts A1, A2 B1,B2 and C2
                        Nurse details to be removed Complete as a minimum,
                        from all current organisations Parts A1, A2 and C2
EFFECTIVE DATE OF THE CHANGE (TO BE COMPLETED IN ALL CASES)
SECTION A; Nurse Prescriber Details
Ref       Description                            Details
1      Nurse NMC Pin Number
2      Nurse Name and Initials
3      Title (Mr/Mrs/Miss/Ms/Sister, etc)
4      Qualification (district Nurse or
       Health Visitor)
5      Nurse prescribing training
       examination pass date
SECTION B; NHS LHB Details
Ref       Description                            Details
1      NHS Trust /LHB code
2      NHS Trust/LHB name
3      NHS Trust /LHB address Centre
       from where the nurse works
SECTION C; : Details of the nurse prescriber in the NHS Trust/LHB
Ref       Description                            Details
1         Start date in the NHS Trust/LHB
2         End date in the NHS Trust/LHB

Signature of NHS Trust/LHB employee providing
information:……………………………….

Name of the NHS Trust/LHB employee providing information
(Printed):__________________ Date_____________
                                                                                    21
                                                                 Created on 12/04/2006
COPIES OF THIS FORM SHOULD BE FORWARDED TO Powys LHB Supplies Dept, Local Person
Responsible for Controlled Stationery, The Medicines Management Team and the BSC Swansea
Signature of NHS Trust/LHB D/N H/V Prescribing Lead ____________________
                                             Date____________________




                                                                                    22
                                                                 Created on 12/04/2006
COPIES OF THIS FORM SHOULD BE FORWARDED TO Powys LHB Supplies Dept, Local Person
Responsible for Controlled Stationery, The Medicines Management Team and the BSC Swansea
                                               Form A2
Notification of Newly Qualified Practice Nurse
         Prescriber Change in Circumstances

Use this form to advise details relating to Practice and PMS Pilot Nurse Prescriber’s

Use only one form per nurse. Effective date of change must be completed in all areas

To:     Health Solutions Wales                   From: ……………………………………
          th
        14 Floor                                       ……………………………………
        Brunel House                                   ……………………………………
        2 Fitzalan Road                                ……………………………………
        CARDIFF                                        ……………………………………
        CF24 0HA                                       ……………………………………

Please TICK and then complete the sections as required

Newly qualified nurse prescriber                          □   Complete sections A and B
                                                              and Part C1

Nurse’s employment ends at a specific unit                □   Complete as a minimum, Parts A1,
                                                              A2, B1,B2 and C2

Nurse details to be removed from all current              □   Complete as a minimum, Parts A1,
organisations                                                 A2 and C2

Section A: Nurse Details

Ref
1      Nurse UKCC Pin Number
2      Nurse Name and Initials
3      Title (Mr/Mrs/Miss/Ms/Sister, etc)
4      Qualification (district Nurse or Health Visitor)
5      Nurse prescribing training examination pass date

Section B: NHS LHB details

Ref
1      NHS LHB code
2      NHS LHB name
3      NHS LHB address




Section C: Details of the nurse prescriber in the NHS LHB

Ref
1      Start date in the NHS LHB
2      End date in the NHS LHB

Signature of Health Authority/Practice/PMS Pilot employee
providing information                                          …………………………………

Name of Health Authority/Practice/PMS Pilot employee
providing information                                          …………………………………

                                                                     Created on 04/12/2000 11.09
                                                                                             23
                                                                Form A4
                  POWYS LOCAL HEALTH BOARD
                       Leavers Check list

Name: __________________________________

NMC PIN Number: _______________________

Qualification: _______________

Locality:     ___________________

Date Leaving: _____________________

Prescription pad returned on:    ____________________

Prescription Pads returned to: Locality Person Designated for Controlled
Stationery
                    Fax Number: External 01874 711983 Internal: 4603

Signature of person returning pads:     _____________________

Print Name:                             _____________________

Witness to the return of unused pads:   ______________________

Print Name: ______________________             Date: _________________

HSW informed?       Yes / No            Date: ___________

If No, reason:      ___________________________________________

Locality Nurse/Line manager completing Form:
_______________________________

Signature: ____________________________

Date: ___________________


Copy of Form sent to Human Resources:          Yes/No




Nurse Prescribing Controlled Stationary Order Form-Form
CSDoc 1
                                                                       24
Order Form for FP10(N)
Community Staff

Nurse Prescription Forms

Please send *complete/authorised form to:             Chris Williams
                                                            Support Services
                                                            Department
                                                            Mansion House
                                                            Bronllys
Fax Number: External 01874 712631              Internal: 2626
                          --------------------------------------
Date: __________

Name

UKCC Number

Unique Welsh Nurse Identifier

Nurse’s Base

Safe Place for Delivery

Nurse’s Signature

Signature of Responsible Person:
(See page 30 NP Policy for list)

* REMINDER - Any unauthorised forms will result in delay in ordering


                              For Supplies Use only

Date order received

Date request sent to Astron

Date prescription pad received in
Supplies
Serial Numbers

Prescription Pads received by

Signature of persons signing pads
out
Transport Drivers Signature

Signature of person accepting
delivery



                                                                               25
                                       Nurse Prescribing Controlled Stationary Documentation----Form CSDoc 2


                                                              POWYS LOCAL HEALTH BOARD
Individual Record of Prescription Pad Orders

Name __________________                         Base ___________________ PIN _____________________

Date               Date                    Number of 1st             Number of Last      Date of    Issued by:   Received by:
Prescriptions      Prescriptions         Prescription sheet         Prescription sheet   Issue to   Signature    Signature
Ordered            Received                                                              nurse




Prescriptions incorrectly filled out   Sign below to   Date     Signature of Witness     Date
number of sheet                        confirm sheet
                                       has been
                                       destroyed




                                                                                                                                26
Nurse Prescribing Controlled Stationary Documentation
                                                   Form CSDoc 3

POWYS LOCAL HEALTH BOARD


Checklist In Case Of Loss Or Suspected Theft of
Controlled Stationery

Date and time when loss or suspected theft noted: _________________

Date Prescription Pad last seen                     ________________

When was the prescription pad last used?            ________________

Number of last prescription pad issued:             ________________

Notification (to be completed by Nurse Prescriber)

Line Manager Informed?
Time? ___________                 Date? _________

Line Manager/manager on call to complete

Police Informed?
Time? ___________                 Date? _________

Name of Officer?     ____________________________

GP Informed?
Time ? ___________                Date? _________

Name of GP? ______________________________


HSW Informed?
Time? _________           Date? _________

BSC (nominated officer)
Time? _________           Date? _________

Investigation commenced on:__________________

Investigating Officer:    ____________________________



                                                                       27
                                           POWYS LOCAL HEALTH BOARD



                                     Nurse Prescribing Documentation--Form NPDoc 1



Record of Nurse Prescriber Items (To be filed in Patient’s notes)



Patient Details:Name: _________________                   D.O.B: _______________



                       Address: _____________________________________________              G.P. __________________


 Date      Name of Item Prescribed      Dosage    Strength    Frequency   Duration   Route Prescriber’s Name   Signature
                                                                                           (Printed)




                                                                                                                     29
30
                                                                           N/PDOC 2
POWYS LOCAL HEALTH BOARD

Personal Record of Staff Support/Nurse Prescribing Sessions

Date______________

Date of Session_________________

Venue of Session______________________

Duration of Session________________________

Feedback from Previous Session




Please give a brief description of issues discussed during this session:




Supervisee Signature                            Name of Supervisor (If supervision)

____________________                            ___________________


Date of next Staff Support Session __________________________-

Venue of next Session___________________________


                                                                                      1
2
POWYS LOCAL HEALTH BOARD
List of Responsible Persons for Receipt of Controlled
Stationery for each Hospital

     Hospital Areas

          Brecon               Angela Williams (5644)
                               Ralph Jones (5606)
                               Claire Nicholas

          Bronllys             Pauline Price
                               George Pigden

          Builth Wells         Denise Thorn (4327)
                               Mandy Kinrade    (4354)

          Knighton             Chris Davis

          Llandrindod Wells    C M Jones

          Llanidloes      Mitch Woodcock
                                Sally Davies


          Machynlleth          Margaret Jones
                               Anwen Jones


          Newtown              Gill Foxley
                               Wendy Evans
                               Anne Evans

          Welshpool       Rosemary Cullen

          Ystradgynlais        C. M. Jones
                               Carol Page




                                                         3
               GP Practice Codes

GP.PRACTICE             PRACTICE CODE

BRECON                  603352
BUILTH WELLS            603356
CAEMMAES ROAD           603360
CRICKHOWELL             603365
LLANDRINDOD WELLS       603362
LLANFAIR CAERINION      603358
LLANFYLLIN              603361
LLANIDLOES              603354
MACHYNLLETH             603363
MONTGOMERY              603350
PARK STREET             603364
PENGORF                 603351
PRESTEIGNE              603438
RHAYADER                603355
TALGARTH                603366
WELSHPOOL               603359
WYLCWM STREET           603353




                                        4
SECTION 22                COLLECTION OF PRESCRIPTION CHARGES

    22.1   No charge should be made for medication administered within hospital
           premises to NHS patients. There is also no charge liability for discharge
           medication. Unless exempt or remitted from charges, patients are liable for
           prescription charges on any medication to be taken out of the hospital. This
           includes day surgery patients and MIU patients. Medication for the treatment
           of venereal disease (STDs) is dispensed free of charge. Patients should sign a
           declaration to say why they do not have to pay or how much they have paid.
           Arrangements should be in place for checks of claims to exemption from
           prescription charges as specified in HSC1999/082 NHS Charges for Drugs
           and Appliances Regulations 2000 (as amended)
    22.2   There are concerns regarding collecting money outside normal office hours.
           At present, prescription charge collection is under active consideration.
           Patients will be asked to send payment by post, or take payment to the hospital
           during opening hours. The proportion of charges collected by this method will
           determine the way forward for out of hours collection in the future.




                                                                  Updated by Kevin Smith
                                                                         Head of Pharmacy
                                                                                  31/12/04




                                                                                            1
SECTION 23                 WASTE MEDICINES


    This section contains information collated from other sections of this document,
    and may therefore duplicate some information.


    23.1.   Any expired, unused, or patients own medication (or any other medicines that
            need destruction and are in a fit state to be handled), should be returned/sent to
            pharmacy at Bronglais, for the northern hospitals (Llanidloes, Machynlleth,
            Welshpool, Newtown). When returning medicines other than via pharmacy
            staff, they should only be sent in a locked pharmacy box. For hospitals
            supplied by Nevill Hall (Ystradgynlais, Llandrindod Wells, Knighton, Builth,
            Brecon, Bronllys) they should be kept and returned with pharmacy staff. All
            controlled drugs should be returned to a pharmacist on the ward.


    23.2.   Records should be kept of all medicines returned to pharmacy, or destroyed on
            the ward.


    23.3.   All controlled drugs should be returned via the pharmacist.


    23.4.   Contents of opened vials, leftovers from syringes, remains in giving sets,
            contaminated single tablets etc, should be disposed of via the sharps boxes.
            These are now subjected to high temperature disinfection rather than
            incineration, but there is an agreement with the Environment Agency that this
            can continue, [providing that tests on the output of the plant (in Bridgend)
            continue to show no evidence of harmful contaminants. This depends on the
            drugs being a small percentage of the total contents (<0.1%). More stringent
            standards apply to cytotoxic drugs]


    23.5.   Drugs prepared for administration, which are subsequently not used, must be
            returned to the pharmacy. For Intravenous fluids and antiseptic fluids which
            are not conveniently returned to pharmacy the Ward COSHH procedures must
            be checked to ascertain the correct method of disposal. No pharmaceutical




                                                                                            1
           fluid must be disposed of via the hospital drainage system without checking
           the COSHH data or pharmacy for advice.


   23.6.   Wherever possible, community staff should return medicines (or preferably
           ask patients/carers to return) to a community pharmacy, or, for items as in 3
           above, place in portable sharps box and return through the hospital as above.


   23.7.   Before disposing of cytotoxic waste material, please check with the supplying
           pharmacy department


   Waste policy in Powys LHB is constantly under review, so this advice may change,
   and any suggestions in the meantime are welcome.


Kevin Smith March 2002-03-18


Review March 2004


Updated 31/12/04




                                                                                           2
SECTION 24                 CONTROLLED DRUGS


  The term Controlled Drugs applies to any drug or medicinal product controlled by the
  Misuse of Drugs Act 1971.


  This section will contain some duplication, since it draws together the information
  from other sections of the medicines policy


  24.1.    Prescriptions for Controlled Drugs (Take Home Medication)


  Prescriptions for Schedule 2 and 3 Controlled Drugs must comply with the regulations
  made under the Misuse of Drugs Act.


  24.2.   Prescriptions:


                 a) Must be in ink or otherwise indelible
                 b) Must be signed and dated by the prescriber
                 c) Must bear in the prescriber’s own handwriting the patient’s name
                 and address
                 d) Must bear in the prescriber’s own handwriting the dose to be taken,
                 the form and where appropriate the strength of the preparation, plus
                 either the total quantity ( in words and figures) or the number of dosage
                 units (in words and figures) as appropriate.
                 e) The dose and frequency to be given must be indicated on the
                 prescription


  24.3.   Ordering of Controlled Drugs for the Ward


                 a)        A controlled drugs ward order book must be used. It must be
                 signed by the nurse in charge (or acting nurse in charge).
                 b)        The nurse in charge of the ward must enter receipt in the ward
                 CD record book.




                                                                                            1
NOTE: Schedule 3 drugs (Phenobarbitone, Pentazocine) do not need to be entered
into the hospital or ward controlled drugs register. Temazepam, however, does.

24.4.     Ward Records of Controlled Drugs


24.4.1.   Controlled drugs must be recorded in the ward CD record book using a
separate page for each preparation. The name, strength and form of the preparation
must be specified at the top of each page. Each time a controlled drug is received
details must be entered into the ward CD record book. Each time a dose of controlled
drug is administered to a patient, details must be entered into the ward CD record
book. The amount of drug in stock must balance with the amount shown in the book.
All entries must be in chronological order.


24.4.2. No cancellations or alterations may be made to entries. Corrections should be
made by marginal notes or footnotes and the date of correction noted. (Correction
fluid MUST NOT not used).


               a)         All entries must in ink or otherwise indelible.


               b)         The CD record book must be kept on the ward to which it
               relates.


               c)         The ward CD record book must be kept for 2 years from the
               date of the last entry on the ward to which it relates.


24.4.3.   Ward stocks of controlled drugs should be checked at least once every 24
hours (ideally every shift change).


24.4.4.   A pharmacist (from the supplying hospital) will check ward CD records at
least once per three months. The line manager for the ward/department should notify
the relevant pharmacy whenever a new ward sister/charge nurse is appointed.




                                                                                      2
24.5.     Storage


24.5.1.    No ward or department may store Controlled Drugs unless there is a
Practitioner in Charge responsible for their storage and use.


24.5.2.    The labels on containers will identify:


                a)      "Controlled Drugs" These will be stored in the Ward
                Controlled Drug Cupboards, reserved solely for drugs of this class.


                b)      Controlled drugs must not be kept in the medicines trolley


                c)      Schedule 2 controlled drugs must be stored in the ward
                controlled drug cupboard. Schedule 3 controlled drugs may be stored
                in the outside section, or other locked cupboard since safe custody
                regulations(Misuse of Drugs Act) do not apply.


24.6.     Custody of Keys


24.6.1.    The Misuse of Drugs Act 1971 requires the key of the Controlled Drug
cupboard to be kept “on the person of the nurse in charge, or acting nurse in charge
for the time being, of the ward or department”.


24.6.2.    The security of all medicines on the ward is the responsibility of the nurse in
charge of the ward.


24.6.3.    Details of any missing medicines must be reported immediately the loss is
discovered to the Senior Nurse responsible for the ward and also reported to the Head
of Pharmacy. Every effort must be made to determine the reason for the loss. Report
using the IR1 form or Datix System. The Head of Pharmacy or supplying DGH chief
pharmacist will advise on the need for police intervention.




                                                                                         3
24.6.4. The quantity of a Controlled Drug remaining in stock must be checked daily
and preferably at each shift change


24.6.5.    Any unwanted or date expired Controlled Drugs must be entered in the
Controlled Drugs Record Book by the pharmacist and witnessed by the nurse in
charge as having been returned. On no account should Controlled Drugs be returned
to the Pharmacy other than by handing to a pharmacist (not a pharmacy technician) on
the ward. Ampoules broken accidentally should be retained until entered into the
ward CD record book and accounted for. Destruction should be witnessed.


24.6.6.    Breach of Security Any incident must be reported immediately and
investigated by the Appointed Practitioner in Charge together with a pharmacist from
the supplying pharmacy department. The LHB Head of Pharmacy should be informed
as soon as possible and receive a report of the investigation and its outcome.


24.7.     Closure of a Ward or Department


If a ward or department is due to close, the Controlled Drugs must be handed over by
an Assigned Practitioner in Charge to an authorised pharmacist member of the
Pharmacy Staff who will sign the appropriate section of the register and return the
Controlled Drugs to the pharmacy.


24.8.     Destruction of Controlled Drugs


Date expired Schedule 2 controlled drugs must be kept on the ward until removed by
a visiting pharmacist. Appropriate entries in the controlled drug book must be made.


NOTE:           It is illegal to transfer controlled drugs between wards.


NOTE:            It is illegal to supply controlled drugs from hospital/ward stock to
community patients.




                                                                                       4
24.8.     Administration of Controlled Drugs


24.8.1.    Controlled drugs will be accessed and administered in the presence of two
persons, one of whom must be a Midwife, Doctor or Registered Nurse. The second
person may be any of these or a Pharmacist, Dental Practitioner, a Learner Nurse or an
Operating Department Practitioner (ODP) or Assistant (ODA).


24.8.2.    Both persons must witness the whole procedure from the preparation to the
actual administration. Both must sign the medication chart and the Controlled Drug
Record Book. The balance of the Controlled Drug register must be checked as part of
the procedure.


24.8.3.     A record of administration of Controlled Drugs must be made in the ward
or department Controlled Drugs Administration Record Book and signed by the
practitioner who has administered the drug and also by the practitioner who has
checked the drug and witnessed its administration.


24.8.4.     The nurse-in-charge is responsible for the security of the ward drug keys.
Note that responsibility for controlled drugs cannot be delegated (eg to an operating
department assistant) under current law.


24.9.     Unused Portions of Controlled Drugs


Any unused portions of Controlled Drugs must be recorded in the register by the two
practitioners involved in making the record. Small amounts of liquid medicine i.e.
5ml or less may be flushed down sink, larger amounts or solid dose medicines will be
returned to pharmacy


24.10.      Patient Controlled Analgesia (PCA) Order


When a PCA is discontinued the amount of solution wasted must be recorded in the
Controlled Drugs record book. The amount discarded, date and signatures of the two
practitioners involved must be recorded.


                                                                                         5
24.11.    Breakages

All breakages of Controlled Drugs must be recorded immediately in the ward
Controlled Drugs record book and signed by two practitioners, at least one of whom
must be a Registered Nurse. Pharmacy must be notified.

24.12.    Alteration to Register

Under no circumstances must an entry in the Controlled Drugs register be erased, or
covered. The error must be scored through with a single thin line allowing the error to
be seen. Any alterations must be accompanied by an explanation, and bear two
signatures - one being that of the Nurse in Charge of the ward.

24.13.    Patients’ Own Controlled Drugs

24.13.1. If patients own Controlled Drugs are to be used whilst in hospital then a
separate entry must be made in the Controlled Drugs register. A separate page must be
used for each individual drug and a record made that the supply is patient’s own.

24.13.2   The number of dose units received from a patient must be counted by two
Registered Nurses, or one Registered Nurse, and a Doctor, or a Pharmacist, working
in the LHB, and both must sign the record book. The Controlled Drugs will remain
the property of the patient and will be returned to the patient on discharge unless there
has been a change in therapy when the patient should be advised accordingly. If the
drugs are returned to the patient an entry on the relevant page must be made in the
Controlled Drug record book that this has occurred, signed and dated by two
practitioners, as above.

Controlled drugs not returned to the patient should be collected by a pharmacist.




                                                                                        6
24.14.     Conveyance of controlled drugs– Community Nursing


A community nurse who has agreed to collect a Controlled Drug, which has been
prescribed in accordance with the requirements set out above, from the community
pharmacist or the patient in his own home, is authorised to have the controlled drug in
her/his possession for conveyance purposes only. She/he may in some circumstances
carry controlled drugs where these are prescribed specifically for clients and provided
they have appropriate written authority for doing so.


24.15.     Unused Controlled Drugs

24.15.1.    Unused Controlled Drugs which are no longer required by the patient / or
where the patient has died at home where relatives / other people are present.

               a)      These may be returned by the patient / relative to the Pharmacy
               which originally supplied the drug. The patient’s notes must be
               endorsed with details (quantity, strength, name) of the drug, the
               reasons for its discontinuation and the arrangements which have been
               made for its disposal, signed by the nurse and witnessed. The
               patient/relative can witness the record where a nurse is working alone.

               b)      If the patient / relative is unable to return Controlled Drugs to
               the pharmacy, the Community Nurse can do this on their behalf, with
               the patient’s authority if this is practicable. The Community Nurse
               will be acting as an agent and is not legally in possession.

               c)      It is good practice for the disposal to be witnessed with both
               parties signing the Patient’s Nursing Records, stating the name and
               quantity of the discarded medicines. This may become law.

24.16. Disposal of Controlled Drugs when a patient dies alone at home

24.16.1.       The Community Nurse has no legal authority to ‘possess’ but may
proceed, as an agent, as described in a) above.




                                                                                           7
24.16.2. Where the Community Nurse acts as an agent, she should document in the
Patient’s Nursing Notes the quantity and strength of the Controlled Drugs being
returned and sign the Notes after this entry. The receiving Pharmacist should also be
asked to sign in the Notes on receipt of the Controlled Drugs.


24.16.3.     If circumstances arise where doubt exists concerning the correct means of
disposal of a Controlled Drug the appropriate Head of Nursing Services or the Head
of Pharmacy should be consulted.


24.16.4. Relatives or patients must sign if they do not wish controlled drugs to be
destroyed.


24.16.5. A community nurse who is asked for advice on the disposal of a Controlled
Drug, after the death of patient, should instruct the family to dispose of it by returning
it to a community pharmacy.


24.17.     Operating Departments


24.17.1. It is the responsibility of the Anaesthetist to establish a safe working system
including a checking process for all drugs where there is ODA/ODP/AN involvement.
ODA/ODP/ANs may be involved in the transfer of drugs into syringes and
intravenous solutions prior to administration by the Anaesthetist. Particular care must
be taken to ensure that all syringes and intravenous solutions that are prepared are
labelled correctly and the ampoules checked by the Anaesthetist.


24.17.2.     The Anaesthetist is responsible for recording the administration of drugs
on the patient’s anaesthetic record. For the administration of Controlled Drugs the
Anaesthetist must also comply with the requirements for recording and checking.




                                                                                         8
SECTION 25                      MIDWIVES


        25.1.     Supply & Administration of Drugs


        25.1.1     Midwives can administer orally on their own authority any medicine
        available on the NHS which is not a prescription only medicine.
Plus:
                  Pentazocine HCI
                  Ergometrine Maleate (not for parenteral use)
                  Chloral Hydrate
                  Triclofos Sodium

        25.1.2.    A midwife may administer parenterally in the course of her professional
        practice prescription only medicines containing:-

                  Ergometrine Maleate                   Pentazocine Lactate
                  Levallorphan Tartrate                 Pethidine
                  Lidocaine *                           Pethidine HCI
                  Lidocaine HCI *                       Phytomedadione
                  Naloxone HCL
                  Oxytocins (natural and synthetic)


                  * may only be administered during childbirth

        25.1.3.     Authorisation for use of drugs by midwives

                  During Labour
                         I.M. Pethidine 100mg x 2
                         Inhalation Entonox
                         I.M. Syntometrine x 1 (during 3rd stage)
                         I.M. or I.V. Ergometrine 500 micrograms (during 3rd stage)
                         I.M. Promazine HCL 50mg x 1
                         I.M. Syntocinon 5 units as an alternative to Syntometrine
                         if blood pressure is raised (requires medical prescription)


                                                                                             1
25.1.4.   Infiltration of the Perineum
               Prior to episiotomy – inj. Lidocaine 1% up to 5ml
               Prior to suturing – inj. Lidocaine 1% up to 10ml


25.1.5.   Post Natal
               Fybogel (one daily)
               Oral Paracetamol (two tabs four hourly as necessary)
               Co-Codamol (two tabs four times daily maximum)


25.1.6.   Prior to Surgery
               Emergency Surgery
               30 ml 0.3 M Sodium Citrate orally


25.1.7.   Ante Natal Clinic - For midwife booked patients
               Ferrograd Folic
               Pregaday


25.1.8.. Emergency Treatment of Newborn
               Naloxone (Narcan)
               NORMAL DOSE – 200 micrograms i.m. (60microgram/kg) as a single
               dose at birth.
               i.m. Phytomenadione 1 mg for pre term labour or following an
               instrumental delivery


25.1.9.   Haemorrhagic Disease of the Newborn
See – Prophylaxis against bleeding due to Vitamin K deficiency.




All doses in excess of above and those marked # to be prescribed by a medical
officer or given under appropriate valid patient group direction.




                                                                                2
25.2.     Midwives & Controlled Drugs


25.2.1.        Hospital - For ordering, storage and destruction of schedule 2 & 3
               Controlled Drugs, please refer to section 24, sections 2,3 & 4. Ward
               stocks of controlled drugs should be checked at least once in 24 hours
               (ideally every shift change).


25.2.2.    Community - No longer applicable


25.2.3.    Patients’ own controlled drugs should not be removed by the midwife as she
would be in illegal possession of controlled drugs. She can however be asked to return
them to the community pharmacy as an agent of the patient. Ideally she should advise
the patient to return them to pharmacy herself, or have the patient destroy them in her
presence and record the destruction, using an appropriate destruction method.


25.3.     Midwives and Other Drugs


25.3.1.     Hospital - Other than schedule 2 controlled drugs a midwife is able to
possess, supply and administer all general sales medicines, pharmacy only medicines
and some prescription only medicines without the need for a prescription signed by a
medical officer. Midwives would need to be satisfied they were sufficiently
competent and have referred to relevant up to date information, before using any
medicine. All drugs must be entered on the normal prescription sheet stating the drug,
dose, route, date and time of administration and signed by the midwife. For ordering
and storage see sections above.




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