Medicines Policy

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					                               Medicines Policy
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Board Library     Document Document           Original        Assured By      Review
Reference         Type     Subject            Document                        Cycle
                                              Author

CLI_IGCE_04       Policy      Medication      Chief           Effectiveness   36
                                              Pharmacist      Forum           months
                              Management

                                                              Effectiveness
                                                              Forum



Version Tracking (updated for all subsequent versions)

Version Date          Revision Description                      Editor        Status

1.1      23 Feb       Significant revision and additions to     Chief      Draft
         2008         previous policy CPC19                     Pharmacist

1.2      9 Mar        Reformatted                               Chief      Draft
         2008                                                   Pharmacist

2.0      17 Mar       Additional comment from consultation      Chief      Draft
         2008         process added                             Pharmacist

2.1      20 May       Comments from Risk Manager                Chief      Draft
         2008                                                   Pharmacist

         2 June       Comments from NMP trust Lead              Chief      Draft
         2008                                                   Pharmacist

2.2      Oct 2008     Revision of some sections.                Chief      Draft
                                                                Pharmacist
                      Addition of appendix on reporting
                      medicines incidents

2.2      20 Jan       Effectiveness forum approved              Chief      Final
         2009                                                   Pharmacist Draft
                      Minor changes suggested to medicines
                      incidents appendix
GOV_IGCE_04                                                                     Medicines Policy




 2.3         17 Feb         Equalities impact assessment undertaken. Chief      Final
             2009                                                    Pharmacist Draft
                            IG Committee approval

 2.3         25 Feb         Board Approval                             Chief      Approved
             2009                                                      Pharmacist

 2.4         24 March       Administrative changes to Training Section Medical        Approved
             2009                                                      Director

 2.41        15 April       Administrative changes to reflect          Chief      Approved
             2009           organisational change and correct spelling Pharmacist

 2.42        1/10/2009 Administrative Changes                          Chief      Approved
                                                                       Pharmacist




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GOV_IGCE_04                                                                                                        Medicines Policy




                                                     Table of Contents

1.      Introduction................................................................................................................... 5
2.      Purpose or Aim ............................................................................................................. 5
3.      Scope............................................................................................................................. 5
4.      Related Procedural Documents ................................................................................... 6
5.      Roles and Responsibilities .......................................................................................... 6
5.1     Implementation ............................................................................................................. 6
5.2     Review ........................................................................................................................... 7
6.      Definitions ..................................................................................................................... 7
7.      Standards .................................................................................................................... 10
8.      Monitoring or Audit .................................................................................................... 10
9.      Archiving of Master Documents ................................................................................ 11
10.     Training ....................................................................................................................... 12
11.     Appendix “A” : Procedures for Medicines Management ......................................... 12
12.     Prescribing of Medicines ........................................................................................... 15
13.     Function of the DPAR (Drug Prescription/Administration Record) ......................... 17
14.     Outpatient prescribing ............................................................................................... 25
15.     Verbal Orders (Prescriptions) and Off-Site Communication ................................... 27
16.     Use of Complementary Medicines and Essential Oils ............................................. 29
17.     Using Medical Gases .................................................................................................. 30
18.     Patient Group Directions............................................................................................ 30
19.     Preparation and Administration of Medicines .......................................................... 31
20.     Self Administration of Medicines by In- Patients ..................................................... 39
21.     Ordering and Receipt of Medicines ........................................................................... 41
22.     Checking of Stock Balances ...................................................................................... 45
23.     Borrowing of Medicines ............................................................................................. 46
24.     Service User and Carer Information .......................................................................... 47
25.     Trust Pharmacy Services ........................................................................................... 47
26.     PHARMACY OUT-OF-HOURS SERVICE .................................................................... 49
27.     TRANSPORT OF MEDICINES ..................................................................................... 49
28.     STORAGE OF MEDICINES ......................................................................................... 52
29.     CUSTODY AND SAFE-KEEPING OF MEDICINE KEYS ............................................. 55
30.     MEDICINES REQUIRING COLD STORAGE ............................................................... 57
31.     STORAGE AND HANDLING OF FLAMMABLE LIQUIDS, GASES AND AEROSOLS 61



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GOV_IGCE_04                                                                                                        Medicines Policy




32.     Medical Gases............................................................................................................. 61
33.     DISPOSAL OF MEDICINES NO LONGER REQUIRED ............................................... 62
34.     SERVICE USER‟S OWN MEDICINES ......................................................................... 64
35.     PHARMACEUTICAL INDUSTRY REPRESENTATIVES .............................................. 67
36.     MANAGING MEDICATION INCIDENTS ...................................................................... 68
37.     REPORTING DEFECTIVE MEDICINES ....................................................................... 71
38.     ILLICIT SUBSTANCES ................................................................................................ 72
39.     COMPLIANCE AIDS (E.G. MEDIDOS BOXES AND MONITORED DOSING SYSTEM
        (MDS)) .......................................................................................................................... 73
40.     CONTROL OF FP10 (NC) PRESCRIPTION................................................................. 75
41.     ADVERSE DRUG REACTIONS ................................................................................... 79
42.     DRUG ALERTS AND RECALLS ................................................................................. 80
43.     COVERT MEDICATION GUIDELINES......................................................................... 81
44.     THE USE OF MEDICINES FOR UNLICENSED TREATMENT INDICATIONS ............ 82
45.     COMMUNITY BASED PRACTITIONERS .................................................................... 84
46.     HANDLING MEDICATION IN COMMUNITY TEAMS ................................................... 86
47.     SELF-MEDICATION OF MEDICINES BY SERVICE USERS ON WARDS .................. 92
48.     Instructions for dispensing emergency medication from Ward and Community
        Team Stock (Secondary Dispensing) ........................................................................ 94
49.     RESEARCH - USE OF MEDICINES............................................................................. 96
50.     Appendix B DISPENSING MEDICATION RECORD FORM ........................................ 98
51.     Appendix C : Agreement Document for Self-medication of Medicines................... 99
52.     Appendix D Management Investigation Report Template for Medication Errors and
        Near Misses............................................................................................................... 100




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GOV_IGCE_04                                                                      Medicines Policy




1.      Introduction

        The Department of Health requires that NHS Trusts establish, document and
        maintain an effective system to ensure that medicines are handled in a safe and
        secure manner.
        In order to meet this requirement, the Trust must ensure that:
              professional practices concerning the use of medicines are current and up-
               to-date and that they remain subject to review and further development;
              all healthcare practitioners dealing with medicines remain aware of current
               policy;
              the concepts of service user focused care and service user empowerment
               are acknowledged and, where possible, are built in to policy and practice;
              Medicines Management is seen as a high priority within Clinical
               Governance.
        The AWP NHS Trust provides treatment to a diverse range of individuals and this
        has been written to ensure that their individual requirements are met. This Policy
        provides a common core upon which the procedures for specific areas or
        treatments can be based. It must be read, together with any local procedures or
        protocols, and adhered to when carrying out care.

2.      Purpose or Aim

        The aim of the Medicines Policy is to ensure that all service users requiring
        medication receive their medication correctly and that the proper procedures
        have been followed. The Policy assists Trust staff in complying with legal
        requirements and standards laid down by their professional bodies.

        This policy provides a framework, advice and guidance on the safe and secure
        management of medicine whilst recognising and respecting the rights of service
        users, staff and the wider community. All persons engaging in medicine
        management as regulated by this policy should give due regard to the
        individual‟s ethnicity, age, disability, gender (including Trans), sexual orientation
        and religion or belief. The safe and secure management of medication is
        extended to meet the 5 principles of the Human Rights Act 1998 (Fairness,
        Respect, Equality, Dignity and Autonomy)

3.      Scope

        This Medicines Policy defines the policies and procedures to be followed within
        the AWP NHS Trust for the procurement, prescribing, ordering, dispensing,
        storage and administration of medicines. The AWP NHS Trust Medicines Policy
        is not intended to apply to any other NHS Trust. Other legal requirements and
        standards laid down by professional bodies must also be followed.




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GOV_IGCE_04                                                                        Medicines Policy




4.      Related Procedural Documents

        This policy relates closely with the relevant Trust policies on:
              Non-Medical Prescribing
              Patient Group Directions
              Management of Violence and Aggression
              Integrated Care Programme Approach and the Assessment and
               Management of Risk Policy, Procedures and Guidance
              Antiinfective Medicines Prescribing Policy or Guidelines
              Complementary Therapies Policy
              Medicines Reconciliation Policy or Guidelines
              and guidance on medication available on the Medicines and Pharmacy
               page of the intranet.

5.      Roles and Responsibilities

        All staff working within the AWP NHS Trust who are involved in some way with
        the use of medicines, must familiarise themselves with the correct procedures
        contained in the Policy. Those in charge of wards and departments are
        responsible for ensuring that their staff, especially new starters and locum staff,
        follow the procedures in the Medicines Policy, which may differ from procedures
        elsewhere. Copies of the Policy will be available in all wards and departments
        and on the trust website.
        The procedures also apply to medical staff, nursing staff and other types of staff
        from other NHS Trusts or from private practices, who are contracted to work in
        The AWP NHS Trust on a temporary basis. Managers who contract for these
        services must make it explicit within the written contract that these temporary
        staff must follow the procedures described in this Policy.

        5.1      Implementation

                 Implementing this Policy is the responsibility of all staff who are involved in
                 any aspect of the prescribing, supplying or administrating of medicines.
                 Team leaders, home and community team leaders, modern matrons and
                 ward managers in conjunction with the Trust‟s directors, heads of service
                 and integrated team managers have additional responsibilities to ensure
                 that staff, working in services for which they have responsibility, are
                 adhering to the standards laid down in the Policy.
                 Effective Clinical Governance arrangements must be in place to ensure
                 the safe practice of prescribing to service users. The overall responsibility
                 for these arrangements lies with the Effectiveness Management Group.




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GOV_IGCE_04                                                                                Medicines Policy




          5.2    Review

                 The Policy will be reviewed regularly, at least every three years, and
                 revised as appropriate in consultation with all relevant staff.

6.        Definitions

                  Term                                                      Definition
Administration                                 The giving of a medicine to another (i.e.: service user) by
                                               either introduction into the body – e.g., orally, injection – or by
                                               external application – e.g., topical application to the skin.

                                               Service users may also sometimes self-medicate medication
                                               and under some circumstances service users may self
                                               administer medication under varying degrees of supervision
                                               and assistance by staff using a progressive staged procedure
                                               of increasing responsibility.
Adverse Drug Reaction                          An unwanted response to a medication. ADRs which cause
                                               serious discomfort or disability should be reported via the
                                               Yellow Card Scheme.
                                               ADRs which militate against prescribing a medication need to
                                               be noted in notes and on prescribing documentation.
Allergy                                        A hypersensitivity reaction to a medicine which cause a range
                                               of effects from mild to very serious. Allergies must be
                                               recorded and will often militate against repeat prescribing of
                                               the causative agent and similar medicines.
Authorised prescriber                          A registered practitioner (e.g., doctor, dentist, nurse, midwife,
                                               pharmacist) who is legally authorised to prescribe medicines
                                               either as an independent prescriber or a supplementary
                                               prescriber.

                                               All registered prescribers may prescribe medicines where
                                               authorised by the Trust to do so (see Non-Medical Prescribers
                                               Policy).    Consultant medical or independent nurse or
                                               pharmacist prescribers may request medicines to be made
                                               available which are new or off label to be added to the Trust
                                               systems and supplied through pharmacies.
British National Formulary (BNF)               The joint publication of the British Medical Association and the
                                               Royal Pharmaceutical Society of Great Britain. It is published
                                               twice a year and provides access to key information on the
www.bnf.org                                    selection, prescribing, dispensing, and administration of
                                               medicines. Out of date editions should not be consulted.
Caution                                        Refers to a medical condition in which the medication which
                                               lists the caution should be used prudently and carefully.
Clinical Management Plan                       A general term to denote an agreed course of action around a
                                               clinical intervention which may include ranges of doses to be
                                               used or advice around monitoring and side effect
                                               management.



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GOV_IGCE_04                                                                                Medicines Policy




                  Term                                                      Definition

                                               Specifically a CMP refers to a tripartite agreement between a
                                               service user, independent prescriber and supplementary
                                               prescriber where the latter may prescribe or review the
                                               medication and change the drug, dosage, timing or frequency
                                               or route of administration of any medication as appropriate as
                                               part of the clinical management plan.
Contra-indication                              Refers to a medicine that should not be prescribed for a
                                               particular service user, either because of a pre-existing
                                               medical condition, or because of the possibility of an
                                               interaction or adverse effects if administered concurrently with
                                               other prescribed medicines.
Controlled Drug                                A medicine subject to control under schedule 1-5 of The
                                               Misuse of Drugs Regulations and The Misuse of Drugs Act
                                               (1971).
Depot injection                                Depot medication most commonly consists of drugs that are
(also known as a long acting                   suspended in an oily solution, for example, sesame oil, that
injection)                                     enables the particular drug to be released over a period of
                                               days or weeks. These injections are given intramuscularly.
                                               The most commonly used depot medications include
                                               Fluphenazine Deconate (Modecate), Flupentixol Decanoate
                                               (Depixol) and Zuclopenthixol Deconate (Clopixol).
                                               Risperidone Injection (Risperal Consta) is a long acting
                                               intra-muscular (I.M.) formulation of Risperidone. If this
                                               medication is used the manufacturers instructions must
                                               be followed closely
Dispensing                                     To prepare an appropriate medicine for administration by
                                               another person (such as the service user or a nurse). The act
                                               of dispensing includes the supply, checking the validity of the
                                               prescription, the appropriateness of the prescription for an
                                               individual service user and assembly of the product.
General Sales List Medicine                    A medicine which is available for sale through any retail outlet
Medicine                                       Any substance or combination of substances prescribed and
                                               administered for treating illness and/or preventing disease.
                                               Any substance or combination of substances that may be
                                               administered with a view to assisting in the diagnosis, or
                                               restoring, correcting or modifying physiological or
                                               psychological functioning.
Nursing & Midwifery Council (NMC)              The statutory professional regulatory body for registered
                                               nurses and midwives. It provides guidelines for nurses
www.nmc-uk.org                                 relating to the administration of medicines.
Patient group directions                       A service user group direction is a specific written instruction
                                               for the supply and administration of a named medicine or
                                               vaccine in an identified clinical situation. It applies to groups
                                               of service users who may not be individually identified before



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GOV_IGCE_04                                                                               Medicines Policy




                  Term                                                     Definition
                                               presenting for treatment.
Patient Specific Direction                     A term defined in the Medicines Act referring to in-patient
                                               “prescriptions”. Patient Specific Directions are equivalent to
                                               prescriptions for in-patient prescribing
Pharmacy Only Medicine                         A medicine that is available for sale only in registered
                                               pharmacies
Practitioner                                   Any health care practitioner, either registered or unregistered,
                                               who is involved in the administration of medication.
Prescription                                   An authorised paper record, relating to a named service user,
                                               and containing the details of the prescribing and
                                               administration of individual medicines. AWP generally uses 3
                                               documents:

                                               DPAR – generally used in ward areas and where community
                                               teams are administering medicines frequently.

                                               Community Prescription – generally used by community
                                               teams where a record of administration is not required or
                                               happens infrequently (e.g. depot antipsychotics).


                                               FP10 prescription – may be dispensed by any community
                                               pharmacist.

                                               Discharge Prescription – prescription for discharge from
                                               hospital

                                               Leave Request – may be completed by registered nurse
Prescribe                                      To authorise, in writing and in accordance with current
                                               legislation, the supply and administration of a medicine to an
                                               identified service user by a registered prescriber (see
                                               authorised prescriber (qv.))
Prescription only medicine (POM)               A medicine that is only available following prescription by a
                                               registered prescriber.
Registered practitioner                        A health care practitioner who is subject to professional
                                               regulation in relation to the prescription, dispensing, and
                                               administration of medicines – e.g., doctor, pharmacist, nurse.
Supply                                         The making available a medicine for administration by
                                               another.
To Take Away/To Take Out                       Medication prescribed for service users in hospital to be
(TTA/TTO)                                      dispensed or supplied for the service user to self-medicate at
                                               home, whilst on leave or following discharge.
Unlicensed indication                          Refers to a medicine that is prescribed for use outside of the
                                               product‟s current licence in the UK.
Unlicensed medicine                            Product that has no product licence in the UK.



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GOV_IGCE_04                                                                              Medicines Policy




                  Term                                                    Definition
                                               A registered practitioner may administer an unlicensed
                                               medicinal product with the service user‟s informed consent
                                               against a patient-specific direction or prescription but NOT
                                               against a patient group direction.

7.      Standards

        Royal Pharmacists Society of Great Britain. The Safe and Secure Handling of
        Medicines.
        Nursery and Midwifery Council. Guidelines for the Administration of Medicine
        2008
        NHS Executive (2000). Patient Group Directions HSC 2000/026 2000
        Medicines Act 1968 (as amended). The Stationery Office, London
        NHS Estates (1994) HTM 2002 Medical Gases
        NHS Executive (1997). Destruction of Controlled Drugs EL (97) 22 1997
        National Patient Safety Agency SABS 18, 19, 20 and 21 (2007)
        Misuse of Drugs Act 1983 and Misuse of Drugs Regulations 2001 and 2006, as
        amended

8.      Monitoring or Audit

        Information from audit, incident reporting and national reports are utilised to
        make improvements to the safe and secure handling of medicines. Audits of
        medicines procedures will be undertaken to assure that practice is to the
        required standard and to implement changes to ensure good governance of
        medicines.
        Compliance with this policy will be monitored through review of medication
        incidents, SUIs and UDAs so that lessons can be learned and disseminated
        throughout the Trust.
        Regular biennial audits covering Controlled Drugs, Medicines Storage, and the
        use of the DPAR will be undertaken. The Trust will take part in external
        benchmarking audits organised by the Prescribing Observatory for Mental Health
        wherever possible.
        The Trust‟s arrangements for Medicines Management will be evaluated annually
        against various external standards, to include Standards for Better Health and
        Clinical Negligence Scheme for Trusts and this performance information is
        available internally and externally.
        On occasion, the Effectiveness Forum may decide to commission an audit to
        monitor compliance with this policy.




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GOV_IGCE_04                                                                      Medicines Policy




9.      Archiving of Master Documents

        This procedural document form part of a formal Trust record, and is to be
        managed in accordance with the Trust‟s records management policies and
        retention and disposal schedules.
        An audit trail of all previous versions of this document is required for auditing
        purposes and will be automatically stored by the Board Library document
        repository.
        The Board Library on SharePoint is the only recognised repository for master
        versions of procedural documents. Copies of this document must therefore not
        be stored elsewhere on the system, e.g. in workgroups. The library system will
        provide records management functionality to allow for the retrieval of previous
        versions of procedural documents stored on it.




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10.   Training

The Trust's overarching policy for training is the Learning and Development Policy and
this should be read in conjunction with this policy. Attached as appendices to that policy
are the Trust's learning and development matrices. These matrices describe the
minimum statutory, mandatory and required training for all staff groups in respect of
medicines management.


The Learning and Development Policy also describes the Trust's arrangements for
training, in particular how there are processes in place to ensure staff receive the
training they require and how non-attendance is followed up. These arrangements are
further supported by management supervision and appraisal processes.


The Trust Lead for Medicines Management has agreed the training standard with the
Learning and Development Team and training standards have been informed by
statutory requirements, professional standards and national best practice.


The trust Lead for Medicines Management participates in a programme of continuous
professional development to ensure that this policy remains up to date and abreast of
developments in this field. Effective Clinical Governance arrangements must be in
place to ensure the safe practice of medicines management. The overall responsibility
for these arrangements lies with the Effectiveness Forum.




11.   Appendix “A” : Procedures for Medicines Management

      11.1. General Principles

             11.1.1. Categories

                      Medicines, whether for internal or external use, will be regarded
                      for the purpose of the Policy, as comprising the following
                      categories:
                      •      Controlled Drugs controlled under the provisions of the
                             Misuse of Drugs Act 1971, with stringent requirements for
                             supply, storage and administration.
                      •      All other medicines and medicinal products prepared for
                             administration to service users and which are controlled by
                             the Medicines Act 1968. This also includes many
                             diagnostic agents, X-ray contrast agents and medical
                             gases. Whilst less stringent regulations apply than in the
                             case of Controlled Drugs, they must be treated with care.
                      •      All complementary medicines e.g. aromatherapy, herbal or
                             homeopathic remedies. These products are used for
                                     CPC 19 Medicines Policy

                                   therapeutic purposes and require the same safeguards as
                                   other medicines.
                           •       Other pharmaceutical preparations: Disinfectants, reagents
                                   and other preparations not used directly to treat service
                                   users. The use of these products in hospital is still subject
                                   to certain rules. It is important to understand that
                                   procedures listed in this document apply to all medicines
                                   used in AWP NHS Trust. These include topical lotions,
                                   applications, intravenous infusions, medicated dressings
                                   and complementary medicines.
                           Full attention must also be given to the requirements of current
                           Control of Substances Hazardous to Health (COSHH)
                           Regulations.

                 11.1.2. The responsibilities of various practitioners

                           The responsibilities of various practitioners associated with the
                           prescribing, ordering, storing, dispensing, issuing and
                           administration of medicines are as follows:
                           •       It is a requirement that all Health Authorities designate a
                                   senior pharmacist to be responsible for the organising,
                                   monitoring and reporting of a system for assuring the safe
                                   and secure handling of medicines. In AWP NHS Trust the
                                   senior pharmacist is the Chief Pharmacist.
                           •       Authorised prescribers must comply with legislation,
                                   professional standards, any agreed formulary, trust
                                   guidelines, medicines application procedures and the
                                   Medicines Policy when performing prescribing duties.
                           •       All registered prescribers may prescribe medicines where
                                   authorised by the Trust to do so (see Non-Medical
                                   Prescribers Policy). Consultant medical or independent
                                   nurse or pharmacist prescribers may request medicines to
                                   be made available which are new or off label to be added
                                   to the Trust systems and supplied through pharmacies
                           •       A record showing appointment and signature of all
                                   prescribers (including locum appointments) should be
                                   notified to the appropriate mental health pharmacist and
                                   updated upon any change by Medical Staffing/NMP Lead.
                           •       The senior registered nurse of the ward or department is
                                   responsible for the day to day stock of medicines held in
                                   the ward or department and for ensuring that stocks of
                                   Controlled Drugs, if held, correspond with the details
                                   shown in the register. The manager is responsible for
                                   ensuring that accurate CD records are maintained.
                           •       Pharmacists and pharmacy technicians are responsible for
                                   the stock of medicines held in the pharmacies, their
                                   manipulation and preparation into user ready presentations

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                                     CPC 19 Medicines Policy

                                   and for their supply to wards and departments. They are
                                   also responsible for advising on the safe, effective and
                                   economic use of medicines. These responsibilities include
                                   advising practitioners on the storage of medicines in
                                   clinical areas. Authorised pharmacy staff will inspect the
                                   stocks of medicines held on the ward or department at any
                                   time to ensure the medicines are in date and stored under
                                   the proper legal and environmental conditions. This will
                                   occur at least annually. Where units receive a regular
                                   pharmacy top-up service, this will occur at least every four
                                   weeks.
                           •       The administration of medicines is the responsibility of the
                                   registered nurse who may delegate these duties to another
                                   Practitioner or Authorised Employee, but must exercise
                                   supervision as is necessary. It is the responsibility of the
                                   registered nurse to ensure that the Practitioner or
                                   Authorised Employee to whom these functions are
                                   delegated has received the relevant training and
                                   experience before being allowed to take on responsibility
                                   for medicine procedures.
                           •       Practitioners in training must be given every opportunity to
                                   become proficient in medicines related activities under
                                   appropriate supervision. The supervising practitioner has
                                   responsibility for medicine procedures at such times.
                           •       The responsibilities for medicine procedures that may be
                                   held by various grades of practitioner are indicated in this
                                   document. Practitioners must be aware of the tasks they
                                   may or may not perform.

                 11.1.3. Homely Remedies

                           A number of medicinal substances for which no PGD or
                           prescription is required for treatment are approved as homely
                           remedies.
                           The following list of medicines are medicines which a registered
                           nurse may administer to service users either from hospital or the
                           service uses own supply without written authorisation by a
                           prescriber, a prescription or PGD. Registered staff must assure
                           themselves that the use of these medicines is appropriate and
                           that there is a minimal risk of adverse reactions.
                           •       E45 Cream
                           •       Any suncream
                           •       Non-medicated external dressings.
                           •       After sun creams and moisturisers.
                           •       KY Jelly and equivalent lubricants
                           •       Mouthwash solution (from tablets)

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                                     CPC 19 Medicines Policy

                           •       Lemon and glycerine Swabs.

12.     Prescribing of Medicines

        12.1. In-patient prescribing

                 Medicines may only be prescribed on official Trust prescription stationery
                 which for in-patient service users is the Trust Drug Prescription and
                 Administration Record (DPAR).
                 Details that must be included in BLOCK capitals on the DPAR are:
                 •       Service user‟s name, including aliases, on every page.
                 •       Date of birth or age
                 •       Gender
                 •       Ward or clinic or community team name,
                 •       Service user‟s address
                 •       Consultant
                 •       Service user‟s AWP number and/or NHS number or local DGH
                         identifier.
                 •       Known allergies or sensitivities to medicines.
                 •       Number of DPAR (if more than one is in use)
                 •       Start date of the DPAR
                 •       Name of medicine, route, dose (next to every time to be given),
                         formulation, time to be given (circled) or dose interval.
                 •       Prescriber‟s signature (with printed NAME next to first signature
                         from that prescriber)
                 Where more than ten medicines are prescribed regularly, a second chart
                 may be used, which must remain with the first. In such circumstances
                 both DPAR must indicate the existence of a second chart. When a
                 service user is re-admitted, including for respite care, a new DPAR must
                 be used. The DPAR of service users transferred from one trust site to
                 another does not require to be rewritten. When service users are
                 transferred from other trusts, the duty doctor must rewrite the DPAR at the
                 time of clerking in, or at the earliest opportunity. In addition to the main
                 DPAR there may be other charts e.g. clozapine initiation chart, the main
                 DPAR must make reference to any therapy indicated on the other chart.

        12.2. Initiation of Treatment

                 It is important to recognise that in most situations only medical staff have
                 the authority to prescribe medicines for hospital in patient service users or
                 for service users attending day hospitals or clinics. However if authorised
                 by the Trust in certain situations non-medical prescribers may undertake
                 this role.



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                 Medicines must only be administered where they have been authorised by
                 a prescriber.
                 This authorisation must be in writing, in the form of a prescription in
                 advance of the administration of the medicine.
                 The recognised exceptions to this are listed as follows:
                 •       In areas where there are no resident prescribers and in cases of
                         clinical urgency a verbal instruction may be acceptable.
                 •       Certain medicines may be administered at the practitioner‟s
                         discretion against an agreed PGD or “Homely Remedies” list. In
                         each instance a record of the administration must be entered on the
                         DPAR in the “Once Only” section.
                 •       Specialist practitioners and clinical pharmacists involved in certain
                         services may be authorised to modify dose regimens and, in certain
                         instances, to initiate or stop medicines therapy in accordance with
                         protocols approved by the Effectiveness Forum (MGG) or following
                         prior agreement with individual prescribers or when agreed with the
                         Area Prescribing Committee or equivalent health community body.
                 •       A number of products which do not require either a prescription or a
                         record of administration includes:
                           •       E45 Cream
                           •       Any suncream
                           •       Non-medicated external dressings.
                           •       After sun creams and moisturisers.
                           •       KY Jelly and equivalent lubricants
                           •       Mouthwash solution (from tablets)
                           •       Lemon and glycerine Swabs.
                 Foundation 1 grade are not permitted to prescribe controlled drugs or on
                 FP10s.
                 Medical students are not permitted to prescribe medicines.

        12.3. Range of medicines to be prescribed

                 Only the following medicines, including complementary and homeopathic
                 medicines, can be prescribed to service users:
                 •       Psychotropic medicines approved for use within the procedures
                         developed by the Trust‟s Effectiveness Forum.
                 •       Physical medicines approved on the local area prescribing
                         committee (qv) formulary.
                 •       Medicines prescribed prior to admission by the registered doctor,
                         dentist, nurse prescriber or authorised supplementary prescriber.
                         Medicines being taken within a formal clinical trial.



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                 •       Over the counter medicines, including service users‟ own
                         complementary and homeopathic medicines following a review by
                         medical staff. If there is any doubt about their safety then the
                         advice of a pharmacist should be sought.
                 •       Medicines being taken within a formal clinical trial.
                 A defined procedure must be followed in order to request a new medicine
                 or new indication for use within the Trust. Details of the procedure are
                 available from the local mental health pharmacist or the Chief Pharmacist.

        12.4. Range of medicines not to be prescribed

                 New medicines, new indications and/or unlicensed medicines unless
                 approved by the appropriate governance forum.

13.     Function of the DPAR (Drug Prescription/Administration Record)

        •        To provide a permanent record of the service user‟s treatment with
                 medicines.
        •        To indicate the service users‟ sensitivity to medicines.
        •        To direct and record the administration of the medicines to the service
                 user.
        A well-written DPAR enables the rapid and accurate interpretation of the
        medicines required by the service user. All prescriptions must be in black or blue
        ink to facilitate legible faxing and scanning.
        The Chief Pharmacist will designate the DPAR and other documents relating to
        medication. Only those approved by the Trust may be used.


        13.1. Prescribing on the DPAR

                 Prescriptions must clearly identify the service user for whom the
                 medication is intended and, whenever possible, be based on the service
                 user‟s choice, awareness of the purpose of the treatment and informed
                 consent.
                 The prescription must be clearly written in BLOCK LETTERS, typed or
                 computer-generated and be indelible.
                 The prescription must indicate the drug, dose, variable dose (if required),
                 timing, frequency, route of administration, original start date, stop date,
                 and prescribers‟ signature.
                 Controlled Drugs must be written clearly and indelibly, by the prescriber,
                 on the DPAR prescription chart. There is no requirement for the quantity
                 of the Controlled Drugs to be written in words and figures on the DPAR.
                 For „drugs given as required‟ additional information max dose/24hrs and a
                 clear indication for use must be stated.
                 Any known allergies or sensitivity‟s to medications must be noted on the
                 drug prescription and Administration Record.

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                 When rewriting the DPAR allergies or sensitivities and any additional
                 information such as weight on admission, smoking status and start dates
                 or „before admission‟ must be carried forward.

     13.2.      Name and Form of the Medicine
                A medicine may have numerous brand names but only one approved or
                generic name, therefore the approved or generic name rather than brand
                name/s should be written clearly in BLOCK LETTERS. However if the
                medicine is a compound (with no approved name) or has a unique release
                property or bioavailability, then the brand name should also be used e.g.
                Priadel. Non-approved abbreviations of the name of the medicines e.g.
                CBZ for carbamazepine must not be used.
                 When prescribing oral medicines, tablets or capsules will be supplied
                 unless another formulation is specified e.g. liquid. In situations where
                 confusion may arise, e.g. creams and ointments, the form should be
                 specified.

        13.3. Dose and Route of Administration

                 The dose must be expressed in metric units, avoiding decimal points
                 wherever possible by using whole units, i.e. 125 micrograms rather than
                 0.125mg. The word “micrograms” must be written in full and not
                 abbreviated to mcg, to avoid confusion with milligrams (mg).
                 Roman numerals such as „II‟ should not be used. In this case the words
                 „two‟ followed by the dose form are satisfactory. The word “Unit” must be
                 written in full rather than abbreviated to “U”, which can frequently be
                 confused with “the number O” and may lead to 10 times the dose of e.g.
                 insulin or heparin, being administered in error.


                 No more than one route can be specified against an entry EXCEPT for as
                 required medicines.




                                               TABLE 1:
                    ACCEPTABLE ABBREVIATIONS FOR THE ROUTES
                               OF ADMINISTRATION


                    Abbreviation                    Route of administration


                        EXT                               External use

                        IM                                Intramuscular

                        IV                                Intravenous



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                        INH                                 Inhalation

                        NEB                                 Nebulisation

                        PR                                  Per rectum

                        PO or O                             By mouth

                        PV                                  Per vagina

                        SC                                  Subcutaneous

                        SL                                  Sublingual

                        TOP                                 Topical


                 All other routes of administration must be written out in full. Note that
                 prescription and administration of any medication by the intrathecal route
                 is not permitted in AWP units by AWP staff.

        13.4. Times of Administration

                 The times of administration must be specified by the prescriber in the
                 appropriate column on the DPAR. Times are specified by circling the
                 appropriate time of administration or if these are inappropriate by crossing
                 them out, replacing with appropriate times expressed as a 24 hour clock
                 and circling.
                 Abbreviations such as „bd‟ „tds‟ are only to be used for as required (PRN)
                 medicines and on take home/outpatient prescription charts. The following
                 abbreviations are standard means of indicating a dose regimen:
                                               TABLE 2:
                     ACCEPTABLE ABBREVIATIONS FOR THE TIMES
                               OF ADMINISTRATION
                         For PRN, FP10 or Community Prescriptions


                       Abbreviation                         Time of administration


                      OD                                  Once a day

                      OM                                  Each morning

                      ON                                  Each night

                      BD                                  Twice daily



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                      TDS                                 Three times daily

                      QDS                                 Four times daily

                      Mane                                Morning

                      Nocte                               At night

                      PRN                                 As required (with interval
                                                          and indication stated)



                 All other dose regimens must be written out in full.

        13.5. Signature of Prescriber

                 Prescription item must be validated by the full signature of the prescriber.
                 The signature should be legible or the printed name of the prescriber
                 should be written next to the first signature of that prescriber on the DPAR
                 or other form..

        13.6. Date

                 Each prescription on the DPAR carries two dates.
                 •       The „start date‟ is the date the drug commenced if initiated on the
                         ward. If the drug was started prior to admission put „before
                         admission‟ in the „start date‟ box. This start date or „before
                         admission‟ must be carried forward to any rewritten prescription
                         charts in the future.


                 •       The „stop‟ date is either specified in advance and administration will
                         stop on the completion of that day unless administration boxes are
                         crossed (X) or the „stop‟ date should be completed on
                         discontinuation of the drug.
                 The start date of the entire DPAR must be completed.

        13.7. Drug Sensitivities/Allergies

                 The following procedure must be followed by the admitting doctor or
                 health acre team:
                 •       Confirm allergy or sensitivity status as soon as possible in the
                         service user care episode.
                 •       It is the responsibility of all staff involved in medication
                         management processes to ensure that any drug allergy or reaction
                         to medicines is recorded in the service user‟s notes and on the
                         DPARs are completed and signed.



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                 •       The medical team must ensure that the medicine allergy boxes on
                         all DPARs are completed and signed.
                 •       If there is a known allergy or serious reaction to a medicine, the
                         following signed and dated entries must be made in the service
                         user‟s notes and on all DPAR s:
                                Generic name(s) of medicine(s) in full, unless otherwise
                                 recommended by the BNF
                                Nature of reaction(s) – to ensure a true allergy or other
                                 reaction is being described.
                 •       Otherwise one of the following designations must be utilised.
                                No Known Drug Allergies or NKDA:
                                 Where the service user/carer, case notes or GP are clear
                                 that the service user has never experienced an allergic
                                 reaction or severe adverse reaction to any medication.
                                Not Yet Ascertained:
                                 Only to be used in exceptional circumstances where it has
                                 not been possible to ascertain allergy status on admission.
                                 Allergy status must be confirmed as soon as possible.

        13.8. Guidance Notes

                 If the allergy status is not documented on the DPAR, prescribing,
                 administering and supplying medicines carries a significant risk.
                 Take particular care with “co-“ named drugs, checking that the service
                 user is not allergic to either constituent. Also take particular care with
                 penicillin, (e.g. co-amoxiclav/Augmentin® is a penicillin).


                 The above principles apply equally to adverse/untoward reactions and
                 severe side effects – this may include previous incidence or suspicion of
                 neuroleptic malignant syndrome (NMS) or neutropenia associated with
                 clozapine. Avoid the use of any other means of documenting or
                 highlighting allergy status.
                 Counsel service users on the need to inform all healthcare professional of
                 their allergy status.
                 Newly identified allergies must be communicated to primary care by
                 documenting in CPA and other communications concerning the clinical
                 care plan.
                 Consider reporting any ADR via the Yellow Card reporting system (see
                 BNF and www.yellowcard.gov.uk)
                 When predictable allergic reactions result from the prescribing and
                 administration of medicines, the most likely causes are:
                 •       Incomplete documentation of allergy status
                 •       Inconsistent location of documentation of allergy status

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                 •       Using brand name of medicines rather than generic (approved)
                         names
                 •       Information on allergy status not being available to relevant
                         healthcare professionals
                 •       Lack of clinical knowledge

        13.9. Alterations

                 Prescribers should not attempt to alter existing instructions. Any change
                 in medication must be written as a new entry. Correction fluid such as tip-
                 ex must not be used.
                 Incorrect prescriptions should be crossed through with a single line, dated
                 in the „stop date‟ box and signed.

        13.10. Cancellation Of Treatment

                 It is important that the prescription is cancelled by a bold line being drawn
                 diagonally over the prescription details and at the end of the administration
                 record and signed by the cancelling professional. The „stop date‟ box
                 must be completed.
                 When the „stop‟ date is specified in advance administration will stop at 12
                 midnight on the stop date unless administration boxes are crossed (X).

        13.11. Length of Treatment

                 DPARs are valid for a maximum of 9 weeks and community prescriptions
                 for 6 months. After this period, treatment must be re-written if it is to be
                 continued. If the prescription is considered ambiguous at any time, the
                 practitioner responsible for the administration of the medicine or the
                 pharmacist must request the prescriber to rewrite it.
                 The prescriber MUST review and re-prescribe the required medication
                 prior to supply or administration.
                 DPARs may be written or re-written by practitioners or pharmacists.
                 However, overall responsibility for the prescriptions remains with the
                 prescriber who signs them. NURSES MUST NOT ADMINISTER
                 MEDICINES FROM PRESCRIPTIONS, WHICH HAVE NOT BEEN
                 SIGNED BY THE PRESCRIBER, OTHER THAN AGAINST VERBAL
                 ORDERS.

        13.12. Once Only Doses (Stat doses)

                 Medicines that are intended to be given once only must be prescribed in
                 the „once only‟ section of the DPAR. This includes test doses of long
                 acting intramuscular injection or Depots.




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        13.13. “As Required” Prescriptions (PRN)

                 The „as required‟ section of the DPAR must only be used for those
                 medicines to be given at the practitioner‟s discretion according to the
                 needs of the service user.
                 Prescriptions which are conditional on an event should generally be
                 written in the “As required” section.
                 An entry in the service user records should give reasons for administration
                 and outcomes. The reason should also be documented on the DPAR.
                 The minimum interval between doses and indication for administration
                 must be clearly specified by the prescriber. The maximum dose or
                 frequency to be given in a 24-hour period must also be stipulated.
                 Different routes must be prescribed separately on the PRN side of the
                 chart. If more than one route is prescribed that maximum dose should
                 include all routes and must state all routes. If different routes have
                 different maximum doses this also must be clearly stated.
                 Care must be taken not to duplicate medicines being taken regularly and
                 thus overdose the service user. Combination analgesics frequently
                 contain paracetamol, which may already be prescribed in the regular
                 section of the prescription chart. Rapid dose escalation using
                 combinations of PRN and regularly prescribed antipsychotic drugs is one
                 of the most commons causes of sudden death and neuroleptic malignant
                 syndrome in service users suffering from schizophrenia.
                 The „as required‟ prescription must be reviewed regularly by a doctor to
                 determine its continuing clinical need. To prevent the accumulation of
                 unnecessary „as required‟ prescriptions the following guidelines should be
                 observed:
                 •       Any „as required‟ prescription that has not been administered for 2
                         weeks should normally be cancelled, unless specific rules apply or
                         continued clinical need is established. Cancellation can be
                         undertaken by pharmacy staff in accordance with clinical practice
                         guidance.


                 •       No more than two „as required‟ medicines should be prescribed
                         together for the same indication. If two are, then the one to be
                         used first line should be clearly stipulated along with information on
                         when the second would be used.
                 •       Transcription of PRN medication on the DPAR to other records
                         such as leave or discharge medication requests should be
                         undertaken sparingly and with clear regard to clinical need
                 Medicines originally prescribed „as required‟, but which are needed
                 regularly as indicated by the administration record, must be reviewed and
                 if appropriate rewritten in the regular prescription section.




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                 If there is any doubt or concern, or the member of staff is unsure of the
                 criteria given for the administration of as required medication, then advice
                 must be sought from the prescriber, a senior colleague or pharmacist.
                 Reasons for not administering as required medication when requested by
                 the service user should also be recorded in the service user‟s notes.

        13.14. Review of the DPAR

                 It is good practice to review medication and prescriptions must be
                 reviewed and re-written by the authorised prescriber at least every nine
                 weeks in hospital settings.
                 As a minimum standard all medication must be reviewed within 6 months
                 in all non-hospital settings.
                 Older people who are on more than 4 drugs should have their medication
                 reviewed at least every 3 months regardless of setting by the prescriber.

        13.15. Specific Medication

                 Methotrexate: service users receiving oral methotrexate could be
                 admitted to any ward or receive outservice user treatment for co-existing
                 conditions. Staff in all areas may therefore be involved in ensuring
                 continuity of prescribing, and monitoring or administering oral
                 methotrexate. Full medication reviews, conducted where possible by
                 pharmacists, should be undertaken on admission and prescribing,
                 monitoring and administration requirements should be recorded in the
                 service user‟s notes. Additional Guidance is available on the Trust
                 intranet.
                 Intrathecal Administration: prescriptions for intrathecal medication
                 MUST NOT be undertaken in AWP NHS Trust.
                 Anticoagulants: additional Guidance is available on the Trust intranet at
                 http://sharepoint/C1/Medicine/default.aspx
                 Intravenous heparin flush solutions: prescriptions for iv heparin flush
                 solutions MUST NOT be undertaken in AWP NHS Trust.
                 Oral Anti Cancer medicines: Treatment must be initiated by a cancer
                 specialist.
                 •       All oral anti-cancer medicines should be prescribed only in the
                         context of a written protocol and treatment plan obtained from the
                         initiating cancer specialist.
                 •       Non-specialists who prescribe or administer on-going oral anti-
                         cancer medication should have ready access to appropriate written
                         protocols and treatment plans including guidance on monitoring
                         and treatment of toxicity.
                 •       Staff dispensing oral anti-cancer medicines will check to confirm
                         that the prescribed dose is appropriate for the patient, and that the
                         patient is aware of the required monitoring arrangements, by having
                         access to information in the written protocol and treatment plan


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                         from the hospital where treatment is initiated and advice from a
                         pharmacist with experience in cancer treatment in that hospital.
                 •       Patients should be fully informed and receive verbal and up-to-date
                         written information about their oral anticancer therapy from the
                         initiating hospital. This information should include contact details for
                         specialist advice, which can be shared with non-specialist
                         practitioners. Written information, including details of the intended
                         oral anti-cancer regimen, treatment plan and arrangements for
                         monitoring, taken from the original protocol should be given to the
                         patient. When shared with pharmacists and dispensing staff, this
                         would enable the above dispensing requirements to be satisfied.
                 •       Full use should also be made of NHS cancer centre web sites to
                         provide information for healthcare staff, patients and carers to
                         ensure the safe use of oral anti-cancer medicines.
                 Opiates : When opioid medicines are prescribed, dispensed or
                 administered, in anything other than acute emergencies, the healthcare
                 practitioner concerned, or their clinical supervisor, MUST :
                 •       Confirm any recent opioid dose, formulation, frequency of
                         administration and any other analgesic medicines prescribed for the
                         patient. This may be done for example through discussion with the
                         patient or their representative (although not in the case of treatment
                         for addiction), the prescriber or through medication records.
                 •       Ensure where a dose increase is intended, that the calculated dose
                         is safe for the patient (e.g. for oral morphine or oxycodone in adult
                         patients, not normally more than 50% higher than the previous
                         dose).
                 •       Ensure they are familiar with the following characteristics of that
                         medicine and formulation: usual starting dose, frequency of
                         administration, standard dosing increments, symptoms of overdose,
                         common side effects.
                 Potassium Chloride Injections: These are NOT to be stocked,
                 prescribed or administered within AWP NHS Trust.
                 Amphotericin Injections: These are NOT to be stocked, prescribed or
                 administered within AWP NHS Trust.

14.     Outpatient prescribing

        14.1. Prescribing using FP10 Prescriptions
                 Only prescribers who are independent non-medical prescribers ort hose
                 authorized by their consultant can hold FP10 prescriptions
                 On appointment a form will be provided by Medical Staffing to record the
                 prescriber‟s signature and initials for use by the local pharmacy. It will
                 also have space for the consultant to authorise the holding of a pad of
                 FP10s if he or she wishes.


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                 This form must be taken or sent to the local Pharmacy service provider
                 and a copy to the FP10 distribution point.
                 If collecting a FP10 pad, the prescriber must provide proof of identity. An
                 audit trail must be available from the FP10 distribution point to the
                 prescriber. Intermediate steps, such as through a team support worker,
                 must have documentary evidence of FP10 movements. This can
                 generally be facilitated through a note of FP10 prescription numbers „in‟
                 and „out‟ with date and signature. Contact the chief pharmacist for details.
                 If collection has not been agreed then an appropriate order form is
                 forwarded to the FP10 distribution point.
                 The use of FP10s is restricted to prescribing for service users of the Trust.
                 Prescribers must ensure that the FP10 they are using is appropriate for
                 their team with the correct address and contact number.
                 Prescriptions for Controlled Drugs, which are subject to prescription
                 requirements must be indelible, and must be signed by the prescriber, be
                 dated, and specify the prescriber‟s address. The prescription must always
                 state:
                 •       The name and address of the service user
                 •       In the case of a preparation, the form and where appropriate the
                         strength of the preparation
                 •       The total quantity of the preparation, or the number of dose units, in
                         both words and figures
                 •       The dose and frequency.
                 Prescriptions for controlled drugs must not be for longer than 30 days
                 except where there is a clear and justifiable clinical rationale. Prescribers
                 should note that prescriptions for controlled drugs are only valid for 28
                 days from prescribing – on day 29 it is illegal for a pharmacist to dispense
                 them.
                 Stationery used for requesting medicines must be kept in a secure place
                 when not in use. Prescription pads (i.e. FP10s), must be locked away
                 when not in use, the responsibility for this lies with the person to whom
                 they are issued.


                 FP10s are typically used in the following circumstances:
                 •       Accessing medication for service users when other routes are
                         unavailable
                 •       For service users of the Substance Misuse Service
                 •       A hospital only medicine is being prescribed e.g. clozapine
                 •       For a drug currently under evaluation by the Effectiveness Forum
                 •       During the initiation phase of a drug later prescribed by GPs under
                         a shared care agreement

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                 •       In exceptional circumstances – for example service users who
                         would otherwise disengage from all services
                 •       An audit trail from issuance of FP10 to the prescriber must be in
                         place.

        14.2. Prescribing using the Community Medication Prescription and
              Recording Card
                 The „Community Medication Prescription and Recording Card should be
                 used for prescribing and recording the administration of depot injections
                 and other medicines in the community and are dispensed by Trust
                 contracted pharmacy services.
                 All information sections should be completed such as team name, care co-
                 ordinator and contact numbers as laid out on the document.
                 Prescribing should follow the policy laid out in document 3.1 to 3.29 where
                 appropriate.
                 The prescription may add instructions for incremental prescribing (such as
                 6 months treatment in one week increments). Note that controlled drugs
                 MUST be prescribed for a maximum of 30 days and repeat prescriptions
                 are not permissible beyond that date.
                 The prescription should state whether a compliance aid is required and a
                 copy of the assessment undertaken must be forwarded to the dispensing
                 pharmacy. Dispensing pharmacies may choose to decline requests for
                 compliance aids.
                 The maximum validity for any one prescription sheet is 6 months.
                 The service user must be reviewed at least six monthly by the prescriber,
                 using the service user‟s multidisciplinary notes.
                 Note that the entire supply of a controlled drug ordered on the form must
                 be dispensed within 28 days - instalment dispensing is not permitted
                 under the Misuse of Drugs Act Regulations 2006.




15.     Verbal Orders (Prescriptions) and Off-Site Communication

        15.1. Verbal prescriptions
                 In exceptional circumstances, where the medication has been previously
                 prescribed (NOT including controlled drugs) and the prescriber is unable
                 to issue a new prescription but where a change of dose or re-prescribing
                 of a drug is considered necessary, a verbal communication conformed by
                 fax or email communication can be accepted from the prescriber.




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                 A verbal order is not acceptable on its own. The fax or email
                 prescription/direction to administer must be stapled to the service user‟s
                 existing medication chart. This should be followed up by a new
                 prescription signed by the prescriber who sent the fax/email confirming the
                 changes within normally a maximum of 24 hours (72 hours maximum –
                 Bank Holidays and weekends). In any event, the changes must have been
                 authorised (via email or fax) by a registered prescriber before the new
                 dosage is administered.
                 Only registered nurses and pharmacists may take such an order.
                 However, Practitioners retain the right to refuse to take orders from
                 prescribers if they do not feel competent to do so, if they feel the order is
                 inappropriate, or if they feel it is not in the service user‟s best interests.
                 The person receiving the instructions will inform the prescriber of all other
                 medicines being taken by the service user. They should request and
                 receive information from the prescriber regarding contra-indications and
                 side effects of the prescribed medications.
                 The registered practitioner must write the message directly on to the once
                 only section of the prescription, indicating the drug, dose, and route of
                 administration, as specified by the prescriber.
                 The registered practitioner must record in the service user‟s clinical record
                 “verbal order confirmed by fax or email” and provide details of the date,
                 time, message, and name of prescriber. This must be signed and dated.
                 The instruction can only be for a single, one-off („stat‟) dose.
                 Any order not yet signed by a prescriber must be reported to the next shift
                 at handover and/or recorded in the nursing notes or record of care.
                 Controlled Drugs cannot be prescribed verbally except benzodiazepines,
                 but not including temazepam.
                 When a pharmacist identifies a medication omission or error, or to alter or
                 clarify a prescription item or to fulfil any policy such as therapeutic
                 substitution, they may receive a verbal order from a prescriber to alter or
                 add a prescription item in line with clinical practice guidance from the
                 MGG. The pharmacist must read the alteration or addition back to the
                 prescriber who must then confirm it.
                 The pharmacist must complete an AWP incident form and refer to the unit
                 manager.

        15.2. Day hospitals
                 The prescribing of medicines for service users who attend day care is
                 usually the responsibility of the general practitioner. In exceptional
                 situations a hospital prescriber may wish to take responsibility for part or
                 all of the prescribing. These situations include:




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                 •       if the hospital prescriber wishes to start a new medicine and
                         stabilize the service user on that medicine before requesting the
                         general practitioner to take over the responsibility;
                 •       if the service user remains on a hospital only drug, e.g. clozapine;
                 •       if arrangements to continue supervision of the prescribing of
                         medicines still remains with the hospital prescriber;
                 •       if the prescription is subject to continual change;
                 •       if there is no other reliable method of ensuring that the service user
                         receives the medicine.
                 There may be occasions where someone may need to receive medicines
                 whilst attending the day hospital. In such circumstances it is preferable
                 that the hospital prescriber prescribes the medicines on the Trust‟s DPAR.
                 It can also be used to provide a record of medicines administration when
                 prescribed by any prescriber.

        15.3. Respite care
                 For service users admitted for respite care, it is usual for the service user
                 or home carers to provide the medicines from the service user‟s own
                 supply. The Practitioner must:
                 •       confirm with the carers, prior to admission, that the necessary
                         medicines to span the period of respite care will be provided by the
                         carer;
                 •       confirm with the service user‟s general practitioner, prior to
                         admission, the medicines to be prescribed for the service user;
                 •       confirm with the hospital prescriber that the service user‟s own
                         supply agrees with the details provided by the carer and the
                         general practitioner. Once the confirmation has taken place the
                         medicines will be prescribed using a DPAR.
                 If all attempts to receive a supply from the carer fail or the supply of
                 medicines is thought unsuitable to use, arrangements must be made to
                 receive further supplies from the GP and/or the community pharmacy,
                 Alternatively, (and temporarily), ward stock may be used, or named
                 service user medicines obtained from the supplying pharmacy.

16.     Use of Complementary Medicines and Essential Oils

        The service user may receive complementary therapies that may be used in
        conjunction with orthodox medical, nursing and paramedical treatments to
        enhance service user wellbeing, quality of life and symptomatic relief. This
        section is in addition to the Trust Complementary Therapies Policy.

        16.1. Service user‟s own complementary medicines or essential oils
                 Complementary medicines or essential oils must be brought to the
                 attention of the service user‟s doctor, this is particularly important with



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                 herbal medicines which can in some circumstances produce marked
                 physiological and psychological effects.
                 Before allowing the service user to use complementary medicines or
                 essential oils the safety of the product and the risk of interactions, should
                 be assessed by pharmacy.
                 Ideally those complementary medicines then deemed not to be harmful to
                 the service user should be written up inside the Drug Prescription and
                 Administration Record.
                 Complementary medicines or essential oils are not generally available
                 from pharmacy and therefore service user‟s own should be used. If
                 necessary the service user may have to purchase their own supply.
                 Staff must also comply with the requirements set out in the
                 complementary therapies and well being interventions policy.

        16.2. New therapies
                 The Effectiveness Forum must approve any complementary medicines or
                 essential oils before they can be initiated for therapy in the Trust.
                 When a complementary medicine or essential oil is approved it can only
                 be used within the guidance of any Trust complementary therapy code.

        16.3. Consent
                 The service user must give informed consent for the use of essential oils
                 or complementary medicines or if an adult is unable to give informed
                 consent the relatives or carers should be involved in the decision.

17.     Using Medical Gases

        All medical gases used in the Trust are Licensed Medicines and as such are
        subject to the Medicines Act and must be treated in the same way as any other
        medicines. See also the chapter – Storage and Handling of Flammable Liquids,
        Gases and Aerosols.
        Under normal circumstances written authority from a prescriber must be obtained
        before a medical gas is administered to a service user. This authority must
        include the name, and concentration of the medical gas (where appropriate), the
        method of administration and the rate of flow. This must be recorded on the
        service user‟s DPAR. This can be achieved by:
        •        A DPAR prescription for an individual ;
        •        a medicine administered under Trust protocol or PGD for oxygen in an
                 emergency.


18.     Patient Group Directions

        It is usually necessary that all medicines administered or supplied to a service
        user by a practitioner be done so on the authority of an authorised prescriber.

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        Patient group directions allow named practitioners to administer and/or initiate a
        supply of medicines without the authority of an authorised prescriber. Patient
        group directions must be authorised by the Chief Pharmacist, Director of Nursing
        and Medical Director on behalf of the Trust.
        The contents of a Service user Group Direction (PGD) must comply with the
        requirements in Health Services Circular (2000/026, including:
        •        details of the condition or situation to which the PGD applies;
        •        details of which service users are included and excluded for the PGD and
                 what action to take if service users are excluded;
        •        a description of the treatment available under the PGD including dose,
                 frequency and the aims of the treatment;
        •        characteristics of staff authorised to supply or administer treatment;
        •        details of records to be kept for audit purposes;
        •        details of practitioners responsible for drawing up the PGD;
        •        signatures of the lead doctor, chief pharmacist, Head of Profession(s)
                 eligible to work under the PGD and the Medical Director on behalf of the
                 Trust.
        It is the responsibility of the manager of each ward, department or area that if
        medicines are administered or supplied under a Service user Group Direction
        that the PGD is valid, the practitioner is authorised to work under the PGD and all
        appropriate documentation is completed.
        Copies of approved PGDs must be available in the areas they are to be used.
        A practitioner working under a PGD cannot delegate responsibility for
        administering and/or supplying a medicine under the PGD.
        The Trust Effectiveness Forum is responsible for monitoring all Patient group
        directions in use and for ensuring the Patient group directions are reviewed
        before they expire (usually two years).
        Individual practitioners are responsible for ensuring that their team manager is
        told three months before their assessed competency to work under a PGD is due
        to expire so appropriate training, if needed, can be accessed.

19.     Preparation and Administration of Medicines

        19.1. Medicines

                 Medicines must only be prepared, checked or administered to a service
                 user by the following categories of healthcare staff:
                 •       a Registered Nurse Practitioner
                 •       a Registered Medical Practitioner


                 •       authorized Pharmacy Staff
                 •       a practitioner in training or an employee training to administer
                         medicines, but only under the direct supervision of a Registered

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                         Practitioner. The registered nurse remains responsible for ensuring
                         that the correct procedure takes place
                 •       other individually authorized employees after formal competency
                         assessed training
                 It is during the preparation of medicines for administration that errors
                 frequently occur, particularly where some form of dose calculation is
                 involved. In the majority of cases, medicines will be presented to ward
                 areas from the Pharmacy in a ready-to-use form, where no further dilution
                 or dose calculation is required.
                 Where the preparation of medicines is performed outside the Pharmacy,
                 the following points must be observed:
                 •       Read the prescription carefully; determine the name, dose, diluents,
                         route for administration and expiry date.
                 •       If a dose calculation is required this information must be included
                         as part of the prescription either by the doctor or the pharmacist so
                         that the Practitioner administering the dose is clear about the actual
                         amount to administer. It is strongly recommended that the
                         Practitioner checks all calculations with a second practitioner or
                         pharmacist before administration.
                 •       Where a calculation is involved and where the medicine is intended
                         for parental administration, or for administration to children under
                         the age of 12, a second practitioner must check all aspects of the
                         preparation of the medicines and sign and date the entry.
                 •       Prescribing for children requires careful consideration as additional
                         requirements for consent may be applicable and many medicines
                         do not have a product license for children.
                 •       If the practitioner is unclear as to the correct medicine diluent or
                         precise method for medicine preparation, he/she must obtain this
                         information from the Summary of Product Characteristics (SPC),
                         BNF, and appropriate Pharmacy Department or on call pharmacist
                         before proceeding. Most SPCs can be obtained from
                         www.medicines.org.uk.
                 The registered nurse is responsible for ensuring that prescribed medicines
                 are administered at the prescribed time. If the timing has been
                 significantly exceeded advice should be sort from the prescriber or
                 pharmacy staff.
                 Before administration of a medicine, a practitioner must check:
                 •       legibility and correct completion of all details on the prescription and
                         recording chart;
                 •       authorization and administration (Form T2 or T3) if the service user
                         is detained under the Mental Health Act 1983;
                 •       all sections of the drug prescription and administration chart to get
                         an overview of all the medicines being administered to identify any
                         prescribing or administration errors;


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                 •       the identity of the service user - extreme care is required to ensure
                         that visual recognition and verbal questioning before proceeding to
                         administer the dose confirm the service user‟s identity;
                 •       the record of the administration of medicines that the prescribed
                         dose has not already been given;
                 •       the name, form and strength, and prescribing period of the drug to
                         be administered against the drug prescription and administration
                         chart;
                 •       the time of administration;
                 •       the route of administration;
                 •       any special guidance relating to the drug, e.g. dilution with water,
                         before or after food;
                 •       the expiry date of the medicine;
                 •       before signing the administration chart, ensure that the medication
                         has been taken.
                 To reduce the risks of inadvertently administering an oral drug
                 parenterally:
                 •       only use labelled oral/enteral syringes that cannot be connected to
                         intravenous catheters or ports, to measure and administer oral
                         medicines;
                 •       do not use intravenous syringes to measure and administer oral
                         liquid medicines;
                 •       make sure stocks of oral/enteral syringes are available in all clinical
                         areas that may need to measure and administer oral liquid
                         medicines in syringes.
                 When service users or carers need to administer oral liquid medicines with
                 a syringe, supply them with oral or enteral syringes.
                 To reduce the risk of inadvertently administering an enteral product
                 parenterally:
                 •       enteral feeding systems should not contain ports that can be
                         connected to intravenous syringes or that have end connectors that
                         can be connected to intravenous or other parenteral lines;
                 •       enteral feeding systems should be labelled to indicate the route of
                         administration;
                 •       three-way taps and syringe tip adaptors should not be used in
                         enteral feeding systems because connection design safeguards
                         can be by-passed.
                 To prevent cross infection, following administration, single use medicines
                 pots and oral syringes must be destroyed. Non-disposable items must be
                 thoroughly washed in hot soapy water via a dishwasher at a temperature
                 of at least 60o C, and allowed to dry or in line with the Trust‟s current
                 infection control policies.


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                 Medicines dispensed by a pharmacy for an individual service user should
                 only be administered to that service user (supplies labelled for individual
                 service users must not be shared).
                 Medicines issued as temporary stock to the inpatient ward may be used in
                 exceptional circumstances, such as no supply otherwise being available,
                 and the supplying pharmacy informed.
                 MEDICINES BROUGHT IN BY A SERVICE USER AT THE TIME OF
                 THEIR ADMISSION MUST NEVER BE USED FOR OTHER SERVICE
                 USERS.
                 The Practitioner who has administered or supervised the administration of
                 the medicine must, at the time of administration, sign with initials in the
                 appropriate column of the drug prescription and administration chart. The
                 Practitioner must observe that the service user has taken their medicines.
                 Prepared medicines must never be left unsupervised.
                 Injections, such as depot injections, which are prepared and not
                 administered immediately must be labelled with product name, strength,
                 volume and the name of the service user for whom it is intended. No
                 more than ONE service users‟ injectable medication can be prepared at
                 any one time .
                 If the service user is absent from the ward, or has missed a dose for some
                 other reason, the delayed dose can be administered at a later time
                 provided a doctor or pharmacist has confirmed that it is appropriate to do
                 so or that it is according to an agreed protocol. The actual time of
                 administration must be clearly recorded in the administration record by the
                 practitioner and appropriate entry into the service user‟s record is made.
                 Service users classified „Nil by Mouth‟ prior to a diagnostic procedure or
                 receiving an anaesthetic and undergoing ECT must have all their
                 prescribed oral medicines administered to them at the prescribed time
                 unless specifically advised otherwise by ECT staff and these omissions
                 must be marked on the drug prescription and administration chart. The
                 medicines should be taken with a small amount of water to enable the
                 service user to swallow these medicines. Only medicines that have been
                 clearly marked on the prescription sheet may be omitted. It is the
                 responsibility of the prescriber to provide clear written instructions to the
                 nursing staff concerning the omission of prescribed doses.
                 Service users receiving medication via a PEG feeding tube must only
                 have their drugs administered by a nurse or authorized employee who has
                 been formally trained by a member of a specialist team responsible for
                 inserting PEG feeding tubes. If a service user is admitted and no formal
                 training has been provided, specialist advice must be sought. Advice
                 should be also be sought from the pharmacy team if any doubt exists with
                 regard to administration of any medication via this system.


                 If a medicine is omitted the following codes must be entered on the
                 prescription sheet and ringed         in pen.



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                 •       „A‟ must be recorded for absence without leave.
                 •       „F‟ must be recorded for fasting or omitted prior to ECT.
                 •       „L‟ must be recorded for on leave.
                 •       „U‟ must be recorded if there is no stock.
                 •       „R‟ must be recorded if the service user refuses.
                 •       „S‟ must be recorded when a service user is sleeping.
                 •       „X‟ must be recorded for a prescribed omission (e.g. alternate days
                         dosing).
                 •       „O‟ must be recorded if a medicine is omitted for any other reason,
                         which must be recorded in the service user‟s notes.
                 •       “M” for when medication is being self administered and
                         administration is not witnessed.
                 In addition it can be helpful to note the dispensing or prescribing source
                 for service users who are under the care of practitioners in the community
                 and where the DMAR may contain medication which is neither supplied
                 nor administered by the team involved but is included to inform the team
                 of all the medicines taken buy the service user and improve clinical safety.
                 The following codes may be used to clarify matters:
                 •       FP10 – Medication is prescribed on an FP10 form and dispensed
                         by a community pharmacist
                 •       GP – The General Practitioner provides a prescription directly to
                         the service user.
                 •       CR. SM, FY, etc – a locally recognised code that indicates which
                         pharmacy service is dispensing the medication
                 •       PO – Where the service user is obtaining a medication for
                         themselves – typically this would cover complementary therapies,
                         nutritional supplements and the like.
                 Refusal of medication by any route may have a serious detrimental effect
                 and should be reported to the senior nurse or doctor.
                 Failure to record the administration of a medicine or an omission code
                 constitutes a medication error and must be reported. The scrutiny of such
                 records will be the subject of regular audit.

        19.2. Two person checking procedure

                 All registered practitioners are authorized to administer medicines without
                 involving a second practitioner. However, it is recognized that certain
                 circumstances exist where involving a second person in the process may
                 enhance safety e.g. when instructing a student or where the service user‟s
                 condition or conditions on the ward indicate that a greater staff presence
                 at the point of administration is required.
                 Except in extreme emergency, two registered practitioners must check the
                 following (including calculations and measured doses):

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                 •       All medicines given by continuous administration, e.g. IV or SC
                         infusion, syringe drivers. There should be a record of the individual
                         practitioner setting up and replenishing each intravenous infusion.
                 •       All bolus injections, IV additives and injections via drip tubing.
                 •       All injections taken from multi-dose vials. When a service user has
                         proven competent to self-medicate the medicine (e.g. insulin) the
                         checking of administration need only involve one practitioner.
                 •       All medicines administered to a child less than 12 years of age.
                 Where a two person administration takes place, the following roles and
                 responsibilities will be assumed:
                 •       The administering practitioner takes sole responsibility for the safe
                         administration of the medication (unless that practitioner is a
                         student or trainee).
                 •       The administering practitioner will read the prescription, prepare
                         and administer the medication, and sign the administration record.
                         This role should not be shared.
                 •       The second person will assist in the identification of service users
                         unknown to the administering practitioner.
                 •       The second person may offer a checking role to the administering
                         practitioner where any uncertainty occurs, but must do so if the
                         administering practitioner is a student or trainee or the two person
                         checking criteria above apply.
                 •       The second person will deflect any possible disruption, which may
                         occur during the administration process, to allow the administering
                         practitioner to fully concentrate on the task of administration.

        19.3. Controlled Drugs

                 In in-patient areas a registered practitioner must administer controlled
                 drugs and all aspects of administration are checked by a second person.
                 In other settings local protocols will apply.
                 In the community Controlled Drugs will be administered and checked by
                 one registered practitioner if the CD has been dispensed for an individual
                 by a pharmacy.
                 The administration will be noted on the service user medication record and
                 signed by the administering nurse.
                 An entry must also be made in the ward or department Controlled Drugs
                 register, including:
                 •       date and time of administration
                 •       name of service user
                 •       dose administered
                 •       full signature of both practitioners



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                 •       remaining stock balance must be checked (this must be physically
                         checked other than for liquids – see below)
                 On completion of the register any discrepancies must be dealt with
                 immediately
                 Any medicine prepared and not used, or only partly used must be
                 destroyed by the practitioner in the presence of an authorized employee.
                 An entry must be made in the Controlled Drug register and signed by both
                 persons.
                 Healthcare workers who have successfully completed the appropriate
                 assessments may be authorized to check Controlled Drugs with a
                 practitioner. However, they may not administer Controlled Drugs to
                 service users.

        19.4. Special Provision for liquid Controlled Drugs

                 This special provision addresses the need to avoid any excessive
                 decanting of liquid medication, (in order to check stock balance), as this
                 can lead to discrepancies in the balance due to loss during measurement.
                 Liquid CD preparations include:
                 •       Concentrated morphine sulphate solutions (Oramorph®
                         concentrated)
                 •       Diamorphine solution and linctus
                 •       Methadone solution and linctus
                 Whenever possible the measurement of doses of oral liquid medication
                 should be by oral syringe, rather than by spoon (which can easily be spilt)
                 or for larger volumes calibrated measures provided by pharmacy, and not
                 by plastic medicine pot. (Such pots are readily available and are in
                 common use but are not accurate).
                 Before the preparation of each dose the persons responsible for the
                 procedure must make a visual check and estimate of the stock balance
                 held. Only if they consider the balance appears inaccurate do they need
                 to physically measure the stock in order to accurately confirm its quantity.
                 The record of stock balance in the CD register must be made routinely.
                 During normal use it will be based simply on the calculation of balance
                 remaining after removal of the dose.
                 The manager remains responsible for balancing the stocks of all controlled
                 drugs at least weekly. Provided no discrepancies have occurred in the
                 preceding period, and particularly where use of a drug has been limited,
                 this again may be carried out by visual estimate. However, weekly
                 balance by measurement should be considered where usage is heavy.
                 An accurate measurement of stock balance, preferably using a calibrated
                 glass measure, must be made whenever a discrepancy occurs, is
                 suspected or a bottle is finished. If significant loss is detected, (e.g.
                 greater than 5ml per 500ml), this must immediately be brought to the
                 attention of the unit manager and the unit pharmacists.


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                 If the discrepancy is less than 5ml per 100ml (i.e. 25ml per 500ml) then
                 the actual stock balance should be recorded in the controlled book and
                 endorsed “stock adjustment” signed and dated by a registered nurse in
                 charge and an authorized employee.
                 Accurate measurement of stock balance may also be carried out by the
                 unit pharmacist at their discretion.

        19.5. Medication to be given as required

                 The administration of the medicine must be recorded on the drug
                 prescription and administration chart to include time, date, dose and the
                 initials of the member of staff administering the medicine.
                 The reason for administration should be recorded on the drug prescription
                 and administration chart and the service user‟s record.
                 If there is any doubt or concern, or the member of staff is unsure of the
                 criteria given for the administration of as required medication, then advice
                 must be sought from the service user‟s doctor, a senior colleague or
                 pharmacist
                 There should be a review procedure in place, which ensures that frequent
                 or regular use if highlighted and brought to the attention of the service
                 user‟s doctor.
                 Reasons for not administering as required medication when requested by
                 the service user should also be recorded in the service user‟s notes.

        19.6. Crushing Solid Oral Dose Forms

                 Where a service user is unable to swallow tablets or other solid oral dose
                 forms alternative medications or dose forms should be sought through
                 discussion between the registered nurse,
                 authorised prescriber and pharmacist. If there is no option but to crush the
                 medication, it must be done with the knowledge and agreement of the
                 authorised prescriber (as the medication is rendered “unlicensed” by the
                 process) the pharmacist and the consent of the service user/client.
                 If the service user/client lacks the capacity to consent, then previously
                 indicated preferences, made in any advance statement, should be
                 respected. Where there is no such statement then the service user/clients
                 wishes should be taken into account.
                 Note: Crushing some oral dose forms can be harmful to the staff
                       undertaking the process. Always consult pharmacy.

        19.7. Using Syringes to administer Oral Medication

                 IV syringes must never be used to measure or administer liquid oral
                 medicines either orally or through an enteral feeding tube.




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                 A medicine cup or 5ml spoon* is used to measure and administer liquid
                 oral medication except in the following situations where an oral syringe is
                 appropriate:
                 •       The dose cannot be accurately measured using a medicine cup or
                         5ml spoon*, i.e. the dose is not 5ml or a multiple of 5ml.
                 •       Administration via an enteral feeding tube.
                 •       Administration from a medicine cup or 5ml spoon is unsuitable e.g.
                         babies and young children.
                 'Press-in bungs' are available for medicine bottles to allow removal of the
                 dose using an oral syringe.
                 There is no requirement for oral syringes to be supplied as sterile except
                 in rare circumstances such as jujenostomy
                 Enteral Feeding – Consult a dietitian and pharmacist before administering
                 medication through enteral feeding apparatus.
                 To avoid potential contamination, once an oral syringe has been used to
                 administer medication directly to a service user , it must not be used to
                 withdraw further doses of that or any other medication from an original
                 container.
                 USED ORAL SYRINGES SHOULD BE DISPOSED OF ACCORDING TO
                 THE TRUST WASTE DISPOSAL POLICY.

20.     Self Administration of Medicines by In- Patients

        20.1. General guidance for self-medication of medicines

                 If the service user has fulfilled the necessary criteria and is deemed
                 suitable to undertake the process of self-medication, a written consent
                 should be obtained from the service user.
                 A registered nurse will give a full explanation to the service user of the
                 procedure relating to the self-medication of their medicines.
                 An information leaflet (UKPPG PAL – available on the intranet) will be
                 given to the service user relating to their individual medication. Any
                 problems or concerns will be highlighted before participating in the self-
                 medication of medicines.
                 A full assessment of the service user's ability to self-medicate (to include
                 physical and psychological factors) will be undertaken prior to
                 commencing self-medication of medicines.
                 A full explanation of the service user's responsibility to keep their
                 medicines safely within the ward, and allow access only by authorised
                 members of the ward team, must be explained to the service user before
                 commencing self-medication.


                 •       If a medication changes after dispensing, any unwanted medication
                         must be removed by a registered nurse or pharmacist and returned
                         to the pharmacy department. If any aids have been used to aid

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                         medication concordance, then these too must be returned to
                         pharmacy for adjustment, if necessary.
                 •       As required medications will be administered separately by a
                         registered nurse.
                 •       Controlled drugs must not be used for self-medication and always
                         be administered adhering to Trust policy.
                 •       Medication will be dispensed by pharmacy and with the service
                         user's agreement, will be their responsibility. Medication will be
                         stored in an individual storage cabinet that is used only for the
                         storage of an individual service user's medicines.
                 •       The storage cabinet will be kept locked at all times when not in use
                         by the named service user, registered nurse or pharmacist.
                 •       The registered nurse must ensure that there is a record of self-
                         medication on the DPAR when service users self-medicate any
                         medicines.
                 •       Service user counselling and education will be undertaken by
                         members of the multidisciplinary team as an ongoing process
                         throughout the self-medication process to ensure full understanding
                         and maximum concordance with medication regimens.

        20.2. Suitability criteria for service users to use their own medicines to
              self-medicate

                 Only medicines that can be positively identified will be accepted for ward
                 use and reissued to service users. (This will exclude the majority of
                 bottled liquid preparations and those contained in compliance aids.)
                 Medicines must have been dispensed within the past six months, unless
                 an expiry date is stated on the container. Ophthalmic preparations must
                 have been in use for less than one month.
                 Medication must be correctly labelled with the service user‟s name,
                 product name and strength, dose and frequency, supplier‟s address and
                 date of dispensing.
                 Each container must hold only one type or brand of medication from a
                 single supply. Containers holding several different drugs or dosage
                 strengths will be discarded.
                 Directions printed on the container must agree with the DPAR or TTA
                 prescription. Service user's own drugs must not be relabelled with revised
                 instructions, with the exception of blister-packed tablets, which will need to
                 be re-labelled by pharmacy if the treatment regimen changes.
                 The responsible practitioners must be satisfied with the general condition
                 of the product and its packaging and labelling. Professional discretion
                 should remain the overriding factor in assessing appropriateness for use.




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21.     Ordering and Receipt of Medicines

        21.1. Controlled Drugs

                 The responsibility for ordering, receipt, storage and recording of Controlled
                 Drugs is that of the senior registered nurse of the ward/department.
                 The ordering of stock Controlled Drugs will use the documentation and
                 standards of the SLA acute trust or other provider of the pharmacy supply
                 service.
                 Some local Substance Misuse Teams may have special supply
                 arrangements agreed with community pharmacies. These local
                 arrangements must be approved by the Chief Pharmacist.
                 Controlled Drugs can only be ordered from the pharmacy by submitting a
                 requisition from the official Controlled Drugs Requisition Book. Ordering is
                 restricted to the senior registered nurse. All Practitioners who may order
                 Controlled Drugs must provide the supplying Pharmacy Department with
                 specimen signatures.
                 All Controlled Drugs must be delivered to wards or departments in a
                 tamper evident package.
                 The tamper evident package can be a locked box such that the person
                 delivering the box has no access to the key, or a package sealed by a
                 tamper evident closure that has a unique serial number recorded.
                 Where appropriate a porter, driver or courier may deliver Controlled Drugs
                 in a tamper evident package.
                 The porter, driver or courier must sign a drugs delivery record sheet or
                 book. A registered nurse must receive the package and sign a drugs
                 delivery record sheet or book. The practitioner signs for receipt of a
                 tamper evident pharmacy container. If the Controlled Drugs are to be
                 collected by a registered nurse, the appropriate part of the Controlled
                 Drugs Requisition Book must be signed and the medicines transported
                 back to the ward in a sealed package.
                 A registered nurse must check the contents of the package containing
                 controlled drugs against the requisition. Any discrepancy must be
                 reported to the appropriate pharmacy IMMEDIATELY. If correct, the
                 nurse must sign the requisition. They must then enter the new stock into
                 the Controlled Drugs register on the appropriate page, witnessed by
                 another practitioner, member of the Pharmacy Staff or an authorized
                 employee who must verify the stock level and sign the register. The
                 medicines must then be immediately locked away.
                 It is unnecessary and confusing to begin a new page with each new
                 receipt of controlled drugs.
                 The receipt of a new supply must be entered on any pre-existing record
                 for that medicines, dose and form and the stock level checked and
                 updated. If it is a new preparation a new page should be made out with
                 the drug, dose unit and form listed at the top.



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                 It is good practice to maintain an index at the front of the CD register with
                 page numbers updated when a new page is required. When it is
                 necessary to start a new page ensure the top has the medicine, dose and
                 form and the previous page references the new page and vice versa e.g.
                 C/F to page XX, C/F from page XX.
                 Where sealed packs of Controlled Drugs are supplied with tamper evident
                 seals, there is no requirement to open these packs for stock checking
                 purposes.
                 Controlled Drugs must be stored in a locked medicines cupboard,
                 approved by pharmacy and reserved for the sole storage of Controlled
                 Drugs. Access must be limited to registered practitioners, Pharmacists or
                 Authorised Pharmacy Technicians.
                 Registers and Requisition Books for Controlled Drugs are controlled
                 stationery. Requisition books must be locked away.
                 Orders and records must be in permanent ink and must be retained for
                 two years.
                 Strengths of diamorphine injection over 10mg must not be kept routinely
                 as stock. Where strengths above 10mg are required only sufficient stock
                 is ordered and held for immediate use. Excess stock must be returned as
                 soon as possible to avoid inadvertent confusion over ampoule strengths.
                 All wards and community teams administering methadone, diamorphine or
                 similar opiates must have access to the opiate antagonist naloxone.

        21.2. All Other Stock Medicines

                 Where appropriate, a list of medicines to be held for stock purposes will be
                 drawn up by Pharmacy Staff in consultation with nursing staff. This list
                 should be reviewed at least annually and revised according to actual
                 usage by the same group.

        21.3. Ordering of stock medicines

                 A registered nurse or authorised member of the pharmacy staff shall be
                 responsible for ordering medicines from the pharmacy for the purposes of
                 maintaining ward stocks.
                 Stock medicines may be ordered by:
                 •       supplying a written requisition from the appropriate order book, or
                         an order sheet signed by a practitioner
                 •       using a fax machine to send a copy of the above;
                 •       by means of the pharmacy top-up service.

        21.4. Non-Stock Medicines

                 21.4.1. Ordering of non-stock medicines
                         Non-stock medicines for individual service users may be ordered
                         by:


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                           •       submitting a signed order plus the service user‟s drug
                                   prescription and administration chart;
                           •       using a fax machine to send a copy of a signed order and
                                   the service user‟s drug prescription and administration
                                   chart;
                           •       by means of the ward pharmacy service.
                           If a service user‟s own medicines are available, they may be used
                           with the service user‟s or their carers (if appropriate) consent,
                           providing they comply with the standards set out in this Medicines
                           Code.

                 21.4.2. Medicines for Short Term Leave or Discharge
                         Short term leave or discharge medication can be ordered by:
                           •       submitting a short term leave or discharge prescription
                                   together with the drug prescription and administration chart
                                   or a copy of the drug prescription and administration chart.
                           •       using a fax machine to send copies of the above (if agreed
                                   locally).
                           Controlled Drugs cannot be supplied to a service user until the
                           original prescription has been received by the Pharmacy.
                           Once the leave/discharge medicine is delivered to the ward the
                           supplied medication and its labelling should be carefully checked
                           by a practitioner against a copy of the drug chart or discharge
                           prescription. Special care must be taken to ensure any medicines
                           not supplied by pharmacy but are already on the ward labelled for
                           leave or discharge e.g. inhalers, are added to the bag of
                           medicines.

        21.5. Delivery of Medicines

                 All medicines must be delivered to wards/departments in a tamper evident
                 or secure container. Where appropriate, a porter, driver of courier may
                 deliver medicines in a tamper evident package or locked box. The porter,
                 driver or courier must sign a drugs delivery record sheet or book. A
                 practitioner must receive the package or box and sign the drugs delivery
                 record sheet or book. The practitioner is signing for the receipt of a
                 tamper evident pharmacy container or locked box and not the contents.
                 If there is a central receipt point then an authorized member of staff may
                 sign for it but a local audit trail needs to be established for onward
                 distribution.
                 Medicines may be collected from Pharmacy by a practitioner or approved
                 messenger and transported back to the ward in a tamper evident
                 pharmacy package or locked box.
                 A registered nurse must:




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                           •       sign for the tamper evident package or locked box in the
                                   delivery record;
                           •       lock the medicines in the medicine cupboard, fridge or
                                   trolley immediately;
                           •       report any discrepancies or errors to the Pharmacy as
                                   soon as possible.
                           •       Delivery notes of stock medication should be retained for 1
                                   month.

        21.6. „One stop‟ Dispensing

                 Where one stop dispensing has been introduced, supplies of inservice
                 user medicines dispensed for the individual service user can be issued for
                 short term leave or discharge, provided:
                 •       there are sufficient supplies;
                 •       the service user has been deemed suitable to receive one stop
                         dispensing supplies following assessment by the primary nurse and
                         a member of the pharmacy team using a Risk Assessment Form
                         (See One Stop Dispensing Procedure). This form should be
                         checked prior to using one-stop supplies for short term leave or
                         discharge;
                 •       the decision has been recorded in the service user‟s notes along
                         with a copy of the assessment;
                 •       the medicines stored in their individual tray(s) within the ward
                         medicine trolley correspond to those prescribed on the discharge or
                         leave prescription;
                 •       the medicines have a label including the name of the medicines,
                         the directions for use and the name of the service user that
                         correspond to those on the prescription, along with the date of
                         dispensing;
                 •       the registered practitioner checking the service users medicines for
                         use has been deemed competent to check „one stop‟ medicines for
                         short term leave or discharge use.
                 Where the short term leave or discharge prescription differs from the
                 medicines in the service user‟s cabinet or when there are insufficient
                 supplies of medicines, the ward staff must contact the Pharmacy to make
                 arrangements for the required discharged medicines to be dispensed.
                 The service user‟s suitability or unsuitability must be reviewed if the
                 service users‟ condition or circumstance change.

        21.7. Controlled Drugs to Take Out

                 Controlled drugs to take out should be ordered on a short term leave or
                 discharge prescription which has been completed and signed by the
                 prescriber in accordance with current legal requirements. The prescription
                 must include the service user‟s name and address, drug name, the form,

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                 the dose, the frequency, and the total quantity (in words and figures). The
                 original prescription must be sent to pharmacy for dispensing.
                 Delivery and receipt of controlled drugs for short term leave or discharge
                 TTO purposes should be as for other medicines, but storage on the
                 ward/department should be in the controlled drug cupboard.
                 N.B.    It is not necessary to enter the TTO into the Controlled Drug
                         Register although individual units may choose to do so if it is felt
                         that additional administrative safeguards are required. It is
                         important to record the issue of CD TTO‟s else the records will
                         become inaccurate.

22.     Checking of Stock Balances

        22.1. Controlled Drugs

                 The minimum Trust standard is that the stock balance of all Controlled
                 Drugs entered in the Register must be checked once a week against the
                 actual stock in the ward/department.
                 There is no need to open packs with intact tamper evident seals for stock
                 checking purposes. It is also good practice to carry out occasional
                 verification of entries in the register against entries made on individual
                 prescription.
                 Two registered practitioners, or one registered practitioner and an
                 authorised member of the pharmacy staff must perform the check.
                 A record indicating this check has been carried out is kept in the
                 Controlled Drug Register or a notebook specifically to record stock checks
                 and must confirm the stock is correct. This record may be a single entry in
                 the stock check notebook or individual entries may be made on each page
                 in use. The record must be dated and signed by both persons. The Ward
                 or Team Manager must ensure that these checks are carried out.
                 The Ward or Team Manager must undertake a random check of at least
                 one drug in their Controlled Drug cupboard at least once a month and
                 record the check in the ward Controlled Drug register on the relevant
                 page. Where possible this random check must reconcile recorded
                 administrations with the appropriate drug prescription and administration
                 charts, if available. Particular attention must be taken of liquid medicines
                 and any stock adjustments made when bottles are emptied and Controlled
                 Drugs stocked but not in current use.
                 Stock balances of individual preparations must be checked after every
                 administration with the exception of liquids.
                 Liquid medicine stock balances must be undertaken whenever a bottle is
                 finished. Due to filling inaccuracies small discrepancies occur with liquid
                 medicines. Stock record adjustments for small discrepancies of less than
                 5ml per 100ml must be made when a bottle is emptied (see Losses and
                 Discrepancies chapter).
                 In the event of a discrepancy between the stock balance and register for
                 Controlled Drugs, the most registered nurse must immediately and

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                 thoroughly investigate the loss. A missing or incorrect entry or arithmetical
                 error must be investigated first and if found corrected. When correcting
                 the error in the register no crossing out or Tippex® must be used on
                 previous entries. A full explanation should be recorded in the register.
                 Any recording must be signed and dated by the registered nurse in charge
                 and a witness. An incident form must be completed where no satisfactory
                 explanation can be found.
                 Any need for more frequent checks will be decided by the manager in
                 liaison with the Chief Pharmacist or Accountable Officer for Controlled
                 Drugs for the Trust
                 A member of pharmacy staff must check the Controlled Drugs balance
                 and all register pages used since the last pharmacy check, at a minimum
                 of six monthly. A record must be made on every page with a stock
                 balance or where a stock has reduced to zero. Where possible there
                 should be verification of a sample of entries in the register against entries
                 made on individual prescription.

        22.2. Other Medicines

                 Local agreements to check other medicines may apply. Any need for
                 checking stock balances of other medicines must be left to the discretion
                 of the ward or team manager. If, however, there is suspicion of abuse of
                 medicines this must be reported to the team or ward manager and the
                 Chief Pharmacist. In such cases it is advised that a stock balance must
                 be recorded and regular checking introduced. If this shows discrepancies
                 the medicine must be made subject to similar procedures as Controlled
                 Drugs and register entries must be made whenever the medicine is
                 administered. It may subsequently be reported to the Service Manager
                 and the Trust‟s Security Adviser, and systems introduced (either openly or
                 covertly), to identify further losses etc.

23.     Borrowing of Medicines

        Medicines must not be borrowed from a ward or department unless a supply
        cannot be obtained directly from the pharmacy during normal working hours.
        Only medicines dispensed by the pharmacy service may be borrowed and
        usually the complete container should be transferred to the receiving ward. If
        only one container is available and the drug is needed on the original ward the
        full container must be taken, the dose administered from it and the container is
        returned to the original ward.
        Only in exceptional circumstances may medicines be transferred into another
        container in order to be transferred. In these circumstances an appropriate,
        clean medicines container must be used, and must be labelled with all details of
        the medication including batch number and expiry date.
        A signed record of the transfer of medicines must be kept in both wards‟ diaries
        involved in the „borrowing transaction‟. The signatures must be those of the
        registered nurses in charge of both wards.



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        Controlled Drugs must not be borrowed except in an extreme emergency.
        Where this does occur, full records of the transaction must be made in both
        wards‟ Controlled Drugs Registers.
        If borrowing occurs Pharmacy should be informed at the earliest opportunity so
        that the stock can be replenished.

24.     Service User and Carer Information

        It is important that the service user (or carer if appropriate) receives adequate
        information about their medicines prior to discharge unless their care plan deems
        it inappropriate.
        The service user should know as a minimum:


•       the purpose of the medicine;


•       how to take it;


•       for how long it is to be taken for;


•       the risks, benefits and alternatives to any treatment option.
        This is the responsibility of the prescriber who may choose to involve authorized
        pharmacy staff in this process and the actions taken should be documented.
        Best use should be made of any Advice Leaflets supplied with the medicines and
        any additional leaflets endorsed by the Trust which are available on the Trust
        website.

25.     Trust Pharmacy Services

        Medicines will be procured, supplied and dispensed in accordance with the
        relevant legislation, professional standards and NHS recommended practice.
        So far as possible, pharmacists will monitor the use of medicines for service
        users in their care, and place special emphasis on complex, potentially toxic and
        high risk medicines that require higher levels of monitoring. Monitoring will
        include the need for the medicine, the medicine selected, the dose regimen
        including the duration of treatment, the medicine formulation and the route of
        administration In addition pharmacists will monitor for medicine interactions and
        adverse reactions and whether the therapy is achieving the desired therapeutic
        end points Continuing medicine treatment will be reviewed as necessary. Trust
        Clinical Pharmacy Guidelines and Service Level agreements/contracts may be
        consulted for further information.
        Authorized pharmacy staff will annotate the prescription where possible. This
        annotation must ensure the approved name (where appropriate); dose, route and
        cautions and any additional information is included on the prescription, to guide
        practitioners when they administer the medicine.


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        Where an authorized pharmacy staff member wishes to make a recommendation
        to change or modify a service user‟s therapy and the prescriber is not
        immediately available and the advice is not deemed to be urgent, he/she will
        liaise directly with the registered nurse and, where considered appropriate, will
        record the recommendation in the service user‟s notes and if available the
        doctors‟ communication book. IF URGENT ANOTHER MEMBER OF THE
        MEDICAL TEAM SHOULD BE CONTACTED.
        Pharmacy staff may, in accordance with approved Trust Clinical Pharmacy
        Guidelines, transcribe prescriptions (not including CD‟s) to discharge or leave
        forms and to replace prescriptions on a DPAR chart to improve service user care.
        Examples include transposing simvastatin 10mg each morning to an evening
        dose. A note should be made in the notes to this effect.
        Authorized pharmacy staff will make and maintain their own record of any
        significant interventions for future reference.
        Service users (or their carers where appropriate) should be advised about their
        medicines by authorized pharmacy staff during their admission stay or period of
        admission unless their care plan deems it inappropriate. This should be a part of
        an agreed programme for each ward. The manager should agree with the
        pharmacist and consultant the arrangements for advising service users (or their
        carer) about their medicines.
        Where practicable and appropriate, practitioners may request the authorised
        pharmacy staff advise service users about their medication during the course of
        their stay, attendance at clinic, or in discussion at educational groups.
        Alternative arrangements for advising service users about their medicine may be
        provided if:
•       the nature of the hospital stay is less than one week;


•       there is a need for a rapid discharge;


•       service users are identified who may need further advise post discharge;


•       the care plan indicates that such discussions would be inappropriate;


•       there is insufficient availability of suitably trained pharmacy staff.


Such alternative arrangements must identify the person responsible for the provision of
information and the nature of the information to be provided.


Authorized pharmacy staff must be involved in advising on security and medicine
storage conditions on the ward/unit or department.




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26. PHARMACY OUT-OF-HOURS SERVICE


Only in cases of clinical urgency will items be supplied out of hours. The supply of the
vast majority of medicines will not be clinically urgent and can usually be safely left to
the next time the pharmacy is open. However, when in doubt any on-call pharmacists
may be contacted and they will assist ward staff to determine the degree of urgency.


It may not always be possible to have individual medicine supplies available from the
pharmacy for the next medicine administration round. Registered nurse practitioners
must make maximum use of service users‟ own medicines and out-of-hours/emergency
drug cupboards (where provided). If the medicines have been ordered and have not yet
been supplied by the pharmacy the registered nurse must record “U” on the medicine
administration chart. Medicines brought in by service users at the time of their
admission must never be used for other service users.


Any Pharmacy out of hours service is also available for urgent medicines information
advice and for reporting suspected significant adverse reactions to medicines or
suspected faulty medicines.


Out of hours services and arrangements differ across the Trust. Contact your local
pharmacy for information.




27. TRANSPORT OF MEDICINES


The transport of medicines by community practitioners is covered in the „Community
Based Practitioner‟ chapter.


Service users transferring between wards either within the Trust or between the Trust
and other organisations must have any medication which has been individually
dispensed for that service user forward to their destination unit or ward.


     27.1.      When transporting service users


     27.2.      Transport within hospitals


Authorized members of staff must transport medicines within hospitals and must not
delegate to service users or carers.


Medicines must not be left unattended at any time during transport.

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When medicines are received at their final destination they must not be left unattended
or unsecured. They should be handed to a practitioner and locked away in medicine
cupboards, drug trolley or fridge at the earliest opportunity.


     27.3.      Transport of medicines between health services premises


Medicines accompanying a service user and being transferred from one hospital to
another may be transported between hospitals with the service user in an ambulance or
by authorized hospital transport, or taxi. It is important that medicines are packaged
securely and are labelled with the final destination.


If the service user is being escorted or transferred by ambulance the medicines must
remain in the possession of the member of staff or the ambulance crew as described
above.


If a relative is ever given responsibility to escort a service user between units, unless
there are concerns about security, medicines and documents can be transported by
them in a sealed package clearly marked with the addressee‟s name and address. The
addressee must be asked to confirm by phone when the medication/documentation has
arrive safely.


     27.4.      Transport of medicines from the pharmacy department


                27.4.1. Transportation using hospital transport


All medicines must be transported in locked boxes or tamper evident containers.


Controlled drugs must be transported in locked boxes or tamper evident containers and
where possible with uniquely numbered tamper evident seals with the number recorded
in the CD requisition book and the top copy kept in pharmacy.


Containers shall be kept securely or under surveillance whilst awaiting collection from or
on receipt at the areas.


On arrival on the wards/departments/clinics, containers should be placed in a secure
area. Once delivered to the ward/department/clinic the responsibility for the security of
the medicines rests with the nurse practitioner who will arrange that the contents be
unpacked, checked and put way securely as soon as possible.



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The driver shall carry a record book stating the destination and the number of
containers for each destination with any unique seal numbers recorded if appropriate.
The authorized person accepting the delivery must sign the record book.


Where the medicines are delivered to a central distribution point local audit trails need
to be established. The containers must be securely stored while waiting to be
distributed to the wards/departments/clinics.


The responsibility for the security rests with those transporting the medicines until the
delivery is completed and the necessary signatures obtained.

                27.4.2. Transportation from pharmacies by Taxis


All items should be transported in locked boxes or tamper evident containers.
Containers with Controlled Drugs in them must not have any special marks to indicate
Controlled Drugs.


If tamper evident seals are used, the seal number of the container must be recorded in
the CD book and delivery note.


The taxi driver should be asked for an approximate time of arrival at his or her
destination. The ward, department or clinic due to receive the delivery must be
telephoned to forewarn them of the delivery and be given a time after which they should
chase the delivery if it has not arrived. This will either be via the pharmacy, or the
pharmacist on-call if out of hours.


Only hospital contract taxis with drivers able to produce identification bearing a
photograph should be used.


Items must be collected from the pharmacy or an agreed manned area and delivered to
the addresses or an agreed manned area, e.g. ward reception.


If items are not delivered directly to the addressee the responsibility for security rest
with those receiving the container until delivery is completed and documentation
countersigned.


On arrival the driver should obtain a signature from addressee or agreed representative.


                27.4.3. Transport of medicines to individual service users at home




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Service users who have left the hospital before all their medicines have been dispensed
must be instructed to return to the hospital later to collect their medicines.


Medicines may be delivered by members of the community teams to the service user‟s
home.


In exceptional circumstances medicines may be delivered to a GP practice, health care
clinic or community pharmacy by authorized hospital transport, taxi or by post, for
collection by the service user. Arrangements must be agreed with the receiving
premises and the registered nurse in charge of the ward who must authorize it. It is
important that medicines are packaged securely and are labelled with the final
destination.


                27.4.4. Collection of medicines by voluntary drivers, relatives or
                        representative of the service user


Voluntary drivers, relatives or representatives of the service user may collect medicines
from a pharmacy on behalf of a service user provided the appropriate pharmacy has
received prior notification of their impending arrival by the ward, day unit or department.
Drivers may be asked for a signature especially if the medicines they are collecting
contain a controlled drug.


Voluntary drivers must carry identification of their role.


28. STORAGE OF MEDICINES


     28.1.      General


The Ward or Team Manager is responsible at all times for the safekeeping of all
medicines on their ward or department. Day to day functioning may be delegated to
registered nursing staff.


The design and location of all ward or department medicine storage cupboards must be
approved by Authorized Pharmacy Staff and regularly monitored.


All internal and external medicines, disinfectants, and reagents must be stored in locked
rooms, cupboards, trolleys or other secure cabinets – all reserved solely for medicinal
products. The only exceptions to this requirement are medicines for clinical
emergencies. Intravenous fluids, sterile topical fluids and nutritional products and some
bulky medicated dressings, which because of their bulk are stored in a clean area (as


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agreed between the practitioners in Charge and an Authorized member of the
Pharmacy staff).


Internal medicines must be stored separately from other medicines. Under no
circumstance must medicines be transferred form one container to another, nor must
they be taken out of their container and left loose.


Medicines should be arranged in a way to ensure clear identification and efficient stock
control. A nominated person should perform regular checks to identify medicines that
are approaching their expiry date.


     28.2.      Positioning of cupboards and trolleys


Cupboards and trolleys must be sited where most convenient for staff, allowing
adequate space and permitting surveillance to afford maximum security against
unauthorized entry. Medicine cupboards must generally be sited in a clean clinic room
to which service users and visitors do not have unsupervised access. Cupboards must
not be sited where they may be subjected to higher than average humidity or
temperatures greater than 25°C. Reagent cabinets may be sited in areas where testing
is carried out.


     28.3.      Review of storage of Medicines


Pharmacy Staff and the Ward or Team manager will regularly review the quantities,
range and storage of medicines to be stocked.


     28.4.      Controlled Drugs


No ward or department will store Controlled Drugs unless a registered nurse will be
responsible for their storage and use.


     28.5.      Sample Medicines or dressings


Medicines or dressings samples must not be left on or accepted by wards, clinics or
departments, including pharmacy or with any member of staff.


Representatives of commercial companies wishing to leave samples must be told that
the Trust will purchase the product should it wish to use it and any samples must be
arranged with the Chief Pharmacist.


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     28.6.      Storage of Medicines


Clinical areas may have some or all of the following medicine storage units:


•      Controlled Drug Cupboards – reserved solely for the storage of Controlled Drugs
and other high risk medicines following specific agreements with authorized pharmacy
staff. These cupboards may be separate from others or be inside other locked
medicines cupboards used to store internal medicines. These cupboards must be
secured to the wall. The lock must not be the same as any other lock in the hospital or
unit. Schedule 2 and 3 controlled drugs must not be stored in trolleys.


•       Internal Medicine Cupboard(s) – for the storage of tablets, liquid medicines,
injections etc.


•     External Medicine Cupboard(s) – for the storage of creams, lotions etc (May also
be used for the storage of reagents and tests).


•      Medicine Refrigerator – medicines are not to be stored together with food or
pathological specimens, but in a separate locked fridge. Medicines requiring storage
below room temperature will be marked “Store between 2°C and 8°C, in a refrigerator.”
All medicines fridges will be fitted with a digital thermometer (maximum/minimum type).
The ward or team manager in charge is responsible for ensuring that max/min
temperatures are monitored daily. Pharmacy should be informed if these temperatures
are outside this range.


•      Reagent Cupboard(s) – situated in the area where urine testing is carried out.
Some wards may not require a separate cupboard if urine testing is only very rarely
carried out but in such circumstance there should be a ward agreement about where
such testing is to take place.


•      A Clean Storage Room – for intravenous fluids and sterile topical fluids, if no
suitable cupboard is available.


•       Medicine Trolley – for storage of medicines in current use on the medicine
administration round. When not being used the medicine trolley must be locked and
secured to the wall. The trolley must not be left unattended during the medicine round.
If the registered Practitioner leaves the trolley, it must be locked immediately.


•      Medicines for Resuscitation – these must only be held where an acute trust crash
team is available or in an ECT suite for use by the anaesthetist. They must be in a
position to afford supervision to prevent unauthorized access. These must be held in a

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tamper evident box and must not be in a locked cupboard. Once opened the box must
be returned to the appropriate pharmacy for replacement.


•       Individual Service user Medicine Cupboards – medicines dispensed for
individuals (together with the service user‟s own medicines) can be stored in an
individual locked medicine cupboard at the side of the service user‟s bed. These
cabinets must be kept locked when not in use and the keys held by a registered
Practitioner. Where self-medication takes place, the individual service user may also
keep keys to this cupboard.


     28.7.      Closure of a Ward or Department


If a ward or department is due to close, the Controlled Drugs must be handed over by a
registered nurse to an Authorized member of the Pharmacy Staff who will sign the
appropriate section of the register and return the Controlled Drugs to the pharmacy. All
other medicines must be returned to the appropriate pharmacy in a locked box that has
been sealed and is tamper evident. Items requiring refrigeration must be stored
separately in an appropriately sealed tamper evident container.


If the closure is only for a short period, (e.g. just one or two days), all medicines may
stay on the ward (other than controlled drugs) provided there is adequate security to
prevent unauthorized access to the cupboards.


     28.8.      Breach of Security


Any suspected incident must be reported immediately and investigated by the ward or
team manager together with a member of the Pharmacy Staff. If a breach of security is
confirmed the Chief Pharmacist (or in his absence the most senior pharmacist on duty)
and the Trust Head of Security (or deputy) must be contacted and a decision made on
whether to call the police.


In the case of an obvious break in or theft then the police must be called immediately.




29. CUSTODY AND SAFE-KEEPING OF MEDICINE KEYS


     29.1.      Keys for Controlled Drug Cupboards


Keys for Controlled Drug Cupboards must be kept on a separate key ring that can be
readily identified.


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The key must be kept on the person of the senior registered nurse on duty or a
practitioner nominated by them. Responsibility remains with the senior nurse.


No practitioner can have access to the Controlled Drug cupboard except in the
presence of the Practitioner officially holding the key. The key must not be handed over
to medical staff.


In the event of the person in charge being inappropriately registered, the key must be
handed to the senior registered nurse of a ward or department in the near vicinity. This
information must be made known to the staff in the ward or department and to the
manager in charge of that section.


     29.2.      Keys for Medicine Cupboards, Medicine Trolleys and Refrigerators


The keys for the external cupboard, internal medicine cupboard, medicine trolley,
medicine refrigerator and pharmacy transport box must be kept together on one key ring
reserved solely for these keys. The keys must be clearly identified.


The keys must be kept on the person of a Practitioner. In the event of no Practitioner
being on duty in a ward or department, the keys shall be handed to a Practitioner on a
ward or department in the near vicinity. This information must be made known to the
staff on both wards or departments and the manager in charge of that section.


At Community Team bases where a number of Practitioners may require access to the
medicine cupboards at different times a digitally accessed key cupboard must be
provided for storage of the medicine cupboard keys. Alternatively a drug cupboard with
a digital lock may be used. ONLY STAFF AUTHORIZED TO ACCESS MEDICATIONS
MAY HAVE THE COMBINATION.




     29.3.      Keys to individual service user‟s medicine cupboards


The master key for individual service users‟ medicine cupboards will open all such
cupboards on the ward. The master key must be kept on the ward medicine cupboard
key ring at all times and must never be issued to a service user.


Keys that open individual service user medicine cupboards must be individually
numbered and stored in a locked cupboard on the ward when not in use.




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If a service user is to fully self-medicate the appropriate numbered key may be issued to
the service user who signs for receipt of this key. The key that is issued to an individual
service user must only open his/her medicine cupboard and must be kept securely by
the service user. On discharge or when the service user is no longer self-medicating
his/her own medicines, the key must be returned to safekeeping and a record made.


     29.4.      Loss of a Medicine Cupboard Key


If theft of the keys is suspected then the on-call manager and the police should be
called. The supplying pharmacy department must also be notified when the department
is next open.


In the event of a lost key every effort must be made to find the key or retrieve it from off
duty staff. Should access to the medicine cupboard be required before the keys are
retrieved the duty manager must be informed and duplicate key may be obtained. A
local policy must exist for securely accessing duplicate keys. The keys must be clearly
identified and easily accessible to the duty manager.


If there is no duplicate key and access to the cupboard is needed immediately, the duty
manager will arrange for the cupboard to be broken open and a new lock fitted.


If the cupboard keys are not located before the end of the shift on which they were
found to be missing, a new lock must be fitted to the cupboard. Any loss of keys
resulting in new locks must be recorded as an incident.




30. MEDICINES REQUIRING COLD STORAGE


     30.1.      General information


Unless specific advice states otherwise medicines requiring cold storage that have not
been properly distributed and stored should NOT be used.


The manufacturer‟s storage requirements for medicines requiring cold storage (usually
2 to 8
Medicines requiring cold storage will deteriorate and become ineffective if stored
outside manufacturer‟s recommendations. Medicines should also be protected against
light.


Each Clinic/Ward is required to have:-


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•      a named, trained individual with overall responsibility for cold stored medicines,
including vaccines, with named deputies;


•       a lockable medical refrigerator;


•       a maximum/minimum thermometer with an audible alarm with a remote probe or
a refrigerator with an integral maximum/minimum thermometer with an audible alarm.


The person must:-


•       have a good knowledge of this chapter of the Medicines Code;


•     be able to read the maximum/minimum thermometer and record the
temperatures daily;


•     ensure that medicines requiring cold storage are stored at the correct
temperature;


•      ensure medicines requiring cold storage are not packed too closely in the
refrigerator, nor stored against the freezer section or in the door;


•       ensure that food and drinks are not stored in a medicine refrigerator;


•       label the power point to the refrigerator to avoid accidental switching off;


•       have nominated deputies to cover in his/her absence;


•       monitor medicine stocks to avoid over-ordering, stockpiling or wastage.


     30.2.      Receipt of medicines requiring cold storage in clinics and wards


      All staff likely to receive delivery of medicines requiring cold storage must be
aware of this section of the chapter.


      A member of staff should have overall responsibility for the receipt and storage of
medicines requiring cold storage. Named deputies should also be identified.


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      Place the medicines requiring cold storage immediately into the refrigerator.
Medicines requiring cold storage must not be left at room temperature.


        The refrigerator should be LOCKED with access to it by authorized staff only.


        Store the medicines requiring cold storage in the correct rotational/date order.


     30.3.      Storage of medicines requiring cold storage


For specific information on storage refer to manufacturer‟s data sheet.


Store the medicines under controlled conditions. Any deviation from these may reduce
the efficacy of the medicines. Medical refrigerators are generally of a higher
specification than domestic varieties and may incorporate an integral fan,
maximum/minimum thermometer and an alarm. They must be lockable.


       Use medicines with the earliest expiry date first. Check expiry dates regularly
        and remove time expired medicines and destroy according to local procedure.


       Medicines should not be packed too closely within the refrigerator - allow for the
        circulation of cold air.


       Store medicines in the main body of the refrigerator. They must not be stored
        against the freezer compartment, the door or bottom.


       Store all vaccines at a temperature between 20C and 80C. No medicine must be
        frozen.


       Store medicines in original packaging to protect from light and temperature
        change.


       Reconstituted medicines may not remain stable and will have an expiry period
        following reconstitution - refer to manufacturer‟s summary of product
        characteristics for reconstituted expiry dates.


       Cautionary notices should be placed on power plugs or sockets or tape the
        power point of the refrigerator, to avoid accidental switching off, or use a
        switchless socket.

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       No food or drink or clinical specimens are ever stored in the medicines
        refrigerator.


       Unless a frost-free model, defrost the refrigerator regularly to prevent build-up of
        ice. Ideally, this should be done when the refrigerator is empty. If this is not
        possible temporarily store the medicines in another refrigerator on another ward.


       Opening the refrigerator door should be kept to a minimum


       The refrigerator should not be situated near a radiator or heat source and should
        be appropriately ventilated.
       Service users taking medicines home should be given written storage
        instructions.


     30.4.      Advice on medicines following problems with the cold storage chain


       Where there are queries as to the efficacy of a medicine due to problems with the
cold storage chain, the local mental health pharmacy team can usually supply advice on
the stability of medicines or contact the medicine manufacturer.


     30.5.      Equipment list


                30.5.1. Refrigerators


Specialised refrigerators are available for storage of pharmaceutical products and must
be used for medicines requiring cold storage and diluents. Ordinary domestic
refrigerators must not be used.


They MUST be lockable.


It would be a sensible precaution to validate any refrigerator intended for medical use by
means of a thermometer or temperature probes, or by assurance from the manufacturer
and also to maintain regular ongoing checks on the temperature to assess suitability for
use. The mains electrical lead should ideally be fitted in a spur point, which should be
fused but not switched. Contingency plans should be made for defrosting activities.




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                30.5.2. Maximum and Minimum Thermometers


A digital maximum/minimum thermometer with a remote probe and audible alarm
should be used. It is advisable to request a certificate of calibration. If a suitable probe
is not provided with the refrigerator a separate thermometer can be obtained. Results
should be recorded in a refrigerator monitoring notebook.


                30.5.3. Temperature control


The temperature of the medicine refrigerator must be continually monitored with a
maximum and minimum thermometer with an audible alarm. Digital thermometers are
recommended. Reset and replace according to manufacturers guidelines, including the
batteries. Thermometers should be checked annually to ensure correct working.
Records should be kept for audit in the temperature log book.


Check and record the maximum/minimum refrigerator temperatures every working day
when the refrigerator is in use. Record the results in the refrigerator‟s temperature log
book.


       If the temperature is not maintained within the correct range or if a refrigerator is
turned off for any length of time, the local mental health pharmacy team should be
contacted to ascertain the action to be taken. Alternatively telephone the medicine‟s
manufacturer for advice or contact the local pharmacist for advice.


      Ensure a repair engineer can be readily contacted in case of a breakdown. Keep
the appropriate number in the front of the temperature log book.




31. STORAGE AND HANDLING OF FLAMMABLE LIQUIDS, GASES AND
    AEROSOLS


       Very small quantities of these may be kept in the external medicines cupboard.
Where larger quantities are held, advice must be obtained from the Trust Fire Safety
Officer.


32. Medical Gases


Oxygen cylinders should be stored in a dry, clean and well-ventilated area and secured
in a safe position where they cannot fall over. Cylinders must never be used or stored
where there are naked flames or high temperatures. Where necessary, the Fire Officer


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should be consulted on the safe use and storage of oxygen cylinders „No Smoking‟
signs should be displayed where oxygen is in use or being stored near areas where
smoking is allowed.


Where cylinders are held they should be in specifically designed trolleys or wall racks to
prevent them from falling over. Their storage position on the ward should be agreed
with the Trust Fire Safety Officer. Staff involved in the use of oxygen should receive
approved and documented training regarding the safe use of equipment including
checking, maintenance and storage of oxygen cylinders.


       When not in use the cylinders must be closed at the cylinder head (with the
        appropriate spanner) as well as at the flow meter.


       Flow meters seals („O‟ rings) must be replaced every 2 years to prevent leakage
        which is a fire risk.


       When changing cylinders hands must be clean as the mixture of oil or grease
        e.g. butter with oxygen is combustible.


More details on the storage and use of medical gas cylinders, and the issues associated
with medical gases together with Health and Safety information will be found in the
guidance set out in Health Technical Manual, HTM2022. A local written procedure
should be available which details the ordering, receipt, handling, storage, issue and use
of medical gases.


33. DISPOSAL OF MEDICINES NO LONGER REQUIRED


     33.1.      Controlled Drugs


                33.1.1. In date Controlled Drugs


Controlled Drugs no longer required by a ward or department must only be removed by
a pharmacist. Upon removal of the Controlled Drugs, pharmacist will enter the
appropriate stock balance and sign the Controlled Drugs Register. The transaction
should be witnessed by a practitioner who will also sign the register. The drugs must
remain securely stored in the CD cupboard prior to their removal.


Any Controlled Drug removed from the ward or department by a pharmacist must be
returned to the pharmacy department where an appropriate entry will be made in the
pharmacy Controlled Drug Register.


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                33.1.2. Partly used or opened Controlled Drugs


       Any dose of a Controlled Drug that is prepared or opened but not administered,
including partly used syringes used in syringe driver pumps, or ampoules, must be
destroyed on the ward or department. This must be done by following the Trust Waste
Management Policy or using a „DOOP‟ or similar container to denature the controlled
drug prior to disposal as for waste medication. An empty syringe or ampoule can then
be disposed of in the sharps box. The destruction of the Controlled Drug must be in the
presence of a second practitioner or, if not available, an authorized employee. The
appropriate entry must be made in the Controlled Drug Register, which includes the
signatures of the two individuals involved in the destruction. For used transdermal
patches, these should be folded over onto themselves to that the drug layer is sealed
with the outer film skin. They may then be disposed of via a sharps-bin for medicinal
waste.


       Failure to dispose of excess drug before placing the syringe or ampoule into the
sharps box will render the sharps box „special waste‟ requiring disposal and additional
costs.


                33.1.3. Out of date Controlled Drugs


       Any dose of a Controlled Drug that is out of date must be destroyed where
appropriate. The destruction of the Controlled Drug must be in the presence of a
pharmacist and a registered nurse in line with local pharmacy procedures. The
appropriate entry must be made in the Controlled Drug Register, which includes the
signatures of the two individuals involved in the destruction. If the Transdermal patch is
a Controlled Drug e.g. fentanyl patch, this destruction needs recording in the Controlled
Drugs Register.


                33.1.4. Service user‟s own Controlled Drugs


        Controlled Drugs brought in to the hospital by a service user may be:


•    used by the ward staff for administration to the service user (see Service user‟s
Own Medicines section) in the absence of wards stock (for example out of hours,
weekends or bank holidays;
•       stored for subsequent destruction on the ward as in above.
In both of the above the controlled Drug must be stored in the Controlled Drug
cupboard, and entered in the Controlled Drug Register on a new page specifically
allocated for that service user‟s own medicine. NEVER add patients own Controlled
Drugs to Ward Stock balances.

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Service user‟s own Controlled Drugs can be returned to the service user on discharge if
appropriate. Service user‟s own controlled drugs must not be returned to a relative or
carer on the death of a service user.


The Accountable officer for the Trust may designate members of staff to lawfully witness
the destruction of CD‟s to facilitate their disposal. Currently designated staff include
registered Pharmacy Staff employed by AWP and contracted to provide services to
AWP.

                33.1.5. Other Medicines


All medicines that are no longer required by the ward or department must either:


•     be returned to the appropriate pharmacy either by a member of staff or in a
tamper evident secure container or
•      disposed of as per the waste policy into appropriate containers. In some parts of
the Trust special waste containers containing absorbent material will be available for
medication (often called “DOOP” bins).


34. SERVICE USER‟S OWN MEDICINES


All medicines brought into the hospital by service users remain their own property and
must not therefore be destroyed or otherwise disposed of without their agreement or, if
this is not possible, their relatives‟ agreement.


Medicines brought into hospital by service users must be reviewed by the admitting
doctor who may or may not wish to prescribe them.


Service users own medicines brought into the hospital may, with the service user‟s
permission, continue to be used provided that:


•     the admitting doctor wishes the medication to continue and has prescribed the
medication on Trust Drug Prescription and Administration Chart;


•       the ward has a procedure to routinely use „service users‟ own medicines;


•       the medication is examined by the Trust doctor, authorized pharmacy staff, or a
practitioner and is considered suitable for use.



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If „service user own medicines‟ are not routinely used they may still be used if:


•     alternative supplies are not available (e.g. because of night time, weekend, or
bank holiday admission);


•      ward stock or named service user supplies remain unavailable from the
supplying pharmacy.


In the case of a service user maintained on a medicine not approved by the Trust the
following options can be considered:


•     the service user‟s prescription can be modified to the nearest equivalent
approved medicines;


•      the service user can agree that their own medicines can be used including
supplies kept at home.


In no circumstances should Trust staff contact a service users general practitioner to
receive a further supply of a medicine. These items may be supplied on FP10 (NC) by
special arrangement with the local mental health pharmacy team. The FP10 (NC) must
be provided by the team wishing to prescribe it.


Dispensing a FP10 (NC) in a community pharmacy will incur a dispensing fee unless
the service user would have been exempt from prescription charges in the community,
e.g. over 60. If a fee is applicable this must be paid to the community pharmacy out of
the ward‟s petty cash. This prescription charge will eventually be credited back to the
Trust.


A Practitioner or Authorized Pharmacy Staff member must check any service user‟s
own medicines, including Controlled Drugs, before they can be used in the hospital.
The following criteria must be used:


•      there is confirmation that the medicines have been stored appropriately, e.g.
items that require refrigeration, such as insulin, have been stored in a refrigerator;


•      the overall appearance of the bottle, label and medicine is acceptable e.g. the
container must be intact and clean. The medicine must be without visible sign of
deterioration;


•     the medicine in the container is all of the same type. If the appearance of the
medicine is not uniform it must not be used;

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•     medicines such as glyceryl trinitrate and eye drops, which have a short shelf life
once opened, must not be used unless the date that the medicine container was
opened is clear and within the accepted expiry date;


•      liquid medication should not be used unless presented in an unopened, sealed
bottle as contamination may not be apparent;


•       items that require refrigeration should not normally be used unless previous
correct storage conditions can be confirmed by the service user or carer. Please note
that insulin retains potency for at least one month at normal room temperature within its
overall expiry date.


The medicine must be clearly labelled with:


•       the name of the service user;


•       name and strength of the medicine;


•       method and frequency of administration;


•       date dispensed (do not use if dispensed more than 6 months ago);


•       name and address of supplier.


If the medicine has no dispensing label, it must not be used unless it is clearly
identifiable in the manufacturer‟s original container and it is within its expiry date.


Controlled Drugs must be stored in the CD cupboard and recorded as detailed in the
procedure for making entries onto the Register. (Wherever possible, a separate register
should be maintained for service user‟s own drugs).


If the service user‟s own medicines are in a compliance aid they must not be used to
administer the medicines to the service user until assessed as being suitable by
pharmacy staff. The compliance aid must be stored on the ward/unit until a full
assessment is carried out by a member of the pharmacy team. Service users admitted
on compliance aids must be drawn to the attention of the pharmacy team.




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When the brand name is the only name appearing on the label and generic name
appears on the prescription the pharmacist must annotate the DPAR prescription sheet
with brand name used on the label.


If the use of service user‟s own medicines is the agreed policy of the ward the
medicines should be stored in an individual section of the medicine trolley or if fully self-
medicating in the service users locked medicine cabinet on the ward.


If service user‟s own medicines are received but not used, they must be kept in a sealed
bag in a separate section of the medicines cupboard, or in a separate locked cupboard.
Such medicines must not be stored in the medicines trolley.


Where medicines are labelled for an individual‟s use it is the responsibility of the
Practitioner to ensure that if a service user is moved to a new location all of their
medicines move with them.


The service user‟s own medicine if not required can be disposed of in one of two ways:


•     if a medicine is no longer required, then with the service user‟s or their relatives‟
consent, the medicines must be sent to the pharmacy;


•     if the service user insists, the medicines may be returned home. The service
user and/agent shall be advised if the medicines are not safe for use.


The practitioner may still make a best interest decision not to return them if they feel it
would be dangerous to do so. This decision must be recorded in the service user‟s
notes.




35. PHARMACEUTICAL INDUSTRY REPRESENTATIVES


       This section should be read in conjunction with the relevant Trust policies on
relationships with external organisations, business conduct and standing financial
instructions.


       Representatives of the Pharmaceutical Industry must not be allowed to visit
service user areas unless agreement has been given by the relevant manager.




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      Casual visits to wards, clinics or other service user units are unacceptable and
appointments should be made with the relevant manager, head of department or
consultant.


      Visits should be limited to the delivery of significant product information.
Information relating to price, pack-size, or similar, does not normally warrant a visit and
should be dealt with by post.


     Details of new product launches must be discussed with the Trust‟s Chief
Pharmacist before discussion takes place with other clinical staff.


      The introduction of new drugs must only take place in line with the Trust‟s New
Drug Policy.


      Medicine samples must not be accepted. Representatives wishing to supply
them should be referred to the Chief Pharmacist.


        Only the Chief Pharmacist may give a Trust commitment to purchase a medicinal
product. No other member of staff is authorized to give such commitments, or to give
any indication of the potential budget for any further purchase, and /or competitors
prices.




36. MANAGING MEDICATION INCIDENTS


Staff should report medication errors and near misses in accordance with the Incident
Management Policy and complete the investigation template attached as Appendix D to
this policy.


     36.1.      Definition


        A medication error or near miss is a preventable incident associated with the use
of medicines, which has or may have put a service user at risk. Such incidents may be
related to any of the steps of the medicine use process. This includes prescribing,
dispensing and administration of the medicines and the transfer of information and may
result in the service user receiving an incorrect dose of their prescribed medicines, a
dose of their medicine being incorrectly omitted or delayed, or their receiving medication
which they have not been prescribed.




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     36.2.      Management


Successful management of a medication error will include the following:


•       A review of the well-being of the service user and the minimization of further risk.
(This is of primary importance).


•      Reassurance for the service user, and where appropriate, their relatives or
carers.


•     A full review of the incident and a full record, (using the Trust incident reporting
procedure), of the identified cause, the outcome and the measures to be taken to
prevent reoccurrence.


•       Where appropriate, counselling for staff involved.


•       Where deemed necessary, further assessment and re-training of staff involved.


and should lead to the effective management of any formal complaints or litigation.




     36.3.      Clinical Management


       Where medication is incorrectly omitted, administered in error or significantly
delayed, the registered nurse must be informed. He/she should then obtain advice from
the service user‟s doctor or from the unit pharmacist regarding further action to be
taken. Any action taken must be recorded in the service user‟s notes.


     36.4.      Informing the Service user/Carer


       Under normal circumstances the service user should be immediately informed
that an error has been made, either by their doctor, their key nurse/worker, or by
another member of healthcare staff directly involved with their care. Whilst there is no
obligation to inform relatives or carers of the incident, consideration should be given to
doing so.


        Where the service user is suffering from a condition which impairs their cognitive
or intellectual function, the decision to inform them, and /or their relatives or carers, will
rest with their doctor.

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        If the service users, relative or carer is subsequently unhappy with the outcome
of the incident or the action taken in response, a senior manager should be called to
see the service user, or their relative or carer, without delay and endeavour to resolve
the situation. If resolution is not immediately achieved, it may be helpful to direct the
service user or their relatives to the Trust‟s PALS and complaints service, who will be
able to assist them in progressing their concerns. .


     36.5.      Reporting/Recording the Incident


       The Trust operates a reporting policy and actively encourages staff to openly
report incidents without fear of retribution. The purpose of reporting and recording a
drug error is to ensure that processes are reviewed in order to prevent or minimize any
change of reoccurrence.


       Whenever possible, review should be followed by the implementation of remedial
action and subsequent further review/audit.


       Any drug error incident or near miss which gives cause for concern should be
reported, and may be reported by any member of staff. Such incidents and near misses
should be reported using the Trust incident reporting procedure.


       The Trust incident reporting procedure must be undertaken as soon as possible
following the incident and the form completed fully and in as much detail as needed to
properly describe the incident. The form should be completed in liaison with the
registered nurse or the unit/line manager as appropriate.


       The completed, signed incident report form is sent to the Risk Manager who in
the case of incidents relating to medicines will copy the form to the Chief Pharmacist.
The Chief Pharmacist will decide if any further action needs to be taken.


      Where an incident occurs which identifies a significant flaw or failure in current
procedures, the Chief Pharmacist will liaise with the appropriate professional lead.


     36.6.      Anonymous Reporting


        If despite the Trust‟s reporting policy a member of staff observes an incident
which they feel should be reported, but feels unable to report it to their manager, or
otherwise in accordance with Trust policy, they may report the incident by telephone, or
in writing, direct to the Executive Director of Nursing, the Chief Pharmacist or the
Executive Medical Director. Anonymity and confidentiality will be maintained and the
incident will receive investigation and review in the normal manner. Alternatively they

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may report it directly to the National Patient Safety Agency via their website
(www.npsa.nhs.uk)




     36.7.      POST INCIDENT MANAGEMENT


REVIEW OF MEDICATION ERRORS


Clinical incident reports, including medication errors, will be regularly reviewed to
establish trends and to propose actions needed to prevent such errors. Action may
involve system redesign and improvement and/or education, training and competency
assessment of employees on any aspect of medicine related incidents:


To minimize the risks associated with the use of medicines it is essential that lessons
are learnt when errors are made. For this to occur a reporting system is needed that
encourages staff to record and report significant medication errors or near misses. To
help achieve this, staff must feel confident that reporting an error will not automatically
lead to someone being disciplined.


However, there will be a small number of occasions when instigating an appropriate
investigation which may lead to a formal sanction being considered appropriate and
necessary.


An investigation under the Trust‟s Disciplinary procedures will always be considered in
the following circumstances:


•       An attempt has been made to 'cover up' a medication error or 'near miss';
•       The behaviour of the practitioner(s) is deemed to be reckless.




37. REPORTING DEFECTIVE MEDICINES


       During the manufacture, storage or distribution of a medicinal product, an error or
incident may occur which alters the specification of that product and which may result in
its reduced performance or efficacy. Where the reduced quality of a pharmaceutical
product is identified it is important that the product be immediately withdrawn from use.



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        Inform the appropriate pharmacy who will advise on all reporting, recording and
investigating on the defect. Out of pharmacy opening hours, if a serious problem has
been identified which is considered to present an immediate hazard to service users,
staff or the public, the on-call pharmacist must be contacted.


      Retain any remaining product and/or the device and any associated products or
equipment (e.g. administration sets, infusion devices etc). Put these into secure
quarantine until collected by pharmacy or a nominated responsible person.


      Record the details of the device and product (including batch number if
appropriate).


        If the defective product has been administered to a service user or the faulty
device has administered too much or too little medication, inform the doctor responsible
for the service user and record the details in the service user‟s notes.




38. ILLICIT SUBSTANCES


       AWP Trust is an illicit substance-free zone. This includes all substances, drugs
and medicines of any category, other than those specifically prescribed or approved for
the service user.


      A separate policy and procedure exists for dealing with the discovery of
suspected illicit substances.


        The procedure for disposing of any substance thought to be of an illicit nature is
as follows:


•       the substance must be sealed in an envelope;


•     on the envelope there must be a description of the substance, together with
where and when it was found; a registered nurse and a second practitioner must sign
the package across the seal;


•      an entry must be made at the back of the Controlled Drug Register or a specific
record notebook describing the substance, together with where and when it was found;
a registered nurse and a second practitioner must sign the entry;




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•      if the quantity of the substance has been deemed to be sufficient to indicate
dealing or is a Class A drug the local police must be notified;


•     where feasible it is good practice to engage with the local pharmacy department
who can be asked to witness destruction on the ward;


•      the substance must be stored in the Controlled Drug Cupboard until collected by
the police or destroyed in the presence of a pharmacist;


•      in the absence of a Controlled Drug Cupboard and Register, the substance must
be stored in the unit‟s locked drug cupboard and a similar entry made in the unit diary.


        Staff must NOT:


•       send the substance to the pharmacy;


•       return the substance to the service user or relative;


•       attempt to analyse the substance.


       A staff member has „legal possession‟ of the confiscated “unknown” substance
and is authorised to destroy/dispose of the substance providing it takes place within 24
hours (where practicable), and is done in the presence of another member of staff
noting date, quantity (when possible), description, type of substance (when possible),
and destruction method. Where possible one of the two members of staff should be a
pharmacist.


        The sealed envelope must not be opened until both are present.


      The contents must be disposed in a DOOP bin or similar after „wetting‟ any light
material with washing up liquid. Consult your pharmacist for advice.


       A record of the destruction must be made in the Controlled Drug Register or unit
diary/notebook (if no Controlled Drug Register) against the original entry and
countersigned and dated by both persons.


39. COMPLIANCE AIDS (E.G. MEDIDOS BOXES AND MONITORED DOSING
    SYSTEM (MDS))



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       Non-compliance with medicines is a major cause of relapse and admission to
hospital. There are many factors that can lead to non-compliance with medicines.
These include:


•       a poor understanding of the need for medicines;


•       a poor understanding of how to take the medicines;


•       forgetfulness;


•       inability to open the containers;


•       visual impairment;


•       a complicated regime of medicines.


      For some people a compliance aid may assist a person to continue self-
medication and remain out of hospital.


Before there is any agreement to provide medicines in a compliance aid, a full
assessment of the reason for non-compliance must take place. It may be that the
provision of a compliance aid may not be of benefit and other strategies may prove
successfully such as reminder charts, large print labels or non-childproof tops. If an aid
to compliance is considered necessary, careful attention should be given to the
assessment of the service user‟s suitability and understanding of how to use an
appropriate aid safely. Ideally a locally recognised assessment tool should be used.
This assessment should normally be carried out by the multi-disciplinary team in liaison
with pharmacy staff.


      Compliance aids vary but most require weekly replenishment. Before
compliance aids are issued and the service user trained to use them arrangements
must be made for their regular replenishment.


        The act of filling a compliance aid involves re-dispensing and re-labelling. Where
it is not carried out by authorized pharmacy staff this will only be carried out by a
registered nurse following an agreed procedure authorized by the Chief Pharmacist .
This procedure must include a check by another practitioner or an authorized employee
who has been assessed as competent to undertake this role.


        Alternatively, practitioners may:


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•       assist service users to fill their own compliance aids;


•       train service users to fill and use a compliance aid as part of a training scheme.


All service users will need to be regularly assessed for continued appropriateness of the
aid. Ideally, any compliance aid, such as a monitored dose container or a daily/weekly
dosing aid, should be dispensed, labelled and sealed by a pharmacist. The sealed
compliance aids are generally referred to as monitored dosage systems. All compliance
aids supplied by the AWP NHS Trust or filled by Trust staff must allow the identification
of contents and be fully labelled.


40. CONTROL OF FP10 (NC) PRESCRIPTION


     40.1.      Prescription Types


        FP10 (NC) prescriptions are used by clinical teams.


       Substance Misuse Services can use PH10MDAss or FP10MDAss prescriptions
for repeat prescribing of methadone, buprenorphine and diazepam and FP10(NC) or
FP10ss for all other prescribing.


     40.2.      Ordering of FP10 Prescriptions


     Community teams will be responsible for ordering sufficient quantities of all
FP10(NC). These will be ordered by the following method


       FP10 (NC) prescriptions will be ordered from the appropriate finance department
using agreed systems for controlled stationery.


     40.3.      Redistribution of FP10(NC) prescriptions


       All FP10(NC) prescription pads, whatever the order point, are delivered to the
finance department from the printers. Until redistributed to the appropriate team the
pads will be stored in a locked filing cabinet.


        The delivery will be checked against the original order(s) and the delivery note.



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       An email will be sent to the nominated person at each pharmacy forewarning of
the imminent delivery and the delivery method. On receipt of the delivery the nominated
person (or their deputy) must acknowledge receipt to the nominated person at the
finance department. If no acknowledgement is received within the anticipated time
scale then the nominated person at finance will chase up the delivery.


       Where possible arrangement will be made for the pads to be collected or
delivered by a member of the appropriate team, the Chief Pharmacist or senior officer.


        In all cases the person collecting the prescriptions must have with them proof of
identity in the form of Trust security badge or be known personally to the staff involved
in issuing the prescriptions.


      If this is not possible then internal post or if necessary, external post delivery will
be used.


     40.4.      Ordering of FP10 Prescriptions by Authorised Persons


       Only authorised individuals who have a completed the controlled stationery
documentation, signed by the consultant, will be eligible to order prescription pads in
their own name.



      All issues to any person must be recorded. The record must have the following
data as a minimum:


•       the unique numbers of the prescriptions released;


•       the team code on the prescriptions;


•       the date released;


•       the name of the prescriber to whom the pad is being allocated;


•       the signature and printed name of the person collecting the prescriptions;


•       the signature of the person issuing the prescriptions.




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        This record should be kept for a minimum of five years.


       Any member of staff who is engaged in the distribution of FP10 prescriptions at
any level in the organisation must follow the above procedure such that there is a
documented auditable trail of accountability to and from the prescriber.




     40.5.      SECURITY OF FP10 PADS IN COMMUNITY TEAMS


                40.5.1. Loss of pads


       It is the responsibility of each individual issued with a pad to keep it secure at all
times. Loss of a pad will lead to significant inconvenience to the team, possible misuse
and additional costs to the Trust.


      In the event of a pad being stolen or, misplaced and not found within a
reasonable time, the following steps must be taken:


        Contact the local police station and provide the following details:


•       the number of prescriptions missing;


•       the serial number of the prescriptions missing;


•     the team name, address and the Trust identification number (unless substance
misuse, this starts with RVN) as printed on the prescription;


•       if there is some uncertainty about the serial numbers involved or the Trust
identification number, contact the distribution point supplying the pads at the earliest
opportunity;


•        full details of the circumstance i.e. location, time last seen, evidence of a break
in, etc;


•       obtain a crime or incident number;


•       complete a Trust incident form


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•      at the earliest opportunity contact the Chief Pharmacist, or in his absence, the
local mental health pharmacist to agree a change in ink colour for any prescriptions
written by the team and the period the change will cover (usually at least a month);


•      the Chief Pharmacist, or in his absence, the local mental health pharmacist, will
contact the Shared Service Agency to activate the stolen FP10 protocol with local
community pharmacies and they will also inform the NHS Counter Fraud Services, who
then inform the Prescription Pricing Authority;


•      at the earliest opportunity inform the locality manager and complete a Trust
Incident Form.


       It is essential that pads are not left on view, pre-signed or stored unlocked in
public building when not in the possession of the prescriber.


     40.6.      Return of FP10 Prescriptions on termination of employment


       On termination of employment or a change of team all prescribers have a
responsibility to return any unused prescriptions to their local supply point. This
department must record, against the original issue record, the number of individual
prescriptions returned along with their unique number and the date they were returned.


       In the unlikely event that a prescriber only discovers they have some
prescriptions in their possession after leaving the area they must phone the appropriate
department to notify them of the prescriptions they have and then destroy them. The
department must make a record of the phone call and record, the number of individual
prescriptions that will be destroyed along with their unique number and the date the
department was notified.


     40.7.      Use of FP10 Prescriptions


       Normal out-patient prescription forms are coded FP10(NC), and are coloured
green so that they can be easily identified by dispensing pharmacists and by the NHS
Prescription Pricing Authority. Those used by the Community Drugs Teams for
instalment prescribing are coded FP10MDAss or FP10MDA, and are coloured blue.


        Prescriptions must be written legibly in ink, or otherwise so as to be indelible,
should state the full name and address of the service user, the name of the prescriber
(in block letters), and be signed and dated.




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       It is strongly recommended that the service user‟s age and date of birth be
recorded on the prescription form. For service users under 12 years it is a legal
requirement that their age be stated.


       The name of the drugs and preparations prescribed should be written clearly,
using generic names whenever possible, and should not be abbreviated


        Drug strengths and dosages should be written clearly and unambiguously.


     Great care must be taken if abbreviations of measurements are used and any
unnecessary use of decimal point should be avoided, e.g. 3mg not 3.0mg


      Doses under 1mg should be written in micrograms, which should not be
abbreviated.


      If doses of less than 1 unit are prescribed, decimal points should be protected by
a preceding zero, e.g. 0.5units not .5units


       When writing prescriptions for Controlled Drugs, the total quantity of the
preparation, or the total number of dose units, must be written in both words and
figures.


      The cost of the medication, together with the dispensing pharmacist‟s fees are
re-charged to the Trust


       Prescribers may not write prescriptions for themselves or for members of their
family. If this should occur, the Trust reserves the right to recover these costs, plus an
administration fee, from the prescriber. And ultimately may consider criminal
proceedings if fraudulent use is suspected.




41. ADVERSE DRUG REACTIONS


       Any medicine has the potential to cause unwanted or unexpected adverse
reactions. It is very important that such reactions are identified, reported and recorded.


       The incident must first be reported to the member of healthcare staff in charge of
the unit.




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      Depending on the severity of the reaction and the health of the service user,
consideration must then be given to informing the service user's doctor.


       A record of the incident must be made in the service user's notes and
consideration given to making a report to the Committee on Safety of Medicines (CSM)
using the "yellow card" scheme.


       Report all adverse reactions for BLACK TRIANGLE medicines and only serious
adverse reactions for other medicines. A report to the CSM may be made by the
doctor, the nurse, or the pharmacist.


       Reports can be made electronically via www.yellowcard.gov.uk or on the yellow
cards found at the back of BNFs.


       Where the reaction is fatal, life-threatening, disabling or incapacitating, it must
also be reported as a "clinical incident" following the Trust's incident reporting
procedure.




42. DRUG ALERTS AND RECALLS


      The Medicines and Healthcare Products Regulatory Agency (MHRA) are
responsible for notifying trusts of defective medicines.


       The supplying pharmacy has a responsibility to notify wards and units of any
defective medicines they may have been supplied with via the pharmacy.


     If a ward or unit receives notification of a defective medicine, it must be
immediately brought to the attention of the practitioner currently responsible for the unit.


       The practitioner must follow the instructions received regarding the identification
and withdrawal of the defective product and the local pharmacy informed if medicines
are withdrawn at the earliest opportunity.


       The withdrawn medicines must be quarantined in a locked medicines cupboard,
sealed in an envelope clearly warning staff that the contents are quarantined and are
awaiting collection by the pharmacy team.




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       In the event that all the stocks of a particular medicine are being quarantined a
discussion needs to take place with the pharmacy team or on call pharmacist to ensure
alternative arrangements are made to ensure service users do not miss doses.




43. COVERT MEDICATION GUIDELINES


Covert medication relates to the administration of medicines to service users who are
unable to give informed consent to treatment and who subsequently refuse to take oral
medication when openly offered to them, and for whom medicines are then
administered in a flavoured drink, jam, or other foodstuffs.


Administering medication in a covert way is deception. Staff must not administer
medication in this way to any service user without following the Trust's guidance.


If a service user has capacity to consent to treatment, then under no circumstances can
medication be administered covertly.


If a service user does not have capacity to consent to treatment, then staff must refer to
the Mental Health Act and current Case Law to consider whether the service user
should be detained.


In exceptional circumstances, it may be appropriate to administer medication covertly to
a service user who lacks capacity to consent to treatment. The medication must be
considered essential for the service user‟s health and well-being, or for the safety of
others. Covert administration must be initialled and the initials CO (ringed) appended to
the administration record.


If the service user‟s Consultant Psychiatrist and the clinical team consider that
medication can be administered covertly, then the following procedure must be
followed:


•      the decision to administer a medication covertly should not be considered
routine, and should be a short-term measure only;


•      any decision to do so must be reached after assessing the care needs of the
individual service user or client;


•      there must be an open discussion among the multi-professional clinical team and
the supporters of the service user or client, and include carers, relatives, advocates, the
multi-disciplinary team and the pharmacist;

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•       family involvement in the care process should be positively encouraged;


•    the method of administration of the medicines must be agreed with the
pharmacist;


•     the decision and the action taken, including the names of all parties concerned,
must be recorded in the care plan or health and social care record;


•       the care co-ordinator will keep the relatives informed of the reviews and record
this in the health and social care record;


•      the decision to continue administering medicines covertly is informally reviewed
by the administering nurse and on a weekly basis by the MDT by updating the care
plan.


•       The principles of the Mental Capacity Act should be adhered to.


Regular attempts should be made to encourage the service user to take their
medication. This might best be achieved by giving regular information, explanation, and
encouragement. This must be recorded in the Health & SC record.


It should be noted that AWP staff cannot recommend covert medication as a means of
administering medication to Care Homes, relatives, etc.




44. THE USE OF MEDICINES FOR UNLICENSED TREATMENT INDICATIONS


The term “unlicensed medicines” is normally applied to those medicines which do not
have Marketing Authorisation (MA) formerly Product Licence (PL) issued by the
Medicines & Healthcare Products Regulatory Agency (MHRA).


It is applicable also to licensed medicines when they are used for unlicensed
applications.


Marketing authorisations often have limited applicability to some groups of service users
such as young adults or older adults.


Prescribers may legally:

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•       prescribe unlicensed medicines;


•     use in a particular (“named”) service user unlicensed products specially
prepared, specially imported or specially supplied;


•       use unlicensed drugs in clinical trials;


•      use, or advise the use of licensed medicines for indications or in doses or by
routes of administration outside the recommendations given in the licence;


•       override the warnings and precautions given in the licence.


The majority of medicines have a marketing authorisation granted by the MHRA.
Should any problems arise because of defects associated with the quality of the
medicine, or its use in an approved clinical situation, the Trust can transfer liability to the
manufacturer.


The responsibility for prescribing any medicines falls on the prescriber. Prescribers
have a duty in common law to take reasonable care. If a prescriber uses an unlicensed
medicine it would be deemed negligent if not used in accordance with practice accepted
at that time by a reasonable body of medical opinion.


In using an unlicensed drug or a drug in a way incompatible with the product
specification, the prescriber must act responsibly and with reasonable care and skill.
When prescribing outside a license it is important that the prescriber does so knowingly,
recognises the responsibility that such prescribing entails and when obtaining consent
to treatment should, where possible tell the service user of the drug‟s license status and
document all the above in the health record.


The Product Liability Directive and the Consumer Protection Act 1987 makes the
producer or supplier liable for damage caused by a defect in the product. Accordingly,
the product can be considered defective on the basis of what the reasonable service
user is entitled to expect. This may be affected by the verbal and written information
and warnings given to the service user.


Recognising that the use of an unlicensed medicine is sometimes necessary in order to
provide the optimum treatment prescribers will:


•       wherever possible prescribe licensed products;



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•       when prescribing products without ANY marketing authorisation the process in
“Managing the Introduction of New Drugs” as approved by the Effectiveness Forum will
be followed;


•      if an unlicensed medicine is used, or one is used outside of its licensed
indications, such use will command the support of a reputable body of practitioners;


•     service users should be informed of the license status of the medicine wherever
possible.


Pharmacy staff providing unlicensed medicines will endeavour to alert, inform, and
advise, but it is the responsibility of each prescriber to be aware of the status of the
medicines they prescribe.


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. The following constitute good practice:


•        check that medicines with a product license either have had a proper therapeutic
trial or have been excluded for sound reasons;


•      prescribers must provide information to service users (and carers where
applicable) on medication and document the fact in case notes;


•       initiate a trial of the medication and monitor the service user closely;


•     case notes must be used to inform present or future colleagues of the rationale
and outcome;


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


The Royal College of Psychiatry and other professional bodies may have further
guidance available.




45. COMMUNITY BASED PRACTITIONERS



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The manager of any team is ultimately accountable for the stock of all medicines held,
ensuring that Trust Medicine procedures are followed correctly and that the security of
medicines is maintained.


All stored medicines must be kept in a separate locked medicine cupboard. Medicines
may be kept for service users which have been prescribed for them by their GP and
dispensed by a pharmacist


It is the responsibility of the manager of a community clinic, (e.g. a depot medication
clinic), to ensure that delivery notes of medicines received from the supplying pharmacy
are retained for 1 month. A full stock inspection should be carried out each month to
ensure that stock is correctly rotated according to shelf-life and that stock levels are
appropriate and concur with those recorded.


All stock of controlled drugs are booked in and out of stock as controlled drugs as per
policy (qv). Where appropriate additional medicines may be recorded in this way.


Community Practitioners must be authorized to possess medicines by their manager. A
valid staff identification badge must be carried at all times.


All other medicines carried by the Community Practitioner must be prescribed as a
specified dose for a named service user by a prescriber.


The Community Practitioner must keep any medicine:


•       secure when visiting a service user;


•     secure and out of sight, e.g. within the locked boot of a care, when traveling
between visits.


Whenever practicable, unused medicines should be returned to the medicine cupboard
at the team base for overnight and weekend storage. Where this is not possible, they
may be securely stored but not for longer than 72 hours.


•       Medicines must not be left in practitioners‟ cars overnight


Any service user‟s own medicines no longer required are returned to any community
pharmacy or dispensing doctor it or disposed of as per Trust Waste Management
procedures.



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Community teams holding service user‟s own drugs on behalf of clients with poor
compliance must have a local procedure to ensure medicines are booked into and out
of the staff base. Medicines should be stored in the medicine cupboard at the team
base. Where this is not possible, they may be securely stored at the practitioner‟s home
but not for longer than 72 hours. Practitioners must avoid leaving medicines in
unattended vehicles.


Although they should not routinely be involved in the disposal of service user‟s
medicines, it is acceptable for practitioners to transport them to a supplying pharmacy or
dispensing doctor for the purpose of disposal.


46. HANDLING MEDICATION IN COMMUNITY TEAMS


When handling medication, it is always necessary to know whether you, or those you
are delegating to, are:


•       Administering
•       prescribing
•       dispensing
•       delivering medication
•       using a concordance aid
•       working with a service user who is self-medicating


The importance of knowing this is that the combination of the above circumstances
necessitates different actions and responsibilities.


     46.1.       Prescription of medicines


All prescriptions must be written on the relevant medicines card, for a named service
user, by a registered prescriber. Within Community teams the prescription of medicines
by FP10 is an acceptable alternative.


The service users GP must be informed of any changes to medication instituted by the
community team.


Prescriptions within the community should be reviewed every six months as part of
routine treatment review processes (e.g., Integrated Care Programme Approach
meetings). Once the prescription is due for this must be brought to the attention of the
registered prescriber, who should (at least once a year) undertake an examination of
the service user prior to re-writing the prescription.

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Under no circumstances should any other member of staff re-write the prescription and
ask the registered prescriber to sign it.


     46.2.      Administration


A clinical team may decide that a service user is unable to self-medicate medicine
independently, without the assistance of a registered practitioner. If direct
administration is considered appropriate, then the discussion and plan for this must be
recorded in the clinical notes and the following steps taken.
•      Administration of medication can only be done by a registered nurse (RN) or
doctor.
•     They must adhere to the Trust policy and procedure for the management and
administration of medicines.
•     A valid prescription or administration record must be taken along with the
medicine to the service user's home.
•      The AWP Community Medication Prescription and Recording Card can be used
to record administration of medication by the team.
•      When administration is very regular, an in-patient medication chart will be easier
to use.


The registered practitioner is accountable for this practice


Home Intervention services are an alternative to hospital admission; this means that an
RN or doctor must be available at all times that medication is due, for every service user
who cannot safely self administer, as this cannot be delegated to a member of the team
who is not an RN or doctor.
.


     46.3.      Supervising a service user who is self-medicating in the community


This guidance relates to the service user who is administering his or her own medicine
under the supervision of an employee, or individual working on behalf of, AWP.


•     The role of the practitioner is to encourage and support the service user in the
self-medication of his or her own medication.


•     Any member of the team, who is deemed competent by the team manager, can
supervise this practice.


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•      The medicine can be kept in the service user's home, unless there are concerns
over the risks this may pose to the individual, e.g. significant risk of overdose.


•       At each visit, the practitioner should ensure that they have the correct medication
for that service user before returning it to them.


•      If the service user is unable to self-medicate, then a registered practitioner must
be involved in the administration of the medicine, e.g. measuring liquid medicine.


A record of administration must be made on the appropriate document. The DPAR can
be used as a medicines administration record if a service user requires frequent
medicines administration. The prescribed medicines are either prescribed directly on to
this chart or are transcribed by a registered practitioner who completes all the details
and completes the signature box with “Prescribed by Dr <name> for <number> days.
Transcribed by <name>


     46.4.      Dispensing


Dispensing is the preparation of an appropriate medicine for administration by another
person (such as the service user or a nurse). The act of dispensing includes the supply,
checking the validity of the prescription and assembly of the product.


“Dispensing includes such activities as checking the validity of the prescription, the
appropriateness of the medicine for an individual service user, assembly of the product,
labelling in accordance with legal requirements and providing information leaflets for the
service user” (NMC 2008). Any local procedure for dispensing must be approved by the
Chief Pharmacist. Medicines once dispensed, are the property of the service user.


Dispensing medication, when NOT undertaken by a pharmacist, is an exceptional event
and must only be undertaken when there is sufficient reason to do so.


     46.5.      Delivery of Medication


Delivery of medication is the safe delivery of medication that has been appropriately
dispensed for a service user for their self-medication. It is carried out by any AWP
employee with the necessary competence. The person delivering will be aware of their
responsibility to judge whether it is either safe to hand over the medication; or if there is
a need to withhold the medication and consult with the RN or doctor who has asked
them to deliver, for example, if the service user presents as unexpectedly drowsy. The
AWP Community Medication Prescription and Recording Card can be used to record
the delivery of medication by the team.

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There may be some circumstances where an urgent prescription needs to be obtained
via the GP. Any member of the team (regardless of discipline or registration) is able to
collect this prescription, arrange for its dispensing and deliver it to the service user's
home. This is merely viewed as delivery and not as part of medicine administration.
Individual team members should be deemed competent by their manager to undertake
this task.
The delivery of medication must be undertaken safely. To avoid mistaken delivery,
medication for a service user can be sealed within a named and addressed opaque
envelope or “Jiffy” type pack before delivery to facilitate both service user and staff
safety.
If the service user is unavailable to receive this delivery then the medicine should be
returned to the team base and stored as indicated above.
It is good practice to deliver medication directly to the service user unless agreed
otherwise in advance.
It is not good practice to post medicines through the letter box except in exceptional
circumstances where risks have been assessed and judged to be acceptable by the
MDT. Individuals must not make decisions concerning delivery. Delivery in this way
must not be undertaken more than once without verification that the service user has
taken delivery and is taking medication. Consideration must be given to factors such as:


•       Are there animals or children known to be at the address.


•      Is the property known to the individual delivering the medication – to avoid
delivery to the wrong address or to shared letterboxes.


•    Where possible it has been agreed with the service user and this has been
documented in the case notes.


•       What is the risk to the service user of non-delivery of the medication.


     46.6.      Concordance Aids


Concordance aids are containers with times of the day and days of the week on them
with a separate compartment for the tablets to be taken at a particular time. They are
used to help service users self administer by a visual indication of what tablets have and
have not been taken, and the ease of taking all tablets that are due from one clearly
marked compartment. Concordance aids must detail their contents i.e. name of drug,
form, dose, and administration times. The filling of concordance aids will ideally be
performed by a pharmacist. It is possible for RN‟s to supervise a service user re-filling a
previously dispensed aid.



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     46.7.      Self Administration


Self-medication is simply a service user taking their own medication as prescribed,
without the need for it to be administered by an RN or doctor. Staff may still be helpful
to the service user by helping them monitor their self-medication as well as other
aspects of medication management. Self-medication of medicines follows the
dispensing of the medication by AWP staff or community pharmacist etc. Where a
practitioner has reason to question a person‟s competence to self administer, then this
should be brought to the RN or doctor‟s attention immediately.


     46.8.      Storage of medicines in Community teams


The general storage requirements apply equally to community teams as well as ward
based medicines management. Storage is in a locked cupboard situated in an area
restricted to staff.


The keys are kept securely stored in an area where there is no public access and only
issued to staff on duty. Consideration should be made to restricting access to a limited
number of staff or to storage in a coded safe.


Medication placed in the cupboard should remain in the original container. A book for
recording details of medication stored in the cupboard should be kept nearby.


For medicines going into and out of the storage cupboard, an RN or doctor may enter
medication details independently. Alternatively, two staff members who are not RN‟s or
doctors but have been assessed as competent should record the details of medication.
Some teams may be dealing with stock medication, pre-packed medication and
medication dispensed for named individuals. Each team‟s system for accounting for
these should be agreed with the Chief Pharmacist.


All entries should be dated and signed by the staff members involved.


Whenever practical, medication that is unused by team members should be returned to
the medicine cupboard at the team base for overnight and weekend storage. Where
this is not possible, medication may be stored in a securely and safely (not left in the
car) for no longer than 72 hours


Only an RN or doctor should remove medication for administration, dispensing or
delivering. The exception to this is medication that an RN or doctor has placed in a
designated part of the drug cupboard/lockable clinic area, for delivering by any
competent member of staff within the following 72 hours, to a service user for self-
medication.


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There is no legal barrier to the storage of medicines, (which have been prescribed either
by a GP or the team's registered prescriber) being delivered and/or administered daily
by team members. This practice may be deemed appropriate in relation to service user
safety or concordance and should form part of the agreed and negotiated care plan for
the individual, and must take place with their full consent.


Service users should be encouraged to store medicines in their own home in
accordance with the instruction of their Pharmacist provided this is assessed as safe
enough to do.


Medicines should be kept in the containers in which they were originally dispensed.
Cutting blister packs of medicines must be avoided as this hinders correct identification
of the medicine.


If there is an immediate and unacceptable risk of serious accidental or deliberate self-
harm by a service user involving their medication, then a member of the Team may
remove the service user‟s medication and transport it to an appropriate place for safe
storage, usually the medicine cupboard at the Team base. Such action would form part
of the service user‟s contingency and crisis plan, be documented and where possible,
be with the agreement of the service user. The medication remains the service user‟s
property, and the return of the medication to the service user should be done in a safe
manner agreed with them. If the removal of medication is thought to be necessary, then
a review of their care plan should be made by the team.




     46.9.      Disposal of medicines and administration equipment


Medicines, which have been obtained by or prescribed for the service user, either
through „over the counter‟ purchase or prescription, are the property of the service user.
Medicines no longer in use or out of date should be disposed of and the practitioner
should encourage and support the service user to do this themselves via their local
community pharmacy.


There may be occasions when for safety of the service user, it would be more
appropriate for the practitioner to remove medicine from the service user's home. This
should be done with their permission, although the practitioner still has a duty of care to
that individual, which may necessitate the immediate removal of medication, which (if
left) places the individual at significant risk.


Disposal of medicines will be in accordance with Trust waste policies. The use of
'sharps boxes' (rigid, puncture-resistant, leak proof containers), must be used.


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Whilst in the service user's home, administration equipment should not be left
unattended.


     46.10. Pre-packed medication for CRHT


Under normal circumstances, all medication should be dispensed by pharmacy either by
the hospital pharmacy with approved prescribing stationery or by a community
pharmacy via an FP10 prescription. When medication is required urgently and
pharmacy is not able to dispense in a timely manner, a small supply of pre-packed
medication will be available.


In each locality, there will be access to medication via an emergency store. This will
consist of a number of packs, depending on team size, of:


        Olanzapine velotabs 5mg x 2
        Olanzapine velotabs 10mgx 2
        Risperidone quicklets 1mg x 2
        Procyclidine 5mg x 4
        Zopiclone 7.5mg x 1
        Lorazepam 1mg x 4
        Diazepam 5mg x 2
        Diazepam 2mg x 2


These are labelled with the name of the drug. There is a space on the label for the
instructions of how the medication is to be taken, the service users name and the date.
These can be dispensed against an approved prescription, signed by a doctor or
recognised prescriber or in certain circumstances against a patient group directive.


47. SELF-MEDICATION OF MEDICINES BY SERVICE USERS ON WARDS


If the service user has fulfilled the necessary criteria and is deemed suitable to
undertake the process of self-medication, a written consent should be obtained from the
service user.


A registered nurse will give a full explanation to the service user of the procedure
relating to the self-medication of their medicines.




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A general information sheet will be given to the service user relating to their individual
medication. Any problems or concerns will be highlighted before participating in the
self-medication of medicines.


A full assessment of the service user's ability to self-medicate (to include physical and
psychological factors) will be undertaken prior to commencing self-medication of
medicines.


A full explanation of the service user's responsibility to keep their medicines safely
within the ward, and allow access only by authorised members of the ward team, must
be explained to the service user before commencing self-medication.


If a medication changes after dispensing, any unwanted medication must be removed
by a registered nurse or pharmacist and returned to the pharmacy department. If any
aids have been used to aid medication concordance, then these too must be returned to
pharmacy for adjustment, if necessary.


As required medications will be administered separately by a registered nurse.


Controlled drugs must not be used for self-medication and always be dispensed
adhering to trust policy.


Medication will be dispensed by pharmacy and with the service user's agreement, will
be their responsibility. Medication will be stored in an individual storage cabinet that is
used only for the storage of an individual service user's medicines.


The storage cabinet will be kept locked at all times when not in use by the named
service user, registered nurse or pharmacist.


The registered nurse on each shift is responsible for checking the number of tablets
remaining against that documented on the prescription chart.


On the day of discharge, the remaining quantity of medication must be checked by the
registered nurse to ensure there is an adequate supply for the service user to take
home.


Service user counselling and education will be undertaken by members of the
multidisciplinary team as an ongoing process throughout the self-medication process to
ensure full understanding and maximum concordance with medication regimens.




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     47.1.      Suitability criteria for service users to use their own medicines to
                self-medicate


Only medicines that can be positively identified will be accepted for ward use and
reissued to service users. (This will exclude the majority of bottled liquid preparations
and those contained in compliance aids.)


Medicines must have been dispensed within the past six months, unless an expiry date
is stated on the container. Ophthalmic preparations must have been in use for less than
one month.


Medication must be correctly labelled with the service user‟s name, product name and
strength, dose and frequency, supplier‟s address and date of dispensing.


Each container must hold only one type or brand of medication from a single supply.
Containers holding several different drugs or dosage strengths will be discarded.


Directions printed on the container must agree with the DPAR prescription chart or TTA
prescription. Service user's own drugs must not be relabelled with revised instructions,
with the exception of blister-packed tablets, which will need to be re-dispensed by
pharmacy if the treatment regimen changes.


The responsible practitioners must be satisfied with the general condition of the product
and its packaging and labelling. Professional discretion should remain the overriding
factor in assessing appropriateness for use.


48. Instructions for dispensing emergency medication from Ward and
    Community Team Stock (Secondary Dispensing)



Under usual circumstances a Pharmacy should dispense all medicines. Due to the
nature of services and the difficulty of access to a Pharmacy this may not always be
possible.
In an exceptional situation TTA/TTO medicines may be dispensed from the community
team or ward medicines stock by a registered nurse. Stock should not generally be
borrowed from other units for this purpose. Teams expecting to undertake secondary
dispensing should ensure they have.


An exceptional situation is defined as one where the patient intends to leave the unit for
unexpected leave or self discharge and the continuation of their medication is
necessary to avoid deterioration in their mental/or physical health OR that medication is


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required for a service user which is unavailable from a dispensing pharmacy within a
reasonable time.
Staff should note the guidance from the Nursing and Midwifery Council.
“Any nurse who undertakes a dispensing role will be extending the scope of his/her
practice and must be aware of the provisions of the Code of Professional Conduct.
Each individual nurse must undertake practice and accept responsibility for activities in
which he/she is competent an if an aspect of practice is beyond the individuals level of
competence, help and supervision from a competent practitioner must be obtained.
This means that nurses cannot be required by an employer to take on a new role or task
if they do not consider themselves competent to do so without breaching the Code of
Professional Conduct and therefore become open to a charge of professional
misconduct. This professional accountability cannot be delegated or suspended by the
nurse or employer. The dispensing of medical products requires familiarity with the
organisation of drugs so as to identify those that are controlled. It also requires
familiarity and the knowledge of the labeling regulations and information to be given to a
patient.
The patient is entitled to the same level of skill from a nurse dispensing medication as
could be expected from a trained pharmacist.”
Ref; Guidelines for the administration of medicines, UKCC now NMC


     48.1.      Dispensing


Registered Nurse dispensing is only to be used when medication cannot be obtained
from a pharmacy before the patient leaves the unit. It should not be used routinely as an
alternative to pharmacy dispensing.


Only medication prescribed by a prescriber on the patient's DPAR may be dispensed.
This will include regular and PRN medication. However, Controlled Drugs including
Temazepam cannot be dispensed under these guidelines.


The TTA should be for a minimum number of days until the patient can obtain further
supplies by means of an FP10 (HP) or by calling back at the unit for TTA/TTO‟s
dispensed by pharmacy.


Bottles, cartons, blister packs, labels, additional labels and bags for dispensing are
provided by pharmacy. A separate container is required for each medicine. A child
resistant closure must be used for tablet and liquid bottles. Blister packed medication is
placed in white cardboard cartons or is enclosed within the Venalink blister pack or
similar system


The nurse in charge is responsible for storing the dispensing materials and ordering
replacements


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Medication will be dispensed and checked by a Registered Nurse and another member
of staff. One is designated as the Dispenser and will dispense the medication and
complete the official pharmacy labels. The other will be the Checker and will examine
the container and verify that the correct medication has been dispensed with the correct
label details


The following details must be on the label for each medicine as a legal requirement:
•       Approved name, form (tablet/capsule/liquid) and strength of medicine
•       Number of tablets/capsules in the container or for liquids mls (millilitres) in the
bottle.
•       Patient‟s name
•       Date of dispensing
•       Directions for use:
dose - number of tablets/capsules/mls (if liquid) to take
frequency - (specify time of day or hours between doses if applicable)
•     Additional labels e.g. „after food‟ „avoid alcohol‟ „for external use only‟ where
possible (see BNF Appendix 10)


Recommended safe practise is to complete the labelling of each medication before
beginning to dispense another.


The checker must examine each container and verify that the correct medication has
been selected with the correct label details.


An Emergency Supply Record Form should be completed and signed by the dispenser
and the checker. This form can be found in the appendices of this document.


When completed, the form should be filed in the folder in the medication storage
cupboard or the medical notes according to local procedure. Ideally, the stock will be
checked and replenished weekly by designated pharmacy staff.


Where appropriate additional systems following the principles outlined here may be
used with the prior approval of the Chief Pharmacist.




49. RESEARCH - USE OF MEDICINES


The use of medicines or placebos in research must comply with UK Medicines for
Human Use (Clinical Trials) Regulations 2004, and the Trust's research and

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development policies, and be appropriately authorised by the NHS Research Ethics
Committee and the Medicines and Healthcare Products Regulatory Agency (MHRA).




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50. Appendix B DISPENSING MEDICATION RECORD FORM
Name of Service user:


Unit Number:


Team Details:




Consultant:


Date:                                          Time: a.m./p.m.


Medicines Dispensed: (List all medicines dispensed)
Include name of medicine, form, strength, quantity and directions




Dispenser: Registered Nurse/Doctor
(BLOCK CAPITALS)
Signature:
Position:
Checker:
(BLOCK CAPITALS)
Signature:
Position:




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51. Appendix C : Agreement Document for Self-medication of Medicines
      Service user's Name………………………. Assessing Nurse…………………
        Hospital No………………………….. Consultant………………………..
        Date of Agreement …………………


                                                                                   Yes/No

 Have the advantages and disadvantages of self-medication of medicines
 been discussed by the multi-professional team, the service user, and their
 carer, if appropriate?

 Has the service user been assessed, mentally and physically a by the
 multi-disciplinary team and deemed suitable to self-medicate?

 Is the service user is able to read the instruction label?
 If no, can they read large print?

 Can the service user open his/her identified medicines storage cabinet?

 Can the service user open:
 Ordinary closures?
 Winged or ridged closures?
 Foil or blister packs?
 Compliance Aids?

 Is the service user is willing to take responsibility for the security and
 administration of their own medicines?

 Does the service user required any special physical aids or equipment in
 order to enable them to self-medicate?

 Have you identified any other problems, issues or concerns that might
 prevent the service user from participating successfully in the self-
 medication of medication?
Signature of service user…………………………………………………………..
Signature of registered prescriber ………………………………………….
Signature of assessing nurse………………………………………………..
Signature of the ward/clinical pharmacist…………………………………..


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52. Appendix D Management Investigation Report Template for Medication Errors
    and Near Misses

http://ourspace/StaffServices/PtoT/RiskCompliance/Documents/Appendix D8.doc




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Guidance on completing the management report template for medication errors
and near misses


Section A


Give the name and date of birth of the service user and the names of the staff involved
and the date of the incident.


Section B


Details of incident


Please attach a copy of the incident form and the medication chart.

Record here any additional information which clarifies what happened.

This section should:
1 Explain what the person making the error intended to do and what they actually did.
2 Identify the medication involved.
3 Specify whether or not there was any adverse effect on the service user



Section C


Immediate action taken


Circle the appropriate response to indicate whether the error was reported as soon as it was
noticed and whether attempts were made to conceal the error.

If the answer to either of these is yes,, then please describe what happened.
Then describe what action was taken when the error was discovered.
This should include:
   1. A list of staff informed of the incident
   2. A summary of the action taken to ensure the safety of the service user



Section D


Service User and Carer / Family Issues




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Circle the appropriate response to indicate whether the service user has been informed and
whether the carer/family have been informed (if appropriate)

If the service user or carer/family have any concerns that need to be addressed by this
investigation, then list them here.



Section E


Contributory Factors

Outline any factors which you feel may have contributed to the occurrence of the incident.

      Aim to consider a wide range of issues – e.g. the busyness of the clinical environment;
       any problems with verbal or written communication; the personal circumstances of the
       individual making the error; any unmet staff training or supervision needs; familiarity with
       the particular medication or the service user; problems distinguishing similar medicines
       etc.

       And then:
      Try to look beyond the immediate cause of the incident. For example, if the person
       making the error was distracted, what was it about the situation that was distracting?


Section F


Summary of the issues / problems identified

Summarise the key issues


Section G


Good practice points identified


List any good practice identified by the management investigation.


Please feed this back to the person concerned and consider informing this person‟s line
manager of any good practice identified.


Section H


How could the occurrence of this incident have been prevented?




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Taking the contributory factors into account, is there any action to be taken that might
prevent the occurrence of similar incidents in future. Try to think broadly and consider,
for example, whether:


  changes to local practice might help e.g. where drug trolley is positioned
  Trust policy needs to be reinforced
  whether there are training and supervision needs

Section I
Further action required within the team
Describe what further action is required within the team. If this incident bears similarities to other
incidents within the last three months (e.g. same member of staff, same type of incident, same
contributory factors) then you should specifically consider what action is needed to address this
pattern.



Section J

Recommendations for action in other teams in the area; SBU and Trust

Consider your review of the incident, the contributory factors and views on how it could have
been prevented and then make any recommendations for your area, SBU and for the Trust as a
whole.


Section K


Please don‟t forget to sign the form



Section L


Review of incident and recommendations by senior clinician (Modern Matron, Designated
Community Nurse, Senior Pharmacist or Lead Clinician as appropriate)


This section is for the team/ward manager‟s line manager to record any comments




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