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Policy for the Safe and Secure Handling of Medicines

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Policy for the Safe and Secure Handling of Medicines Powered By Docstoc
					                 Policy for the Safe and
                  Secure Handling of
                       Medicines



Document Number:                              CPCT/001/050
Date ratified:                                17/11/2010
Date issued:                                  17/11/2010
Review date:                                  17/11/2012




                  POLICY STATEMENT:
       The policy defines the mandatory
       requirements of the trust with regard to the
       prescribing supply, handling and
       administration of medicines. It identifies the
       wide range of activities associated with the
       handling of medicines and the actions and
       responsibilities of the groups of staff involved
POLICY DOCUMENT CONTROL SHEET

Title           Title                       Policy for the Safe and Secure
                                            Handling of Medicines
                Version                     5
Supersedes      Supersedes                  MM/MH/179-v1
                Description of amendments
Accountable     Lead                        Mike Bewick
Director        Designation                 Medical Director
Policy Author   Lead                        Fiona Gunston
                Designation                 Practice Support Pharmacist
Consultation    Circulation List            Medicine management Team
Circulation                                 Locality general managers
                                            Governance group
                                            IV strategy Group
                                            Non medical Prescribers group
                                            Professional Leads (health visitors,
                                            children’s nursing, school of
                                            nursing)
                                            Extended scope practitioners


Approval by     Committees/Groups
                Consulted Date
                Executive Director
                Name/Date
                Trust Board Date
Circulation     Issue Date                  8/02/2010
                Circulated by               Mel Bradley
                Issued to                   See list above
Review          Review Date
                Responsibility of           Andrea Loudon Head of Medicine
                                            Management
Monitoring      Use standard template and
Audit Tool      attach to policy
Equality        See Appendix
Impact          Initial Assessment          YES / NO
Assessment      completed
                Full Assessment completed   YES / NO
Version Control Sheet

Versi     Date          Author      Status                   Comment
 on
1       8.12.2009   Fiona Gunston   Draft    Initial draft
2       11.3.2010   Fiona Gunston   Draft    Incorporating
                                             feedback/comments
                                             receivedAreas updated
                                             Medicine Reconciliation
                                             Anticoagulant medication
                                             Injectables
3       15.3.2010   Fiona Gunston   Draft    Incorporating
                                             feedback/comments received
                                             Areas updated
                                             Patient own drugs
                                             Self administration of medicines
                                             Administration in community
                                             setting
                                             Administration of pre filled insulin
4       20.3.2010   Fiona Gunston   Draft    Incorporating
                                             feedback/comments received
                                             Areas Updated
                                             Verbal request to administer
                                             Disposal of medicines
                                             PGDs
                                             NPSA guidance missed doses
5       21.3.2010   Fiona Gunston   Draft    Incorporating
                                              feedback /comment received
                                             Areas Updated
                                             Second check/witness
                                             Transcribing
                                             All SOPs and Appendices
6       13.10.2010 Fiona Gunston    Draft    Incorporating
                                             feedback /comment received
                                             from patient voice group
TABLE OF CONTENTS

INTRODUCTION...................................................................................................................... 8
1 PURPOSE OF POLICY .................................................................................................... 8
2 SCOPE OF DOCUMENT.................................................................................................. 8
     3.1    Statement of Intent............................................................................................... 8
     3.2    Statement of Staff Groups Document is Applicable to ..................................... 9
4. PRESCRIBING ................................................................................................................. 9
     4.1    Medicines Reconciliation (Appendix 1; SOP 1) ...................................................... 9
     4.2    Prescribing Requirements (Appendix 1; SOP 2) ............................................. 10
     (Appendix 1; SOP 2) ....................................................................................................... 11
4.2.1 Specific Requirements for Anticoagulants..................................................................... 11
4.2.2 Specific Requirements for Injectables ........................................................................... 11
4.2.3 Specific Requirements for Oral Anti-cancer Medicines ................................................. 12
     4.3    Transcribing (Re-writing Prescriptions) (Appendix 1; SOP 4)............................... 12
     4.4    Lost Prescriptions Charts ..................................................................................... 13
     4.5    Prescribing for Self or Family ............................................................................... 13
5. SECURITY OF PRESCRIPTION PADS ......................................................................... 13
     5.1    Reporting Missing/Lost/Stolen NHS Prescription Forms ...................................... 14
5.1.1       In-hours ................................................................................................................ 14
5.1.2       Out-of-hours (OOH).............................................................................................. 14
6. SUPPLY.......................................................................................................................... 15
     6.1    Approved Suppliers .............................................................................................. 15
     6.2.1 Medicines for Emergency Use.............................................................................. 15
6.3 Ordering Medicines (Appendix 1; SOP 5) ........................................................................ 16
     6.4    Receipt of Medicines (Appendix 1; SOP 5) .......................................................... 16
     6.5    Use of Patients’ Own Medicines when In-patients (Appendix 1; SOP 6).............. 16
     6.6    Supply of Medicines for Patients to Take Home................................................... 17
6.6.1 On Discharge (Appendix1; SOP 7)................................................................................ 17
6.6.2 Community Settings ...................................................................................................... 17
7. STORAGE ...................................................................................................................... 18
     7.1    Storage Facilities.................................................................................................. 18
7.1.1       Trust premises...................................................................................................... 18
7.1.2       Patient’s Home ..................................................................................................... 20
     7.2    Medicine Security in Clinical Areas ...................................................................... 20
     7.3    Custody of Keys ................................................................................................... 20
7.3.1       Keys for Patients Self-administration of Medicines ........................................ 21
7.3.2       Loss of Keys......................................................................................................... 22
     7.4    Storage During Transport ..................................................................................... 22
7.4.1       Transportation of Medication by Community Staff................................................ 23
     7.5    Medicines for Emergency Use.............................................................................. 23
     7.6    Storage of Drugs during Ward Closure or Clinical Area ....................................... 23
8. ADMINISTRATION ......................................................................................................... 23
     8.1 Staff Involved in Administration ................................................................................. 24
8.1.1 In-patient Areas ............................................................................................................. 24
8.1.2 Community Settings ..................................................................................................... 25
     8.2 Training and Competency ..................................................................................... 25
     8.3 Administration Details (Appendix 1; SOP 8).......................................................... 26
     8.4    Cases of Doubt..................................................................................................... 28
     8.5    Self-administration of Medicines (Appendix 1; SOP 9)......................................... 28
Safe and Secure Handling of Medicines                                                             Page 4 of 154
October 2010
8.5.1      Obtaining Patient Consent.................................................................................... 29
8.5.2      Assessment ........................................................................................................ 29
8.5.3      Levels of Supervision ........................................................................................ 30
8.5.4      Teaching and Supervision................................................................................. 31
8.5.5      Documentation ................................................................................................... 31
8.5.6      Daily Assessments............................................................................................. 32
8.5.7      Amber Supervision ............................................................................................ 32
8.5.8      Changes and Problems in Self-administration ................................................ 33
8.5.9      New or Discontinued Medicines ....................................................................... 33
8.5.10     Controlled Drugs ................................................................................................ 33
8.5.11     Care Home Setting............................................................................................... 34
     8.6   Administration of Homely Remedies .................................................................... 34
     8.7   Administration of Intravenous Medicines .............................................................. 35
     8.8   Administration of Medicines through PEG Tube................................................... 36
     8.9   Administration of Cytotoxic Drugs: .................................................................. 36
     8.10 Administration of Medicines via a Syringe Driver ................................................... 37
     8.11 Administration of Pre-filled Insulin (Appendix 1; SOP 10) .................................... 37
     8.12 Verbal Request to Administer Medicine ............................................................... 38
     8.13 Refusal of Medication........................................................................................... 40
     8.14 Distractions .......................................................................................................... 41
     8.15 Administration of Medicines in an Emergency...................................................... 41
     8.16 Administration to Self or Colleagues .................................................................... 42
9. DISPOSAL...................................................................................................................... 42
     9.1   Out of Date Medicines or Medicines No Longer Required ................................... 42
9.1.1       Trust Premises .................................................................................................... 42
9.1.2      Patient’s Home ..................................................................................................... 42
9.1.3      Care Home ........................................................................................................... 42
     9.2   Medicines Prepared but Not Used........................................................................ 42
     9.3   Cytotoxic drugs..................................................................................................... 43
10. CLINICAL TRIALS ......................................................................................................... 43
11. MEDICATION INCIDENTS ............................................................................................. 43
12. MEDICINE DEFECTS..................................................................................................... 44
13. SUBSTANCES OF ABUSE ............................................................................................ 44
14. UNLICENSED MEDICINES ............................................................................................ 45
     14.1 Use of Unlicensed Medicines ............................................................................ 45
     14.2 Liability................................................................................................................ 45
     14.3 Patient Information and Consent ...................................................................... 46
15. PATIENT GROUP DIRECTIONS AND PATIENT SPECIFIC DIRECTIONS ............... 46
15.1 Patient Group Directions ................................................................................................ 46
15.2 Patient specific direction.............................................................................................. 47
16 RESPONSIBILITIES....................................................................................................... 48
     16.1 All Staff................................................................................................................ 48
     16.2 Individual Responsibilities ................................................................................ 48
16.2.1 Healthcare professionals............................................................................................. 48
16.2.2 Support Staff such as Assistant Practitioners and Healthcare Assistants ................... 48
16.2.3     Prescribers ........................................................................................................... 48
16.2.4     Registered Nurses................................................................................................ 49
16.2.5     Witnesses............................................................................................................. 49
16.2.6     Pharmacists.......................................................................................................... 49
16.2.7     Appointed Nurse or Authorised Healthcare Professional in Charge ..................... 50
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16.2.8    Head of Medicines Management.......................................................................... 50
16.2.9    Director of Clinical Services.................................................................................. 51
17 STAFF TRAINING IMPLICATIONS................................................................................ 51
    17.1 Implementation of this Policy............................................................................ 51
    17.2 Monitoring and Review ...................................................................................... 51
18 DEFINITIONS ................................................................................................................. 52
19. REFERENCES................................................................................................................ 53
20. APPENDICES................................................................................................................. 55
    20.1 Appendix 1 – Standard Operating Procedures................................................... 55
SOP 1 - Medicines Reconciliation....................................................................................... 55
SOP 2 - Prescribing Medicines ........................................................................................... 57
SOP 3 – Prescribing, Preparation, and Administration of IV Drugs................................. 65
SOP 4 – Transcribing ........................................................................................................... 76
SOP 5 – Ordering and Receipt of Medicines from Pharmacy........................................... 78
SOP 6 – Use of Patients’ Own Medicines........................................................................... 79
SOP 7 – Discharge Medication............................................................................................ 81
SOP 8 – Administration of Medication to Patients ............................................................ 84
SOP 9 – Self-administration of Medication ........................................................................ 86
SOP 10 – Pre-loading and Administration of Insulin......................................................... 88
    20.2 Appendix 2 – Assessment of Competency to Transcribe ................................. 91
    20.3 Appendix 3 – Theoretical Knowledge Assessment of Transcribing for
    Adults ............................................................................................................................. 92
    20.4 Appendix 4 – Competency Assessment Framework and Annual
    Transcribing Audit Tool................................................................................................ 94
    20.5 Appendix 5 – Signature Requirements for Transcribing ................................... 96
    20.6 Appendix 6 – Medication Re-use and Disposal Consent Form......................... 97
    20.7 Appendix 7 – Patient Own Drugs (PODS) ........................................................... 98
    Assessment Checklist for Administration by Nurses................................................ 98
    20.8 Appendix 8 – PODS Assessment Checklist for Self-administration or
    Discharge....................................................................................................................... 99
    20.9 Appendix 9 – Self-administration of Medicines – Information Card ............ 100
    20.10 Appendix 10 – Self-administration of Medicines – Patient Assessment
    Form 102
    20.11 Appendix 11 – Self-administration of Medicines – Medication Risk
    Assessment Form ....................................................................................................... 103
    20.12 Appendix 12 – Self-administration of Medicines – Audit Tool ..................... 104
    20.13 Appendix 13 – Formulary Exception Request Form ..................................... 105
    20.14 Appendix 14 – NHS Cumbria Waste Medicines Disposal Procedure ........... 106
    20.15 Appendix 15 – Intravenous Drug Quickguide ................................................ 109
    20.16 Appendix 16 – IV Cannula Observation Chart ............................................... 115
    20.17 Appendix 17 – Criteria for IV Drug Administration in the Home
    Environment ................................................................................................................ 117
    20.18 Appendix 18 – Assessing Risk: The pre-loading of Insulin......................... 119
    20.19 Appendix 19 – Safe and Secure Handling of Medicines: Self
    Assessment Checklist ................................................................................................ 120
    20.20 Appendix 20 – SOPs Accountability Record.................................................. 121
    21.   ASSOCIATED DOCUMENTATION ................................................................... 124
    21.1 Template 1 – Training Needs Analysis and Training Plan............................... 124
    21.2 Template 2 – Document Implementation Effectiveness Audit Tool ................ 127
    Policy Author21.3 Template 3 – Initial Equality Impact Assessment................... 127
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   21.3 Template 3 – Initial Equality Impact Assessment.......................................... 128
   21.4 Template 4 – Full Equality Impact Assessment (if applicable)..................... 130
   21.5 Template 5 – Glossary of Terms ..................................................................... 132
   21.6 Template 6 – Consultation Circulation List.................................................... 133
   21.6 Template 6 – Consultation Circulation List.................................................... 133
   21.7 Template 7 – Consultation Checklist for Individual Use ............................... 134
   21.8 Template 8 – Consultation Checklist for Patient Voice Group ..................... 139
CONSULTATION CHECKLIST FOR PATIENT VOICE GROUP ........................................ 139
   21.9 Template 9 – Author’s Summary of Consultation Comments (for Author
   Use Only) ..................................................................................................................... 146
   21.10 Template 10 – Implementation Template........................................................ 152
   21.11 Template 11 – Policy Advisory Group Checklist ........................................... 153




Safe and Secure Handling of Medicines                                                           Page 7 of 154
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INTRODUCTION

        This document lays down policy for all staff that may be involved in the
        prescribing, acquisition, storage and administration of medicines. It defines
        the mandatory requirements of the Primary Care Trust (referred to as the
        Trust). This policy identifies the wide range of activities associated with the
        handling of medicines and the particular care that is needed.

        This policy complies with the Medicines Act 1968, Misuse of Drugs
        Regulations 2001, Special Waste Regulations 1996 and Control of
        Substances Hazardous to Health Regulations 1999, as well as guidance
        contained within The Safe and Secure Handling of Medicines - A Team
        Approach, published by The Royal Pharmaceutical Society of Great Britain
        (RPSGB) in March 2005 and the NMC Standards for Medicines Management
        (2007).

        The safe and secure handling of Controlled Drugs is not considered in detail
        in this policy. Please refer to The Safe and Secure Handling of Controlled
        Drugs Policy for more information.


1       PURPOSE OF POLICY

        Implementation of this policy will ensure that:
        • Information is available to enable an authorised practitioner to correctly
           and appropriately prescribe medicines.
        • Medicines are accurately and appropriately supplied, stored and
           transported.
        • Medicines and prescriptions are checked for accuracy and completeness
           prior to dispensing and administration.
        • Medicines are accurately, appropriately and safely administered.
        • Medicines are correctly controlled and recorded to prevent the loss,
           inappropriate access and misuse by patients, residents, staff or any
           member of the general public.
        • Practitioners involved in the delivery of care are responsible for their
           actions.
        • Incidents and errors involving medicines are minimised.


2       SCOPE OF DOCUMENT

        3.1     Statement of Intent

        The safe and secure handling of medicines is the responsibility of every
        member of staff and healthcare professional, who must ensure that they work
        within their respective professional guidelines, ethics and codes of conduct.

        All healthcare professionals are accountable for their actions. This
        accountability cannot be delegated, nor can anyone else answer for the
        actions of an individual healthcare professional.
Safe and Secure Handling of Medicines                                Page 8 of 154
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        Tasks can ONLY be delegated to a member of staff who is legally entitled,
        authorised or appropriately trained to carry out those tasks. Deviation from
        this policy may result in disciplinary action being taken against the employee
        and reporting to the professional body.


        3.2      Statement of Staff Groups Document is Applicable to

       This policy applies to all employees of the Primary Care Trust including bank
       staff and agency staff working in the Trust; it also covers employees not
       working on Trust premises. The policy also applies to members of staff who
       are not directly employed by the Trust but who act in a professional capacity
       within the Trust through a service level agreement.

        All NHS contractors registered with the Primary Care Trust should also be
        compliant with this policy. It is written to be consistent with the North Cumbria
        University Hospitals Trust (NCUHT) and University Hospitals of Morecambe
        Bay Trust medicines policies, to avoid any potential difficulties for staff who
        work across organisational boundaries. Any significant differences or
        discrepancies between the acute and primary care policies should be pointed
        out to the authors.


4.      PRESCRIBING

        The Trust follows the Lothian Joint Formulary (LJF) www.ljf.scot.nhs.uk for
        medicines and dressings.
        The Trust uses its own antimicrobial formulary, deviations from which must
        only be made following consultation with a microbiologist.
        Prescribing for patients must, under most circumstances, reflect the Lothian
        formulary choices. Where there is a specific reason for requiring a medicine
        for a specific inpatient which is not on the formulary, the prescriber must
        complete a “Non-formulary request” (Appendix 13) which will be assessed on
        an individual basis. Hospital pharmacy purchasing staff are not authorised to
        purchase non-formulary medicines without this form. It is not acceptable to
        complete this form in retrospect.


        4.1      Medicines Reconciliation (Appendix 1; SOP 1)

        The aim of medicines reconciliation on admission to hospital is to ensure that
        medicines prescribed on admission correspond to those that the patient was
        taking before admission. The National Prescribing Centre defines medicines
        reconciliation as:

              • Collecting information on medication history (prior to admission) using
                the most recent and accurate sources of information (e.g. GP repeat
                prescribing record supplemented by information from the patient and/or
                carer), to create a full and current list of medicines and
Safe and Secure Handling of Medicines                                 Page 9 of 154
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              • Checking or verifying this list against the current prescription chart in the
                hospital, ensuring any discrepancies are accounted for and actioned
                appropriately, and
              • Communicating through appropriate documentation any changes,
                omissions and discrepancies.

        Medicines reconciliation can occur when patients are admitted to hospital,
        transferred to other units within the hospital or to another hospital, or
        discharged from hospital.

        Factors that may contribute to medicines reconciliation errors include the
        following.

            • No access to the patient’s prescription list from Primary Care.
            • Discrepancies between the Primary Care prescription list and the
              medications the patient is taking. This may happen because the patient
              is no longer taking prescribed medications, because they are taking
              medications they have obtained themselves (e.g. over-the-counter
              medicines, herbal medicines or vitamins), or because they are taking the
              incorrect dose.
            • Difficulties in obtaining an accurate account of a patient’s medication,
              which may be caused by an acute condition, sensory or cognitive
              impairment, lack of access to family or carer support, or language
              barriers.
            • Errors in transcribing medication details to the hospital clinical record.

        Admission to hospital provides an opportunity to make appropriate changes to
        medication. However, the process of medicines review is beyond the scope of
        this guidance, as is medicines reconciliation on transfer to other units or on
        discharge.

        It is the role of the person taking the drug history e.g. Medicines Management
        Technician (MMT), Pharmacist, Doctor or Nurse Practitioner to document and
        provide as comprehensive a medication history as possible. It is their
        responsibility to refer any issues that arise from this to the Clinical Pharmacist
        or the Doctor as appropriate. (Appendix 1; SOP 1)

        4.2      Prescribing Requirements (Appendix 1; SOP 2)

        Before prescribing the prescriber should consider the following;
        •     Need / indication for new and current medications
        •     Allergies and sensitivities
        •     Evidence for the drug choice or efficacy
        •     Adverse effects including side effects and drug interactions
        •     Patient concordance issues including religious or belief systems
        •     Tests/monitoring required
Safe and Secure Handling of Medicines                                    Page 10 of 154
October 2010
        •   Risk reduction /possible cause of admission
        •   Simplification / switches to improve compliance or cost effectiveness
        Prescriptions must be written in accordance with the SOP for prescribing
               (Appendix 1; SOP 2)
        Prescribing must be detailed and enable the prescription to be interpreted
        accurately and in a timely fashion. Health professionals may request that a
        prescription be re-written by a prescriber if at any time it becomes ambiguous
        or unclear.

        In Community Hospital setting pharmacists may make minor clarifying
        amendments to charts but must consult the prescriber first if the original
        intention is unclear.

        A clinical check by pharmacy staff will include, but is not limited to, the
        following:
        • Completeness of the drug chart or discharge prescription, including patient
            demographic detail
        • Documentation of allergies and sensitivities
        • Appropriateness of each prescribed medicine for the condition to be
            treated where this is known
        • Appropriateness of dose
        • Interactions between medicines
        • Calculations, including dilution volumes and rates of administration of
            intravenous fluids with or without additions of medication


        4.2.1 Specific Requirements for Anticoagulants

        Prescribers who prescribe anticoagulants are required to have successfully
        completed appropriate training approved or delivered by the PCT and
        demonstrated the necessary competencies as outlined in the NPSA Patient
        Safety Alerts (18 and 20 respectively www.npsa.nhs.uk).
        Refer to the NPSA site for Actions that can make anticoagulant therapy safer
        http://www.npsa.nhs.uk/nrls/alerts-and-directives/alerts/anticoagulant/ and to
        the NHS Cumbria Warfarin Management Guidelines
        http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelin
        es/Warfarin%20management%20guidelines.pdf



        4.2.2 Specific Requirements for Injectables

        Injectables should not be prescribed unless a risk assessment has been
        completed. Prescribers who prescribe injectables are required to have
        successfully completed appropriate training approved or delivered by the PCT
        and demonstrated the necessary competencies as outlined in the NPSA
        Patient Safety Alert 20( www.npsa.nhs.uk).


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        The prescribing of injectables is covered by the Standing Operating
        Procedure for the Prescribing, Preparation and Administration of Intravenous
        Drugs (Appendix 1; SOP 3).


        4.2.3 Specific Requirements for Oral Anti-cancer Medicines

        All oral anticancer medicines should be prescribed ONLY in the context of a
        written protocol and treatment plan. Non-specialists who prescribe 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. (www.npsa.nhs.uk - Rapid Response Alert NPSA/2008/RRR001)


        4.3     Transcribing (Re-writing Prescriptions) (Appendix 1; SOP 4)

        The Nursing and Midwifery Council (NMC) , whilst not encouraging nurse
        transcription of prescriptions, acknowledge that this practice is permissible.
        Transcribing should ONLY be done in exceptional circumstances, when the
        original prescriber or another independent prescriber is not available to
        prescribe the medication and the patient’s condition is such that he/she
        cannot wait until a prescriber is available. Transcribing should NOT be
        routine practice. The individual nurse completing the transcription remains
        professionally accountable for the information they transcribe.
        Transcribing is a voluntary activity and, if there are concerns about a
        prescription that cannot be resolved by discussion with the prescriber
        or responsible doctor, transcribing must not be undertaken
        To undertake the transcribing role within the Trust the practitioner must:
        • Complete an assessment of their understanding of this role and the
           transcribing framework (Appendix 2 & 3)
        • Complete an assessment of ‘transcribing’ in practice which will be marked
           – pass mark 100% (assessed first assessment at 6 months and thereafter
           annually against the transcribing audit tool Appendix 4)
        • Follow the SOP for Transcribing (Appendix 1; SOP 4)

        It is the responsibility of the transcriber to recognise their learning and
        development needs in relation to this transcribing role. If they do not feel
        confident or competent in this role at any time they must not transcribe and
        must contact their line manager to resolve the situation.

        When the administration record for at least one of the drugs has become full,
        the entire drug chart must be re-written. A current drug chart received on
        patient transfer from another site or hospital need not be re-written
        immediately, unless there is a clinical reason for doing this.

        If necessary, in exceptional circumstances as noted above, authorised
        nursing staff may transcribe information from a previously prescribed drug
        chart, onto a new drug chart.


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        Prescriber Responsibilities

        •     It is the responsibility of the registered prescriber (non-medical or medical)
              to provide a legible, accurate list of medication including details of route,
              dosage and frequency in order that the transcribers can transcribe safely
              and accurately.
        •     It is the responsibility of the registered prescriber (non-medical or medical)
              to check transcribed medication, ensuring that all active prescriptions have
              been transcribed and are appropriate.
        •     The prescriber must then sign each prescription as soon as possible, and
              before the medicine is administered.

        Transcriber responsibilities

        •     The transcriber must transcribe all information from the original drug chart
              onto the new one, including the information on the front sheet and patient
              sensitivities, ensuring that the correct number of active prescriptions is
              transcribed.
        •     It is the responsibility of the transcriber to inform the prescriber of any
              transcribed charts so that these can be signed by the prescriber.

        Medicines Management, Cumbria PCT will be advised of all transcribers who
        have successfully completed the training and competency framework, as
              outlined in the Medicines Policy. (see Appendix 5)


        4.4      Lost Prescriptions Charts

        If a drug chart appears to be lost, all possible effort must be made to locate it
        before a new chart may be written. If a new chart must be started because of
        “loss”, a note of this must be made on the front, stating that it is a replacement
        chart. An incident form must be completed and a copy entered into the
        patient’s notes.


        4.5      Prescribing for Self or Family

        Prescribers must not prescribe for themselves or members of their family.


5.      SECURITY OF PRESCRIPTION PADS

        There are Regulations covering security measures to prevent users unlawfully
        obtaining supplies of drugs and syringes; prescription pads; and headed
        notepaper from surgeries.

        Prescribers and other staff should be aware of security:
        • Upon delivery of prescription forms, managers should ensure a process is
           in place to record relevant details in a stock control system (see NHS SMS
           Security of prescription forms guidance)
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        •     Records of serial numbers received and issued should be retained for at
              least three years
        •                                                                        s
              Blank prescriptions should never be left unattended on a prescriber' desk,
              or elsewhere
        •     Blank prescriptions must never be pre-signed
        •     Pads should always be locked away when not in use
        •     Prescribers must never use blank or out of date prescription pads as spare
              notepads
        •     Blank prescriptions forms should never be left at care homes for GP visits

      As a matter of best practice, prescribers should keep a record of the serial
      numbers of prescription forms issued to them. The first and last serial
      numbers of pads should be recorded. It is also good practice to record the
      number of the first remaining prescription form in an in-use at the end of the
working day. This will help to identify any prescriptions lost or stolen overnight.


        5.1      Reporting Missing/Lost/Stolen NHS Prescription Forms

        5.1.1 In-hours

        The prescriber must inform their Line/Practice Manager, and together inform
        the Accountable Officer for CDs, the Police and Lancashire and South
        Cumbria Agency (LASCA) (Tel: 01772 221349) for the South and Caroline
        Taylor, Registration, Cumbria PCT (Tel: 01228 603517) for the North as soon
        as they become aware that the prescription pad has been stolen/lost. LASCA
        and the PCT registration officer will inform all pharmacies in the area.

        LASCA and the PCT Registration officer will complete a Missing/lost/stolen
        NHS prescription form(s) notification form and forward it to the Local Security
        Management Specialist who will submit it to the NHS Counter Fraud Security
        Management Service.

        The Line/Practice Manager must submit a completed Incident Form (Lilac
        form).

        The prescriber must write/sign prescriptions with a red ink pen for 4 weeks.


        5.1.2 Out-of-hours (OOH)

        The prescriber must inform the OOH Duty Manager. The Duty Manager will
        disseminate an alert to the local community pharmacies that are currently
        open and those open for the remaining OOH period. The Duty Manager will
        inform the Police.

        At the start of the in-hours period the Duty Manager will follow the above
        procedure for in-hours.


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        The Duty Manager must submit a completed Incident Form (Lilac form).

        Non-medical prescribers (NMP) must inform their line manager at the start of
        in-hours.


6.      SUPPLY

        Medicines must be obtained to ensure that the right medicine is available in
        the right quantity and quality at the right time for the right patient.

        6.1     Approved Suppliers

        All medicinal products must be obtained from an approved supplier. Approved
        suppliers are:
        • The North Cumbria University Hospitals Trust pharmacy department
        • University Hospitals of Morecambe Bay Trust pharmacy department
        • Community pharmacies
        • Dispensing practices (only for patients registered as dispensing patients)

        Patients may use their own supplies (see 6.5 below).

        Samples of medicines must not be left on ward or clinical areas, and must not
        be used for administration to patients.

        Only pharmacy staff may transfer medicines from one container to another for
        the purpose of supply to wards, departments and individual patients.

        6.2     Stock Medicines

        If a stock of medicines is kept on PCT premises, a stock list is compiled by
        pharmacy staff or medicines management staff in conjunction with the
        appropriate clinical manager/ appointed nurse in charge. It will specify the
        usual quantities and type of medicines to be kept as stock. It is the
        responsibility of the clinical manager/ appointed nurse in charge to review and
        revise the list at regular intervals, to reflect usage patterns, together with
        pharmacy/medicine management staff.

        Non- stock items are medicines not on the stock list. They are obtained for a
        named patient. When no longer required for that patient they should be
        removed from stock and disposed of on the ward following NHS Cumbria
        Waste Medicines Disposal procedure (appendix 14).


        6.2.1 Medicines for Emergency Use

        All clinical areas will have a sealed, tamper evident container of drugs for
        emergency use. Once the seal has been opened, the authorised healthcare

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        professional must ensure that a request is made to pharmacy to replace this
        container.
        It is the responsibility of the authorised healthcare professional in charge of
        the clinical area to ensure that the medicines kept for emergency use are in
        date.


        6.3 Ordering Medicines (Appendix 1; SOP 5)

        Health professionals, with authorised signatures, are responsible for ordering
        medicines. Nurses or a member of the pharmacy or medicines management
        staff using the top-up system are responsible for ordering ward stock items.
        Authorised signatures are those which have been recorded on a form and
        authorised by the appointed nurse in charge or the clinical manager (who has
        checked NMC registration as valid). The completed form must then be
        returned to the appropriate Acute Hospitals Trust pharmacy department.


        6.4      Receipt of Medicines (Appendix 1; SOP 5)

        Delivery of medicines will be by an authorised messenger, who may be any
        member of the pharmacy staff, Trust or Facilities portering staff, a courier or,
        in exceptional circumstances, a taxi driver.

        All medicines should be of the quantity and quality expected and the receiving
        member of staff must ensure that they are assured that deterioration has not
        occurred (e.g. breakage of cold chain).


        6.5  Use of Patients’ Own Medicines when In-patients (Appendix 1;
        SOP 6)

        Where possible, systems should be set in place so that patients’ own
        medicines, including those which they have brought in with them on
        admission, can be administered to that patient only.

        Patient’s own medicines, brought in on admission, should be used as long as:

        •     There are suitable storage facilities for them.
        •     They have been assessed as suitable for use, following PCT procedures
              (Appendix 7)
        •     The patient has signed a consent form, authorising the medicines to be
              used. (Appendix 6)

        It is necessary to obtain patient consent for the re-use and disposal of a
        patient’s own medicines. The medicines they bring into hospital are their own
        personal property, and must be treated as such. The nurse must provide
        adequate information and be satisfied of patient understanding in order to
        obtain consent. Information may be obtained from Applied Language
        Solutions (tel 0845 367 7000 when English is not the patient’s first language.
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        When the patient signs the consent form, it must be witnessed and signed by
        the nurse, and retained in the nursing notes. Written consent is not absolutely
        necessary. Where the patient is unable to give written consent, but the staff
        are satisfied that implied consent is given, the staff may document this on the
        consent form, again with a witness.

        If a patient’s own drugs are considered unsuitable for use, the nurse or
        pharmacist should advise the patient that the medicines are of an
        unsatisfactory quality and of the associated risks. Consent for disposal of
        these medicines will then be required. (Appendix 6)

        Patients’ have the right not to agree to the use or destruction of their
        medicines. When this occurs the medicines should never be used or
        discarded. They should be returned to the patient on discharge or sent home
        prior to this with a relative. However, staff should advise patients if continued
        possession is medically inadvisable. If this occurs, it may be prudent to
        ensure once more that a valid refusal of consent has been signed and filed in
        patients’ notes.


        6.6     Supply of Medicines for Patients to Take Home

        6.6.1 On Discharge (Appendix1; SOP 7)

        A discharge medication summary is required for all patients, whether a new
        supply of medicine is required or not. A copy should be faxed to the patient’s
        GP on day of discharge.

        Discharge summary should include
          • A complete medication profile
          • Whether the drugs are to be continued
          • Any changes to medication from medicines on admission and the
             reason for those changes.

        Normal practice should encourage the early prescribing of discharge
        prescriptions so that these may be dispensed by pharmacy during normal
               opening hours.

        The requirement for discharge/leave prescriptions should be notified to
        pharmacy at least one working day before they are required (48 hours if
        Venalink trays required).

        6.6.2 Community Settings

        The supply must only be made if there is a valid prescription or through the
        legitimate use of a Patient Group Direction.

        The pharmacy supplies a range of pre-packaged, pre-labelled medication
        specifically for supply by authorised healthcare professionals. The healthcare

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        professional must fill in the patient’s name, date, dose and frequency of use in
        the appropriate blank spaces.

        These medicines must be given to the patient in their pre-packed form. If the
        quantity prescribed is not available in the pre-packaged units then the patient
        should be given more than the required amount and advised to dispose of the
        excess appropriately.

        The healthcare professional providing the patient with the medication must not
        alter the contents in the pre-packaged units in any way.

        If an over-labelled pack is not available, then a prescriber may write an FP10
        for the patient to obtain at a community pharmacy or dispensing practice.

        An FP10 is the preferred route to source Controlled Drugs for the patient to
        obtain at a community pharmacy or dispensing practice.


7.      STORAGE

        An individual could potentially use any medicine to harm themselves or
        another individual, either accidentally or deliberately. The Trust has a
        responsibility to ensure that the risk of deliberate or accidental harm is
        minimised by ensuring adequate security of medicinal products, including
        tablets, liquids, injections and other formulations.

        Staff have a responsibility to ensure that all medicines are stored safely,
        cupboards and storage areas are locked at all times and keys kept out of
        sight.

        7.1      Storage Facilities

        7.1.1 Trust premises

        Separate, lockable cupboards, or clearly separated areas of a lockable
        cupboard, must be available for the following:

        •     Internal medicines
        •     Parenteral medicines
        •     External Medicines
        •     Diagnostic reagents, including blood and urine testing equipment

        Cupboards should conform to BS2881(1989) – NHS Estates Building Note No
        29. If not, they should be of a standard approved by the Trust Head of
        Medicines Management.

        When wards are upgraded, medicines cupboards should be replaced with
        cupboards conforming to British Standard reference BS2881.


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        Strong potassium chloride ampoules and methotrexate must be treated and
        stored as Controlled Drugs.

        Purple plunger oral syringes must be stored with or nearby liquid medicines.

        Medication currently in use for the purposes of drug rounds may be stored in
        a separate lockable drug trolley. Storage on the shelf below the medicine
        trolley or on top of cupboards is not acceptable.

        Intravenous fluids and bulk sterile topical fluids should be stored preferably in
        a lockable area where there is plenty of space, to minimise the risk of picking
        errors. It is not always practical to store bulk IV fluids in cupboards as such.
        However they must not be stored in public areas or anywhere that could
        cause a safety hazard.

        Stocks of medicines must be used in rotation and expiry dates checked
        regularly to avoid wastage. Where a pharmacy top-up system is in operation,
        stocks will be checked at regular intervals; agreed with the pharmacy dept.

        Medicine Refrigerator
        Medication requiring refrigeration must be kept in a separate lockable drugs
        fridge. This refrigerator must be used only for the storage of medicines and
        should be of pharmaceutical quality. It should be defrosted regularly and kept
        clean and locked.
        There should be monitoring of the temperature of the fridge on each working
        day, using a calibrated maximum-minimum thermometer to ensure the
        temperature remains between 2º-8ºC. The temperature should be recorded
        (Appendix 21) and signed by the person monitoring the temperature and a
        written procedure in place, indicating the action to be taken if the temperature
        is outside the range. Ideally fridges should have an alarm which activates
        when the fridge temperature goes out of range and be connected by a fused
        spur.

        Patient Specific Medicines Cabinets
        Medicines which are part of a patient’s own medicines or self-administration of
        medicines scheme must be kept in lockable cabinets identified for the secure
        storage of an individual patient’s medication. Patient specific medicines
        cabinets may be at the bedside (be secured to the wall or bedside cabinet, or
        an integral part of the bedside cabinet) or in a central location (e.g. in the
        clinic room). A risk assessment must be carried out by the ward
        manager/team leader and the pharmacist when deciding the location and
        security of the cabinets.

        Medicines intended for patients to take home on discharge should be securely
        stored on the ward in a way that allows them to be readily identified and
        separated from ward stocks.


        Emergency Drug Boxes (For drugs used in emergency)

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        Should be stored in a suitable location on the ward/department, where quick
        access can be obtained but not in areas accessible to patients and visitors.
        Tamper proof seals should be used, which should be regularly checked.
        Boxes should be clearly marked “Emergency Use”. Once opened, a
        replacement should be obtained from pharmacy, and the used box returned.


        7.1.2 Patient’s Home

        The storage of medicines kept in a patient’s home is the patient’s
        responsibility, although appropriate healthcare professionals should advise
        the patient on the safe storage of medicines in their home.


        7.2     Medicine Security in Clinical Areas

        The responsibility for the safe and secure storage of medicines rests with the
        appointed nurse in charge or authorised healthcare professional.
        Responsibility is delegated to the assigned nurse in charge in the absence of
        the appointed nurse in charge.

        Medicines must be kept in either a locked cupboard, medicines fridge or
        medicines trolley as above. All medicines storage areas must be kept locked
        unless they are in use at the time. The medicine trolley must be locked and
        secured to the wall when not in use and must not be left unattended when
        open.

        Storage on the shelf below the medicine trolley or on top of cupboards is not
        acceptable.

        Medicines, including injection ampoules, must be stored in the intact original
        container, not decanted into other storage boxes or cartons.

        Pharmacy or Medicines Management staff will check the security of ward
        stock regularly.

        The loss of any medicines from the ward must be reported to the appointed
        nurse in charge or nurse in charge of shift immediately and to the appropriate
        pharmacist and Service/operational Manager as soon as possible. In the case
        of controlled drugs the CD accountable officer should also be informed as
        described in the Safe and Secure Handling of Controlled drugs Policy



        7.3     Custody of Keys




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        The appointed nurse in charge or authorised healthcare professional in
              charge of the clinical area is responsible for the development,
        implementation    and maintenance of an effective system to ensure the
        secure management of    the drug keys.

        The drug keys must never be left unattended, and must be kept on the person
        of the nurse in charge when not in the possession of other authorised staff
               (see below).

        The keys may be given to other authorised staff, when required for legitimate
        purposes, but responsibility for the custody of the keys and medicines
              remains with the nurse in charge.

        Legitimate purposes will include:

        •   Other healthcare professionals working on that ward who require access
            to medication for their patients
        •   Pharmacy or Medicines Management staff for the purposes of
            replenishment of stock medication (“top-up”) or to check individual patient
            medication

        The nurse in charge or authorised healthcare professional in charge must
        accompany any other individual who requests the keys, for example, estates
        staff to repair cupboards.

        A student nurse must not be offered or accept custody of the medicine keys.

        7.3.1 Keys for Patients Self-administration of Medicines

        The nurse-in-charge will hold master key/s for the individual drawers/cabinet
        with the main ring of drug keys. These are for use by primary nurses or team
        leaders at the discretion of the ward sister. Master keys must be stored in a
        locked cupboard when not in use. A check to account for all master keys must
        be made at least once in 24 hours. Ideally this should be done between the
        late and night shifts. Checks may be made more often at the discretion of the
        matron.

        Patients assessed as suitable to self-administer medicines at green level (see
        section 8.5.3) can be given custody of their medicines and responsibility for
        the individual key to their drawer/cabinet. Patients should keep the key out of
               sight and be instructed to return it to their nurse on discharge.

        The nurse discharging the patient from the ward is responsible for retrieving
        the key from them.

        The ward must retain custody of keys for those patients unable to self-
        administer at green level.

        Individual keys must be kept locked either in the centralised ward key locker
        or in the locked bedside drawer when not in use.
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        Some medicines, such as items that require refrigeration, sprays and creams,
        may be exempted from the above.


        7.3.2 Loss of Keys

        Loss of keys is a serious matter and may lead to disciplinary action being
        taken.

        Should keys be lost, this must be immediately investigated by the nurse in
        charge who must, in turn, report the loss at once to the senior nurse/manager.
        (This includes situations where it is believed that a nurse on a previous shift
        took the keys home in error and that nurse cannot be contacted).
        A thorough search must be made of all ward or department areas, including
        domestic waste containers.

        If a member of staff has inadvertently taken the keys home, it is the
        responsibility of the member of staff in possession of the keys to bring the
        keys personally back to the ward. Keys must not be handed over to any other
        person.

        If a patient takes his key home, every effort must be made to retrieve it.

        If the keys cannot be found, replacement keys and/or locks must be arranged
        as a matter of urgency through the appropriate Estates or Facilities staff.

        The hospital pharmacy should also be notified where access to stocks is likely
        to be delayed significantly, in order to arrange temporary supplies.


        7.4     Storage During Transport

        Medicines will be transported from the pharmacy department to other
        hospitals and clinics in sealed, tamper evident or locked containers.

        Medicines in transit must be handled in a way that maintains the security and
        integrity of the medicines.

        Medicines must not be left unattended and unsecured while in transit.

        If patients are transferred from one ward to another during an inpatient
        episode, the assigned nurse co-coordinating the transfer must ensure that any
        medicines stored on the ward for that patient are transferred to the receiving
        ward.

        Cold chain control within the limits appropriate to the individual product must
        be maintained for items requiring refrigeration.



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        7.4.1 Transportation of Medication by Community Staff

        Transportation of medication is not encouraged but community staff may carry
        medicines from a community base, pharmacy or GP to a patient’s home. In
        such an instance the member of staff is acting on behalf of the patient as their
        agent.

        Wherever possible medicines should be transported in a locked box or locked
        case. This must be kept locked in the boot of the car when not required. If this
        container is lost or stolen then it must be reported immediately to the line
        manager.

       Vaccines and other medicines requiring refrigeration should be transported in
       a cool box/bag in accordance with the PCT Cold Chain Policy

       Unused medicines are the responsibility of the patient. Any unused medicines
       should be returned to a pharmacy by the patient or carer. However, the
       practitioner at his/her discretion can do this if the patient is unable to do it
       themselves providing they have gained the patient consent


        7.5     Medicines for Emergency Use

        All clinical areas and wards must have access to medicines for this purpose.

        Medicines for emergency use are stored in a tamper evident container and
        must be kept in an easily accessible place.


        7.6     Storage of Drugs during Ward Closure or Clinical Area

        The safety of all medicines must be ensured during ward closure. The nurse
        in charge must consult the pharmacy department or a member of the PCT
        Medicines Management team for advice.

        Wards closing for short periods, such as weekends, should make written
        arrangements with the pharmacy department to ensure that storage of
        medicines left over short periods is secure.
        When a clinical area is closed, the keys to the medicines cupboard must be
        securely locked in an appropriate key safe, under the control of a senior
        clinical manager.


8.      ADMINISTRATION

        Authorisation for administration of Medicines

        The authorisation for medicines administration is given in one of the following
        ways:
        • An instruction written by a medical practitioner/authorised prescriber on an
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October 2010
            approved prescription chart, or on a PCT-approved administration form
            (green form) or an FP10 for community patients.
        •   In accordance with locally approved Patient Group Directions
        •   Verbal instructions in emergency situations (see telephone orders below)

        Staff administering medicines to patients will check appropriateness in line
        with the SOP for Medicines Administration (Appendix 1; SOP 8)


        8.1 Staff Involved in Administration

        The Medicines Act (1968) states that any person may legally administer a
        prescription only medicine provided that this is done in accordance with the
        written directions of a qualified prescriber (independent or supplementary).
        This task is, therefore, not legally restricted to medical and nursing staff.

       The staff requirements for the following settings are as follows:


        8.1.1 In-patient Areas

        A registered nurse, medical practitioner or other authorised healthcare
        professional may undertake single-person administration of medicines, with
        the following exceptions:
        • A witness must be involved in all stages of the checking and administration
           process for Controlled Drugs (see Policy for Safe & Secure Handling of
           Controlled Drugs).
        • A witness must be involved in the administration of all blood and blood
           products.
        • A witness must be involved in all situations where the dose, concentration
           or rate of administration has to be calculated.
        • A witness must be involved in the administration of all parenteral cytotoxic
           drugs.
        • A witness must be involved with drug administration using a syringe driver.
        • A witness must be involved, where possible, with the administration of
           intravenous medication.

        The witness should preferably be a registered nurse. If a second nurse is not
        available, the witness may be a doctor, pharmacist, other appropriate
        healthcare professional or, an assistant practitioner or a healthcare assistant
        who has undertaken training e.g. Level 2 practical awareness and
        administration of medicines and who has been assessed as competent to
        perform a witness check by a registered nurse

        In any instance where a witness checks medicines, that witness must confirm
        all the details of the medicine and the patient against the prescription chart ,
        prescription or PGD and must witness the entire administration process.( see
        SOP 8 )They must then document the role by signing all relevant stationery.


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        Administration of medicines should be in accordance with NMC Standards for
        Medicines Management and relevant NPSA Safety Alerts.



        8.1.2 Community Settings

        All medical and dental practitioners and registered nurses can perform full
        administration of medicines. Registered nurses employed by the PCT may
        administer medicines alone without a second check, in accordance with NMC
        guidance, and in line with policies within individual services and the relevant
        NPSA Safety Alerts.

        A registered nurse is permitted to administer a medicine which has been
        dispensed by a community pharmacy or a dispensing doctors’ practice,
        without gaining further written authorisation from the prescriber except for the
        following:

                Controlled drugs
                Insulins
                IV antibiotics
                patient details, dosage and frequency are not clearly written or are
                ambiguous (including ‘as directed’)


        In such situations prescribers must be asked to provide signed, written
        confirmation of a request for a nurse to administer in a patient’s home, and
        this written confirmation should be provided on a PCT-approved
        administration form.

        The nurse must be satisfied that the medicine is in its original container, as
        dispensed (if this is a compliance aid that it is one made up and dispensed by
        a pharmacy) and that the directions for administration have not changed since
        the medication was dispensed.

        Other staff including assistant practitioners and health care assistants may
        administer medicines after receiving appropriate training and a competency
        assessment at local level in relation to the task to be performed.


        8.2     Training and Competency

        Service managers must ensure that staff carrying out the administration of
        medicines have received appropriate training.

        For assistant practitioners and health care assistants involved in witnessing
        and/or administering medicines this should be include basic medicine
        awareness training e.g. Level 2 practical awareness and administration of
        medicines

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        The member of staff carrying out the administration or witnessing of
        medicines must have agreed with their manager that they are competent to
        carry this out.

        Student nurses or midwives should be encouraged to participate in the
        administration of medicines under the supervision of registered nurses as
        often as possible. This must be regarded as a learning opportunity and the
        student nurse will not be acting in a formal witness role.

        Return to practice nurses or supervised practice nurses may not undertake
        single person administration of medicines until the return to practice
        programme has been successfully completed and the nurse is re-registered
        with the NMC.

        Return to practice nurses or supervised practice nurses should be
        encouraged to participate in the administration of medicines under the
        supervision of registered nurses as often as possible. This must be regarded
        as a learning opportunity and the return to practice nurse will not be acting in
        a formal witness role.


        8.3     Administration Details (Appendix 1; SOP 8)

        Medicine must be administered in accordance with the prescription.

        No covert disguising of medicines is permitted. In exceptional circumstances,
        if covert administration of medicines is considered, refer to Policy for Consent
        to examination or treatment (CPCT/007/010).

        Do not crush, break, mix with food or water, or otherwise alter the dosage
        form of a medicine as dispensed, without first getting advice from the
        pharmacy department or a pharmacist. Document the advice received in the
        patient’s notes. Advice need not be sought on each individual occasion that
        an altered dosage form is administered, but must be sought before the first
        time each different medicine is administered to an individual in this way. This
        statement does not apply if the dispensing label or manufacturer’s information
        advises alteration of the dosage form (eg “take one tablet, dissolved in water,
        each morning”).

        Oral syringes must be used to measure oral liquids with a dosage requiring
        volumes less than 5mls.

        If a drug is unavailable at the time required the pharmacy department should
        be notified at the earliest convenience, dependent upon medical need.
        Assessment should be made of the impact of non-administration and the
        medical team informed as appropriate.

        All records of drug administration must be completed using indelible ink, in
        accordance with the NMC and PCT Guidelines for Record Keeping.

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        All authorised healthcare professionals involved in any part of the checking
        and administering process must ensure that they complete and sign their
        entry on the prescription chart/record sheet but only after witnessing
        administration.

        Medication that is not given due to wastage, refusal or lack of availability
        should be recorded.

        Medicines must not be transferred from one container to another, except
              where specifically allowed in Trust policy.

        Medicines must be prepared for administration immediately before
        administration.

        Medicines prepared for use or administration and subsequently not used or
        not given in the treatment of the patient concerned must be disposed of. They
        must not be returned to the container from which they were taken, stored in
        another container in the ward, or left out for later administration.

        Whoever administers a medicine must be satisfied that the use is appropriate
        for the patient at that time and the physical state of the product is appropriate
        for use.

        Sufficient data and information about the medicine should be available to staff
        and/or patient to enable them to identify the product and use it correctly.
        Information about the purpose and side-effects of medicines should be given
        to patients by the prescriber, pharmacist or registered nurse, supported by
        written material.

        Where the above conditions are not met the medicine should not be used to
        treat the patient.

        8.3.1 Missed or omitted doses (NPSA Rapid Response Report 009)

        The timeliness of administration is crucial for some medicines or conditions,
        as delays or omissions can cause serious harm.

        The following list of medicines has been identified as those where serious
        consequences are more likely to occur:
    •   anti-infectives (antibiotics and antifungals)
    •   anticoagulants (e.g.warfarin),
    •   insulin,
    •   resuscitation medicines
    •   medicines used to treat Parkinson’s disease.

        This list is not exclusive.

        The prescriber or pharmacist should be contacted for advice as soon as
        possible if any of the medicines above been omitted or delayed.

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        For other medicines further information should be obtained e.g. using the
        product information leaflet in the box which sometimes provides advice on
        missed     doses      or     the    Electronic  Medicines    Compendium
        (www.emc.medicines.org.uk). If in doubt always contact the prescriber or
        pharmacy for further information.

        All delays and omissions should be reported using the PCT safety incident
        report form so that these may be reviewed, audited and appropriate steps
        taken. This includes delays and omissions resulting from poor reconciliation of
        discharge information, out of hours procedures, as well as inpatient incidents.


        8.4     Cases of Doubt

        Where there is any doubt as to the accuracy, safety, completeness or
        appropriateness of an individual prescription, it is the responsibility of the
        healthcare professional holding that doubt to confirm the details with the
        prescriber and/or a pharmacist before administering the medicine.

        Medical practitioners should refer to a senior colleague or pharmacist.

        If the member of staff is still not satisfied, they or the pharmacist must contact
        a more senior member of the medical team about the concern.

        Any concerns and details of the action taken must be recorded in the nursing
        record or case notes.

        If the prescriber insists that the medicine must be given, but the health
        professional who would have administered it is still in doubt, the prescriber
        shall personally administer and therefore be responsible for any resulting
        consequences. The member of staff involved must complete an incident form,
        following PCT procedures for significant events.

        If the drug is not administered or is deliberately withheld this must be
        recorded, signed clearly and the prescriber must be informed as soon as
        practicably possible, depending upon the patient’s need. The reason why the
        drug has been omitted must be recorded and the situation explained to the
        patient.


        8.5     Self-administration of Medicines (Appendix 1; SOP 9)

        Self-administration of medicines by patients is encouraged where appropriate
        and within a risk management framework. The aim of self-medication is to
        help patients maintain or develop control over their medicines and thus their
        condition to ensure they are taken correctly and safely. The procedures for
        self-medication vary according to the circumstances of the patient.

        The term Self-administration of Medicines means selected patients are
        responsible for storing and administering their own medicines, with the nurse
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        and pharmacist acting as supervisors and educators of the process. This
        system of supervision and ongoing assessment by the nurse ensures that the
        medicines are taken correctly and safely and that the patient has received
        clear explanation and understands their medicines regimen.

        For patients in community hospitals and in the intermediate care setting, but
        not within their own homes, self-medication is part of the rehabilitation
        process to enable them to return to their own homes and manage their
        medicines safely. The level of support required may be greater for this patient
        group.

        The staff in charge will retain responsibility and accountability for the storage
        and administration of medicines. Through this policy, the staff can exercise
        their duty of care to the patient, whilst safely, and sometimes gradually,
        enhancing the patients knowledge and control over their own medicines. It
        allows staff to identify and resolve medication problems, which would
        otherwise prevent the patient from self-administering at home. We must adopt
        steps and procedures to ensure that patients receive the highest possible
        quality care.

        A nurse or pharmacist should establish whether a patient is responsible for
        administering their drug treatments at home. Where a patient appears suitable
        and with the patient’s consent, they should be assessed for entry into the self-
        administration scheme. If the patient does not wish to be involved then the
        nurse must administer the medicines during the hospital stay.



        8.5.1 Obtaining Patient Consent

        It is necessary to obtain patient consent for inclusion in a self- administration
        scheme. The nurse or pharmacist must provide adequate information and be
        satisfied of patient understanding of the scheme in order to obtain consent.
        Applied Language Solutions (0845 367 7000).). may be contacted to obtain
        information for non English speaking patients
        On admission, the nurse must help every patient to complete a Re-use and
        Disposal of Medicines Consent Form (Appendix 6), which includes consent for
        Self-Administration of Medicines. When the patient signs the consent form, it
        must be witnessed and signed by the nurse, and retained in the nursing
        notes.

        When a patient is being assessed for self-administration, ensure this form has
        been completed - look for this form in the nursing notes to see if it is
        completed and if so, confirm with the patient that they are still consenting. If
        they have not yet given consent, this should be done now.


        8.5.2 Assessment



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        Patients who have given their consent must be assessed by the nurse or
        pharmacist for their suitability to enter the scheme (see Appendix 10). This
        should be documented in the nursing records and medical notes, with details
        of any problems identified and how they were resolved. Some patients may
        require a referral to the pharmacist who can provide administration aids such
        as bold/large print labels, screw tops for bottles and compliance aids.
        Consider the implications for discharge of any patient you decide is unable to
        administer their own medicines. Consider referral to the pharmacist or
               social worker.

        The Medication Risk Assessment Form (see appendix 11) is a useful tool and
        can be used to assist in assessment for self-administration.

        Confused patients should never be given custody of their medicines.
        However, they may self-administer with close nurse supervision at the amber
        level (see section 8.5.3) if this is considered helpful for determining true ability
        and needs.

        Careful consideration must be given to the benefits and risks for individual
               patients who have a history of alcohol or drug abuse. If such a patient
        is entered into the scheme, the reason for this decision must be documented
        in     the nursing records. It is appropriate to have the agreement of both a
        nurse and a pharmacist before self-administration is started.


        8.5.3 Levels of Supervision

        In order to encourage progress towards greater independence for the patient,
        the self-administration scheme works on three levels. When the patient has
        given consent and been assessed, the nurse must write “Self Administration”
        in the blank box in the top right hand corner on the front of the prescription
        chart. The nurse should also document the level of self-administration and the
        date in the comments section on the back of the prescription chart. It should
        be noted that assessment is continual throughout the patient’s stay in hospital
        (see section 8.5.6).

        RED LEVEL (Level 1) Patient is not yet suitable for self- administration. Nurse
        administers medicines giving full explanation.

        AMBER LEVEL (Level 2) Nurse controls storage and access to medicines.
        Patient is encouraged and educated to take more control over their
               medicines.
        Patient initiates requests for medicines with some prompting from staff and
        administers with or without staff supervision.

        GREEN LEVEL (Level 3) Patient administers their medicine without
        supervision and is given responsibility for the key to their drawer/cabinet




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        The amber level indicates a stage of education and assistance by staff in
               order to bring the patient closer to total independence. Ideally the
        patient will be operating at level green before discharge.


        8.5.4 Teaching and Supervision

        All patients should receive information regarding the correct use of their
        medicines before commencing a self-administration scheme. Information
        given should be tailored to each individual patient’s needs. Knowledge should
        be checked and information reinforced throughout the programme. This
        should include the following:
           • The name of the drug
           • The purpose of the drug.
           • The dose and frequency of the drug
           • Any special instructions
           • Possible side effects
           • Duration of the course.

        The information should be both verbal and written e.g. labelling on the
        medicines, patient information leaflets within the medicines and green
        medicine information card if appropriate.

        Patients who participate in the scheme may benefit from a green Medicine
        Information Card. The nurse/medicines management technician/pharmacist
        can complete the Card following local procedure. The pharmacist will check
        the Medicine Information Card with the in-patient prescription on regular visits
        to the ward and prior to discharge. The pharmacist will also initial the card to
        indicate that it has been checked. The card is then retained by the patient and
        may be taken home for use in the community.
        If nursing staff are satisfied that a green medication card is not required, this
        should be documented in the nursing notes.
        After full explanation, if the patient does not know how or when to take their
        medicines, supervision and further instructions must be given before they are
        allowed to self-administer independently. Progress towards independence
        must be documented in the nursing records.


        8.5.5 Documentation

        All patients will have a drug chart regardless of self-administration level.
        If appropriate, patients in the programme should have a green Medicine
        Information Card completed and given to them. This gives details of all their
        medicines with extra information relating specifically to their medicines. The
        pharmacist or doctor may add additional information.

        Self-administering patients will administer their own medicines with or without
        supervision as deemed appropriate following assessment.

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        The patient is not required to keep a record of doses taken for any medicine,
        even ‘when required’ medicines, unless specifically asked to do so (e.g. for
        “when required medication” if the nurse wishes to know how much analgesia
        the patient is requiring).

        Tablet counts are not necessary unless it is part of a programme to assess,
        with the patient’s consent, whether they are genuinely managing their
        medicines correctly or not.
        Where self-administering patients are on a variable dose of any medicine, the
        nurse will supervise the dose to be taken prior to administration, e.g. Warfarin
        treatment and reducing courses of steroids. The Medicine Information Card
        should be marked to indicate the above.


        8.5.6 Daily Assessments

        Patients participating in self-administration must be assessed by the nurse
        each day for their ability to continue. Nurses are responsible for acting upon
        changes in a patient’s condition that may require moving the patient from one
        level to another. All staff must remain vigilant to ensure that drugs are locked
        away and bedside locker keys kept out of sight.


        8.5.7 Amber Supervision

        Patients who are considered suitable for amber self-administration are often
        at this level in order to determine just how well they can cope with their
        medicines, because their explanation of how they cope is not complete, or
        perhaps they have new medicines or regimens, and it is a chance for them to
        become familiar with their new medicines.

        Documentation in the nursing notes about progress and problems is crucial
        for the future assessment of a patients needs on discharge. Please make full
        notes every time you help a patient to take their medicines at this level.
        At the beginning of every shift, determine which patients are at this level. It
        may be helpful to identify yourself to the patient so they know who to speak to
        if they are going to prompt you when they think it is time for their medicines.
        At any administration time, determine from the notes how much independence
        can be attempted with the patient. Try to encourage use of the green card if
        that will help them. You may be able to present them with several boxes of
        tablets to see if they can determine which one they need at that time. You
        may be able to determine if they can tell that they have more than one pack of
        the same medicine, including different brands of the same generic drug.
        You may be able to let them try to pop the tablet out of the box, to see if they
        have the physical dexterity to manage the packaging.

        You may ask the patient to show you how many they think they ought to be
        taking. Encourage them to explain to you what they think the medicine is for.


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        Supervision means that you can correct any errors they may be making, to
        ensure that they get the correct medicine at the correct dose, and try to
        educate them so that they won’t make the same mistake again.
          • Be aware on every shift which patients are self-administering at amber
             level so that you can devote the appropriate amount of time to that
             supervision and education
          • Allow the patient to be as independent as possible, but supervise them
             closely, and explain any mistakes
          • Document their progress so that the ability of the patient continues to be
             assessed and future ability and needs are easily determined


        8.5.8 Changes and Problems in Self-administration

        When it becomes apparent that a patient is not coping with their self-
        administration level, the nurse or Pharmacist must review the situation and
        change the level of administration appropriately. This may be because of
        forgetfulness, or unsafe storage, or some other issue. This must be fully
        documented on the drug chart and in the patient’s notes – nursing and
        medical.

        If a patient intentionally over, or under-doses, resume custody of the patient’s
        medicines and responsibility for their administration. Inform the patient’s
        doctor, document the incident in the nursing records and complete an
        untoward incident form. Reassess the patient prior to discharge and agree a
        course of action with the doctor regarding the supply of medication.
        Conversely, as a patient becomes more able to self-administer, perhaps
        through improved health status, or greater understanding through education,
        the level of self-administration maybe altered to increase independence.
        These changes must be fully documented as above.


        8.5.9 New or Discontinued Medicines

        Medical staff must inform the patient and the nurse of any additions to,
        deletions from or changes of dosage in a patient’s drug regime. The nurse
        should then update the Medicine Information Card.

        When medicines regimens are altered, self-administering patients must be
        fully aware and understanding of any changes.

        Drugs no longer required should be removed from the drawer/cabinet by the
        pharmacist, pharmacy technician or the nurse. The patients own drugs should
        be stored at ward level until the patient is discharged. Discontinued patients’
        own medicines must be destroyed following NHS Cumbria Waste Medicines
        Disposal procedure (appendix 14), assuming the patient has given consent.


        8.5.10 Controlled Drugs

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        Storage
        Patients’ own Controlled Drugs must not be stored in patients’ drawer/cabinet.
        Due to the legal issues involved in the storage of Controlled Drugs, none of
        these items may be included in the self-administration scheme. This also
        includes items designated as controlled drugs within this trust.
           • Morphine sulphate oral solution 10mg in 5ml
           • Methotrexate

        Administration
        All Controlled Drugs should be issued from the Controlled Drug Cupboard
        following appropriate procedures.

        Remember you can still encourage the patient to prompt you to get their
        medicine at the appropriate time.


        8.5.11 Care Home Setting

        Patients may receive intermediate care in a care home setting. The care
        home may have its own policies, procedures and risk assessment tools for
        self-medication that should be complied with. Where these do not meet the
        needs of patients receiving intermediate care the healthcare professional
        responsible for delivering this care must discuss the situation with the
        registered manager of the home.

        In situations where intermediate care staff consider the PCTs procedures to
        more appropriately meet the needs of patients these can only be implemented
        with the agreement of the registered manager. There must be clear definition
        of the roles of intermediate care staff and the care home staff with respect to
        the assessment, patient support and monitoring which must be fully
        documented in patients’ care plans. This will also have training implications
        for the care home staff that must be appropriate to support self-medication
        and to safely meet the needs of the patients.



        8.6     Administration of Homely Remedies

       The administration of household remedies must follow the NMC guidelines.
       Community hospital staff must also refer to the Homely Remedies in
       Community Hospitals (CPCT/001/041)

       In areas where it is appropriate to undertake the administration of household
       remedies a definitive list must be drawn up in agreement with the doctors and
       the pharmacist.

       Administration of these remedies must be limited to the period of time agreed
       and be within a specific dose schedule.


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       8.7      Administration of Intravenous Medicines

       Intravenous drug administration can be delegated to a registered practitioner
       who has undergone a PCT approved course of training and who feels
       competent and confident to accept responsibility for the administration of drugs
       intravenously in line with the NMC Code of Professional Conduct and the
       Scope of Professional Practice (NMC 2002) and relevant NPSA Safety Alerts
       (Alert 20 and Alert 18 if administering heparin (www.npsa.nhs.uk).

        Staff involved in the preparation and administration of IV medicines should
        refer to the Marsden Clinical Guidelines on vascular devices and
        administration of medicines.

        A Standing Operating Procedure is required for the administration of
        injectables (www.npsa.nhs.uk). The administration of injectables is covered
        by the Standing Operating Procedure for the Prescribing, Preparation and
        Administration of Intravenous Drugs (Appendix 1; SOP 3)

        Wherever possible, additional medicines should not be added to an
        intravenous infusion, and the infusion ideally should be sourced ready-made
        from the pharmacy department.

        Where possible, all intravenous infusions with additives that require
        preparation must be checked by two registered healthcare professionals.

        An I.V. drug additive label must be attached to the back of the infusion bag, or
        the barrel of the syringe, with the following information:

        •    The patient’s name and hospital number (in-patient setting only)
        •    The patient’s ward (in-patient setting only)
        •    The drug added
        •    The dose added
        •    The date and time the drug was added
        •    The signatures of both healthcare professionals

        The batch number of the intravenous infusion must be recorded on the
        administration chart.

        In the community setting both the patient and the GP responsible for their
        care must consent to the treatment being carried out at home and the
        environment must be assessed as suitable and have telephone access in
        case of an emergency/anaphylaxis. The practitioner should not rely on access
        to a mobile telephone. (Appendix 17 – Criteria for suitability of IV drug
        administration in Home environment following discharge)

        As part of the assessment, agreement must be reached as to who is
        competent and responsible for resiting the cannula if required.

        The patient’s condition must be assessed as stable and skilled staff be
        available throughout the treatment with epinephrine (adrenaline) available for
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October 2010
        emergency use. Epinephrine (adrenaline) packs for treatment of anaphylaxis
        should be carried by the nurse.

        The cannula should be checked for patency before drug administration
        (Appendix 16 – IV Cannula Observation Chart)

        All patients with an intravenous access device in place must have the site
        checked at least daily for signs of infusion phlebitis, using the Visual Infusion
        Phlebitis Score (Appendix 16 – IV Cannula Observation Chart)

        Patients and carers must be educated in the safe use and storage of these
        drugs.


        8.8     Administration of Medicines through PEG Tube

        Staff involved in the preparation and administration of medicine via a
        Percutaneous Gastrostomy (PEG) tube should refer to the relevant Marsden
        Clinical Guidelines.

        Only use labelled oral/enteral syringes that cannot be connected to
        intravenous catheters or ports to measure and administer oral liquids (see
        NPSA Alert 19 www.npsa.nhs.uk).

        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.

        Before administering medicines through a PEG tube, the healthcare
        professional must be sure that the dispensing pharmacy was aware of the
        intended route of administration, and seek further advice from the pharmacy
        department or a pharmacist as required, to ensure the medicine is suitable for
        PEG administration. The healthcare professional must be competent and
        knowledgeable of the procedures required to administer medicines in this
        way.
        http://nww.staffweb.cumbria.nhs.uk/acute/policies/m_s/naso%20gastric.pdf
        http://nww.staffweb.cumbria.nhs.uk/acute/policies/m_s/peg.pdf

        8.9     Administration of Cytotoxic Drugs:

        Practitioners administering these drugs must be trained and competent to do
        so and should attend annual updates. They should have a written prescription
        stating clearly the drug name, dose, rate (if appropriate), frequency and timing
        and route of administration and, where appropriate, a review date of the
        treatment. This should be signed and dated by a medical practitioner.

        All cytotoxic medication, whether oral or injectable, should be obtained in a
        ready-to-administer form. Nurses must not perform dose preparations or
        manipulations for safety reasons.

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        An assessment should be made of the suitability of the patient’s home
        environment including telephone access in case of emergency/anaphylaxis.

        Cytotoxic waste must be disposed of in a cytotoxic waste bin or other
        receptacle, which should be supplied by the hospital at the same time as the
        supply of the drug. For further information refer to the Trust’s Waste
        Management Policy.

        Practitioners, who administer cytotoxic drugs, including oral anti-cancer
        medication, should have ready access to appropriate written protocols and
        treatment plans including guidance on monitoring and treatment of toxicity
        and dealing with accidental spillage of cytotoxic medication.



        8.10 Administration of Medicines via a Syringe Driver

       Syringe drivers are used for the continuous administration of drugs over time
       and are used to deliver analgesia, anti-emetics and sedatives via a
       subcutaneous route.

       Assessment of pain is key to the success of the treatment regimen. This
       should be a regular activity carried out in collaboration with patient, his/her
       carers and the patient’s GP.

       The practitioner should be familiar with the device used as calculating the rate
       of delivery can vary between different models of syringe driver.

       Several drugs may be used in combination, but advice should be sought from
       a hospital or community pharmacist, specialist hospital or hospice services to
       ensure compatibility.

       Education and information are essential for successful management of the
       patient at home and for compliance with the drug regimen.

       Patients receiving analgesia via a syringe driver require as a minimum, daily
       visits from the practitioner to change the syringe and with access to support
       and advice between visits.

       The practitioner should be aware of and refer to syringe driver information on
       the North Cumbria Palliative Care website.
       http://www.gp-palliativecare.co.uk/?c=clinical&a=syringe_drivers


        8.11    Administration of Pre-filled Insulin (Appendix 1; SOP 10)

        There are a significant number of patients with diabetes who cannot convert
        to using an insulin pen which is often due to poor manual dexterity, lack of
        strength, personal preference or even reluctance to change (RCN 2006). As a
        result many patients require input from community nursing teams to prepare
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        insulin injections for patients to administer in their own homes at a later time.
        The pre-loading of insulin enables patients to preserve their independence
        and facilitate patient choice.

        On some occasions community nursing teams are also required to administer
        the insulin. Up until now the RCN has had support from the Nursing and
        Midwifery Council (NMC) that this practice was acceptable, but following the
        withdrawal and then introduction of new insulins, the RCN Diabetes Forum
        updated guidance on the advance preparation of insulin syringes. The RCN
        Diabetes Forum believes that this practice should only be undertaken
        following thorough assessment of a patient (Appendix 18) and it is thought
        that only a small number of patients would require having their insulin pre-
        loaded.

        The Department of Health (DOH) and the Medicine and Healthcare products
        Regulatory Agency (MHRA) guidance stipulates that pre-loaded syringes
        should be drawn up and stored for no more than 24 hours at a time.

        Pre-loading of insulin for injection should only begin following a thorough
        assessment of the patient’s treatment, care and understanding. Patients
        would be required to be able to self administer the pre-loaded syringe.

         Patients should be advised of the correct storage conditions.

         Patients need to have received appropriate education to ensure that they are
        able to tailor their insulin injection to the right time using the correct injection
        technique.


        8.12    Verbal Request to Administer Medicine

8.12.1 For medication previously prescribed
       In exceptional circumstances, where medication (excluding Controlled Drugs)
       has been previously prescribed and the independent prescriber is unable to
       issue a new prescription, but where changes to the dose are considered
       necessary, the prescriber may make a telephoned request to a registered
       nurse. This should only be a last resort, if no other options are available (for
       example, delivery of prescription by courier or taxi). The request MUST be
       confirmed by fax or email, which should be attached to the prescription chart,
       MAR chart or Care Plan. This should be followed up by a new prescription
       signed by the prescriber who sent the fax/email confirming the changes within
              normally 24 hours (72 hours maximum – Bank Holidays and
       weekends)

        The prescriber must state the following:

        •   Name of patient
        •   Name of the drug
        •   The dose to be given
        •   The route of administration
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        •   The timings and frequency of administration
        •   Duration of the prescription (72 hours maximum)


        The registered nurse must:

        •   Be satisfied that the individual they are speaking to is genuine, and is a
            registered prescriber
        •   Be satisfied that the circumstances justify accepting the verbal request
        •   Repeat the information back to the prescriber in order to confirm it
        •   Make an immediate record in the nursing notes and sign it, recording:
               o That a verbal order was taken and the details of that order
               o The prescriber’s details
               o The time
               o The date
        •   Request confirmation by fax/email before medicine may be administered

.
        8.12.2 For medication NOT previously prescribed
        In exceptional circumstances a medical practitioner may need to prescribe
        remotely for a previously unprescribed medicine e.g. in palliative care or in
               remote and rural areas.

        A nurse or midwife independent prescriber may not prescribe remotely if s/he
        has not assessed the patient, except in life threatening situations. See
        Standard 20 of the Standards of Proficiency for Nurse & Midwife Prescribers
        (2006) (www.nmc-uk.org/aArticle.aspx?ArticleID=2021)

        This should only be a last resort, if no other options are available (for
        example, delivery of prescription by courier or taxi). The prescription must be
        confirmed by fax or email before it is administered. 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).

        The prescriber must state the following:

        •   Name of patient
        •   Name of the drug
        •   The dose to be given
        •   The route of administration
        •   The timings and frequency of administration
        •   The duration of the prescription (maximum 72 hours)




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        The registered nurse must:

        •   Be satisfied that the individual they are speaking to is genuine, and is a
            registered prescriber
        •   Be satisfied that the circumstances justify accepting the verbal request
        •   Repeat the information back to the prescriber in order to confirm it
        •   Make an immediate record in the nursing notes and sign it, recording:
               o That a verbal order was taken and the details of that order
               o The prescriber’s details
               o The time
               o The date
        •   Request confirmation by fax/email before medicine may be administered

        The registered nurse may ask the prescriber to repeat the information to a
        second nurse for confirmation

        The registered nurse is accountable for ensuring all relevant information has
        been communicated to the prescriber and may refuse to accept a remote
        prescription if it compromises care to the patient. In this instance she should
        document accurately the communication that has taken place.

        Remote prescribing cannot be undertaken in a care home because they do
        not have access to a stock of medicines.

        A prescription is required when the drug is to be both supplied and
        administered.

        For administration only, a direction to administer is sufficient.

        Refer to the GMC Good Medical Practice Guide for further information


        8.13    Refusal of Medication

        Any patient has a right to refuse medication at any time.

        If this occurs, then the healthcare professional responsible for administering
        the medicine must identify by discussions with the patient the reason he/she
        does not wish to accept the medication.

        If, after this discussion, the healthcare professional still believes the
        medication is correct for the patient, they should ensure that the patient has
        sufficient information to make an informed decision, seeking additional
        information from a pharmacist or a prescriber as required.

        If the patient decides that they do not wish to accept the medicine, the
        prescriber should be informed within an appropriate timeframe, depending on
        medical need.


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October 2010
        If, after discussions with the patient, the healthcare professional believes that
        the medication is not suitable for that individual, then this should also be
        reported to the prescriber.

        For all of the above the patient must be informed of the procedure and a
        record made on the administration record


        8.14     Distractions

        It is the responsibility of the healthcare professional concerned to ensure that
        they are able to give their full concentration to the administration of
        medication.

        If non urgent situations or distractions occur, the healthcare professional
        should finish administering the medication to the patient and reach a point
        where they feel it safe to adjourn before dealing with the situation.

        In emergency situations it may be required that the healthcare professional
        stops administering and assists with the urgent situation. Where this happens
        the medicines must be locked up safely, the emergency situation dealt with,
        and then the administration process started from the beginning once the
        emergency situation is over. Any medication which has been previously
        placed into a medication pot etc, but not handed to the patient, must not be
        used, but disposed of appropriately.

        Dealing with an emergency situation or an untoward incident can be stressful
        and therefore have a psychological impact on the staff involved. Where a
        healthcare professional has been involved with an emergency or untoward
        incident and is then required to administer medication, the healthcare
        professional themselves must judge whether they are able to safely carry out
        this duty.

        In wards where healthcare professionals feel they are frequently distracted
        when administering medication it is their responsibility to report this to the
        nurse in charge. It is then the responsibility of the nurse in charge to assess
        the problems and determine whether any further action is needed.


        8.15    Administration of Medicines in an Emergency

        All clinical areas on PCT premises will have a sealed, tamper evident
        container of drugs for emergency use.

        A healthcare professional may only administer any of these drugs to a patient
              if they are familiar with the use of these drugs in emergency situations,
        and are confident in their competence to administer them. Further advice from
        a professional experienced in dealing with emergencies must always be
        sought in cases of doubt.


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        8.16    Administration to Self or Colleagues

        Staff are not permitted to use medicines from ward stock to treat themselves
        or colleagues, unless they are themselves in-patients, and are being treated
        in accordance with the rest of this policy.


9.      DISPOSAL

        9.1     Out of Date Medicines or Medicines No Longer Required

        9.1.1 Trust Premises
        Stocks no longer required cannot be returned to the pharmacy department.

        Unwanted stock items, out of date medicines and Patients’ own drugs (with
        appropriate consent) must be disposed of on the ward following NHS Cumbria
        Waste Medicines Disposal procedure (appendix 14).

        Controlled drugs disposed of following PCT Safe and Secure Handling of
        Controlled Drug policy.


        9.1.2 Patient’s Home

        The disposal of medicines kept in a patient’s home is the patient’s / next of
        kin’s responsibility. Healthcare professionals must advise the patient / next of
        kin that they must take the medicines to their local pharmacist for safe
        disposal. If there is no suitable next of kin then the healthcare professional
        must use their professional judgement to decide on an appropriate method for
        disposal.


        9.1.3 Care Home

        The disposal of medicines kept in a care home is the responsibility of the Care
        Home. Homes which were formerly classed as nursing homes must dispose
        of medicines with their clinical waste, in accordance with waste regulations.
        Homes which used to be classed as residential homes may take medicines to
        their local community pharmacy for safe disposal.


        9.2     Medicines Prepared but Not Used

        Individual doses of medicines that have been prepared for administration but
        not given must be destroyed in the clinical area, in the presence of a witness,
        by emptying the medication into a sharps bin, following NHS Cumbria Waste
        Medicines Disposal procedure (appendix 14).

        Medications must never be disposed of into the mains sewerage system.
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        9.3      Cytotoxic drugs

        Cytotoxic waste must be disposed of in a cytotoxic waste bin.

        Cytotoxic waste in Community Hospitals and clinics disposed of following
        NHS Cumbria Waste Medicines Disposal procedure (Appendix 14).




10.     CLINICAL TRIALS

        All trials must be approved by the local Research Ethics Committee, and
        registered with the PCT’s Research and Development department.

        When medicines have been prescribed for a patient as part of a clinical trial,
        the prescriber and any authorised healthcare professional administering the
        medicine must ensure that he/she is aware of the potential safety issues,
        including side effects, and that the patient has given informed consent to
        participate in the trial.

        A copy of the protocol for the trial must be available for any member of staff
        involved in the patient’s care to read.

11.     MEDICATION INCIDENTS

        Any incident that occurs which falls outside the guidelines and regulations set
        out within this policy must be reported immediately to the appropriate line
        manager. The PCTs’ system for significant event reporting must be followed.

        Such incidents will include administration errors, prescription errors and
        includes failure to administer prescribed medications without due cause. Near
        misses must also be reported.

        It is paramount that the patient is made safe.

        •     If required, take observations of blood pressure, pulse and respiration
              rates.
        •     Inform the doctor and the appropriate clinical manager immediately,
              providing details of the incident and the patient’s condition.
        •     Further observations may be required. This will be determined by the
              patient’s condition.
        •     As soon as possible after the incident has occurred and before the end of
              the shift, a record must be made within the patient’s notes, and the
              significant event reported following PCT procedure.

        The patient has the right to know if an incident has occurred, and must be
        informed of this as soon as possible. Often it is the patient who brings it to the
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        attention of the staff. At the earliest opportunity the responsible medical
        practitioner should also inform the relative or carer.


12.     MEDICINE DEFECTS

        The reporting and recall of medicines which are known or suspected to be
        defective must be carefully and promptly carried out to ensure that patients
        are not put at risk.

        Defects with medicinal products may become apparent on receipt of the
        product from pharmacy, at the time of preparation for use, or during
        administration to a patient. Defects may relate to any kind of medication,
        including infusion fluids, injectable drugs, eye drops and topical products,
        tablets, capsules and medicated dressings.

        Whilst many product defects are of a minor nature, some defects may pose a
        significant hazard to patients. For instance, a cloudy infusion fluid may
        suggest the presence of microbial contamination. In such cases it is essential
        that immediate action be taken to notify the dispensing pharmacy in order to
        prevent potential harm to patients.

        Defects of a less serious nature, unlikely to influence patient care, include the
        presence of broken tablets in a container and problems with security seals.

        The healthcare professional in charge of the ward/department must assess
        the seriousness of the product defect.
         If the defect is potentially serious and could affect patient care, contact the
        dispensing pharmacy as soon as possible.

        If microbial contamination is suspected contact the Control of Infection Officer
        or deputy immediately for further advice.

        If in doubt about the appearance or suitability for use of a medicinal product,
        do not use, and seek advice from the pharmacy.


13.     SUBSTANCES OF ABUSE

        Where a patient is found to be in possession of a suspected illicit or
        unidentifiable substance on PCT premises, they will be requested to place
        these in the custody of staff. If the patient refuses, then contact the medical
        practitioner with responsibility for their care in order to agree a clinical
        management plan for the patient.

        The substance must be sealed in a plastic bag marked “non-
        prescribed/unknown substance”, witnessed by a second staff member and the
        pharmacy contacted for further advice.



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        Once removed from the custody of the patient, the substance cannot be
        returned to them, e.g. on discharge from the ward, since this would be illegal.

        Outside normal pharmacy hours the substance must be stored in the
        Controlled Drugs cupboard and an entry made in the Controlled Drugs
        register similar to the arrangements for recording patients own Controlled
        Drugs, until the pharmacy can be contacted. No patient details shall be
        recorded against the substance.


14.     UNLICENSED MEDICINES

        UK medicines legislation requires that medicinal products be licensed before
        they are marketed in the UK. Accordingly, no medicinal product may be
        placed on the market unless a Marketing Authorisation (formerly known as a
        Product Licence) has been issued by the Medicines and Healthcare Products
        Regulatory Agency (MHRA).

        Unlicensed products are not subject to any assessment by the Licensing
        Authority. Neither prescribers nor pharmacists can make the same
        assumptions of quality, safety and efficacy about unlicensed products as they
        do for licensed medicines.

        For additional details and guidance refer to MHRA Guidance note 14 (revised
        May 05) “The supply of unlicensed relevant medicinal products for individual
        patients”. www.mhra.gov.uk/Publications/Regulatoryguidance/index

       Guidance on the use of unlicensed medicines in paediatric practice is available
       from the Royal College of Paediatrics and Child Health


        14.1    Use of Unlicensed Medicines

        Unlicensed medicines must only be used where the clinical needs of the
        patient cannot be met by a licensed medicinal product. Unlicensed medicines
        can either be those with no licence or not licensed for the proposed indication.


        14.2    Liability

        When a licensed medicine is used, the liability for an untoward event caused
        by the medicine remains with the manufacturer or licence holder provided it
        has been used in accordance with the terms of its licence. However, when the
        medicine is unlicensed, or is used in an unlicensed way, any untoward event
        becomes the responsibility of the prescriber.

        Some licensed products are utilised for unlicensed uses, and although
        situations vary it may be that there is a recognised body of evidence in
                support of such therapeutic use.

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        Those involved in the prescribing, or administration, of an unlicensed
        medicine should be aware of the products unlicensed status and any known
        relevant risks associated with its use. Advice on the licensed status of a
        product should be obtained from a pharmacist.

        Whenever unlicensed medicines are prescribed, or licensed medicines are
        prescribed for unlicensed indications, prescribers are professionally
        accountable for their judgement and may be called upon to justify their
        actions. This includes non-medical prescribers where eligible to prescribe
               unlicensed medicines.


        14.3    Patient Information and Consent

        Patients have the right to know when any medicine prescribed for them is
        unlicensed, or outside its licence.

        Information must be given to the patient prior to prescribing an unlicensed
        medicine, or a licensed medicine for an unlicensed indication. It must be
        documented in the patient’s medical record that this information has been
              given and that the patient has agreed to the prescription.

       .

15.    PATIENT GROUP DIRECTIONS AND PATIENT SPECIFIC DIRECTIONS

       The preferred way for patients to receive medicines is for trained healthcare
       professionals to prescribe for individual patients on a one-to-one basis.
       However there may be circumstances where it is more appropriate for a
       patient to receive a medicine directly from another health professional via a
       patient specific direction or a patient group direction.

        15.1 Patient Group Directions

       A Patient Group Direction (PGD) provides a safe and legal framework, which
       enables medicines to be supplied and/or administered by a range of
       healthcare professionals in circumstances when a doctor or other prescriber is
       not necessarily available to prescribe that medicine for an individual. PGDs
       are written instructions for the supply and/or administration of named
       medicines in an identified clinical situation. This means that an individual
       prescription is not required each time the medicine is administered.

       The majority of clinical care should be provided on an individual, patient
       specific basis. The supply and administration of medicines by Patient Group
       Directions should be reserved for those limited situations where this offers an
       advantage for patient care without compromising patient safety, and where it is
       consistent with appropriate professional relationships and accountability.

       All staff developing, reviewing and utilising PGDs must be competent to do so.

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       (refer to NHS Cumbria Policy for the Development, Review and Use of Patient
       Group Directions (PGDs)).

       All PGDs must follow the agreed PCT format. PGDs must only be used by
       individuals who are legally allowed to use them. The following groups of
       qualified health care professionals are currently permitted to supply and/or
       administer medicines under a PGD. However the professionals may only do
       so as named individuals and must sign a declaration that they understand the
       terms of the PGD and are competent to work under its direction.
            - Nurses
            - Health visitors
            - Midwives
            - Pharmacists
            - Physiotherapists
            - Dieticians
            - Occupational therapists
            - Speech & language therapists
            - Optometrists
            - Orthoptists
            - Orthotists & prothetists
            - Chiropodists (podiatrists)
            - Radiographers
            - Ambulance paramedics

       Where medicines are to be supplied to a patient for self-administration (e.g.
       minor injuries or ailments), the medicines should be in pre-packs supplied by
       an appropriate pharmacy. The EC Labelling and Leaflet Directive 92/97 will
       apply to supplies of medicines made via PGD. There must be a secure
       system for recording and monitoring such medicines to enable reconciliation
       of incoming and outgoing stock on a patient by patient basis.

       If a team or an individual recognises a need for a PGD, they should contact
       the Head of Medicines Management who will advise on whether a potentially
       suitable PGD already exists or is in development.

       The PCT has approved PGDs for a range of circumstances, e.g.
       immunisations, emergency hormonal contraception, minor ailments etc.
        These PGDs are available at
       www.cumbria.nhs.uk/professionalzone/medicinesmanagement


15.2    Patient specific direction

       A patient specific direction (PSD) is a written instruction from an independent
       prescriber (doctor, dentist or non-medical prescriber) to another healthcare
       professional to supply and/or administer a medicine to a named patient or to
       several named patients, following patient assessment by the prescriber.

       A PSD is specifically tailored to the needs of an individual patient and
       therefore should be used in preference to a PGD where appropriate
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16      RESPONSIBILITIES

        16.1    All Staff

        All staff that prescribe, handle, supply or administer medicines are responsible
        for:

        •   Ensuring they have read and understood the sections of this policy that
            apply to them
        •   Working within current legislation


        16.2    Individual Responsibilities

        16.2.1 Healthcare professionals

        Each registered healthcare professional that prescribes, handles, supplies or
        administers medicines is responsible for:

        •   Working within current legislation and within the code of conduct of their
            professional body.
        •   Maintaining registration.
        •   Undertaking Continuous Professional Development and relevant training.
        •   Reporting medication errors and near miss incidents


        16.2.2 Support Staff such as Assistant Practitioners and Healthcare
        Assistants

        Each Assistant Practitioner and Healthcare Assistant who handles or
        administers medicines is responsible for:

        •   Undertaking relevant training.
        •   Ensuring that they have the relevant competencies


        16.2.3 Prescribers

        Each prescriber is responsible for:

        •   Prescribing safely, accurately and appropriately
        •   Reporting medication errors and near-miss incidents
        •   Seeking advice when needed. A prescriber must be confident of their
            competence to prescribe a particular medicine. Prescribers are personally
            accountable for their prescribing decisions.
        •   Ensuring that they do not put pressure on other healthcare professionals
            to act in direct contravention of this policy

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        16.2.4 Registered Nurses

        Each nurse is responsible for:

        •   Acting within the framework of current legislation and in accordance with
            NMC Code of Conduct Standards for medicines management and in line
            with Trust policy and guideline documents.
        •   Reporting medication errors or near-miss incidents
        •   Bringing to the attention of their line manager any educational needs they
            may have in relation to ensuring safe practice in this important function,
            and undertaking necessary training.
        •   Taking professional accountability for their actions – for example, any
            nurse who has been given responsibility for the administration of
            medicines to a patient is personally responsible and accountable for the
            administration of that medicine to the patient. That accountability cannot
            be delegated or shared with another person, whether the task has been
            delegated or not.


        16.2.5 Witnesses

        Any individual who performs the role of witness (second checker e.g.
        healthcare assistants or assistant practitioners) is responsible for:

        •   Witnessing the administration process from preparation of the medicine,
            through to its administration to the patient, and the appropriate disposal of
            any surplus medicine. ( Appendix 1 - SOP 8 )
        •   Signing the appropriate documents providing evidence of their role in the
            check procedure.
        •   Ensuring they have received appropriate training.

        16.2.6 Pharmacists

        Pharmacists are responsible for:

        •   Ensuring that processes are in place so that medicines are prescribed,
            supplied, stored, prepared, administered and destroyed correctly.
        •   Ensuring that policies and procedures are followed.
        •   Bringing to the attention of their line manager any educational needs they
            may have in relation to ensuring safe practice in this important function,
            and undertaking necessary training




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        16.2.7 Appointed Nurse or Authorised Healthcare Professional in Charge

        The appointed nurse or authorised healthcare professional in charge is
        responsible for:

        •   Ensuring that all relevant policies relating to the storage and administration
            of medicines are available and followed within the ward/department. They
            must ensure that all staff know how to access these documents on the
            Intranet and that these documents form part of the core induction
            programme for all registered nurses joining their clinical area.
        •   Ensuring audits are carried out and actions identified are implemented.
        •   Ensuring that an up to date list of authorised signatures is maintained and
            lodged with the pharmacy department.
        •   Ensuring that all medications are kept in a safe and secure manner at all
            times and that access to them is controlled.
        •   Ensuring that appropriate checking procedures are in place to monitor
            adherence to these points.
        •   Ensuring that appropriate levels and range of stock drugs are established
            in conjunction with pharmacy staff.
        •   Ensuring that any Patient Group Directions are used according to safe
            systems and processes approved by the PCT.
        •   The development, implementation and maintenance of an effective system
            that ensures the secure management of the drug keys.
        •   Ensuring that access to controlled stationery such as prescriptions and
            Controlled Drug stationery is restricted to authorised staff.
        •   Checking that their staff are registered with their professional body
        •   Ensuring that medication errors are reported and investigated.


        16.2.8 Head of Medicines Management

        The Head of Medicines Management is responsible for:

        •   Establishing a system which ensures the procurement of pharmaceuticals
            of appropriate quality.
        •   Establishing a system for the safe and secure handling of medicines.
        •   Establishing and maintaining a system and audit trail for the supply,
            distribution, return and destruction of medicines.
        •   Establishing and maintaining a system that ensures the availability of
            advice and medicines for use in an emergency.




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        16.2.9 Director of Clinical Services

        The Director of Clinical Services is responsible for:

        •   Ensuring that safe systems and practices are implemented maintained and
            monitored within wards, departments and/or teams.
        •   Ensuring there are systems in place to provide relevant education and
            training for nursing staff
        •   Developing, auditing and effectively managing non-medical prescribing.
        •   Ensuring medication errors are reported and investigated.


17      STAFF TRAINING IMPLICATIONS

       All relevant employees of the PCT must receive appropriate training regarding
       all aspects of this Policy, and are expected to identify any training needs in
       their personal development plan.

       It is the responsibility of the service manager or professional supervisor/team
       adviser to ensure that suitable training is carried out.

       Staff must not undertake prescribing, supply or the administration of medicines
       unless they are legally authorised and are competent to do so.

       PCT Pharmacists will assist in identifying the training needs of any PCT staff
       using medicines, and will participate in training provision.

       The PCT is committed to training and continued development of staff,
       including supporting contractor services on all relevant issues around this
       policy.

        Detailed training needs analysis has been undertaken as part of development
        of this policy (see template 1). Full details of training requirements can be
        found in the Trust Training Matrix
        http://nww.staffweb.cumbria.nhs.uk/cumbriapct/Departments/training/Training
        %20Matrix.doc


        17.1    Implementation of this Policy

        Details of the implementation plan for this policy can be seen in Template 10


        17.2    Monitoring and Review

        Monitoring Compliance with this Policy

        The PCT will have key indicators to monitor infection prevention and control
        that will be included in all PCT performance processes, including the
        Assurance Framework. The performance indicators will be:
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            a)   Reduction of MRSA Bacteraemia.
            b)   .Reduction of clostridium difficile associated diarrhoea
            c)   ..
            d)   ..
            e)   ..
            f)   ..


18      DEFINITIONS

     Appointed nurse in charge          The senior nursing appointment for the ward
                                        or department
     Assigned nurse in charge           The senior nurse on duty for the ward or
                                        department who has been identified as the
                                        nurse in charge for that shift.
     Assistant Practitioner             Non-registered staff who support nurses and
                                        other healthcare
                                        professionals in the provision of direct care.
     Audit trail                        A system whereby all transactions regarding
                                        a specific medicine can be traced from the
                                        act of purchase to the point of use.
     Clinical manager                   The senior healthcare professional in charge
                                        of a ward or department.
     Controlled Drugs                   Controlled Drugs (CDs) are classified in
                                        various schedules depending on their
                                        therapeutic usefulness and potential for
                                        harm.     Each      schedule    has    different
                                        requirements in relation to storage, handling,
                                        record-keeping. The classifications are set
                                        out in the current Misuse of Drugs
                                        Regulations.
     FP10                               NHS prescription form used by prescribers in
                                        the community, dispensed at community
                                        pharmacies or in dispensing doctors’
                                        practices.
     Head of Medicines                  The individual with an overall responsibility to
     Management                         ensure responsibilities regarding medicines
                                        safety are met. At times this will be delegated
                                        to other senior pharmacists.
     Healthcare Assistant               Non-registered staff who support nurses and
                                        other healthcare
                                        professionals in the provision of direct care.
     Healthcare professional            Used throughout this policy as an inclusive
                                        term     for    all    registered    healthcare
                                        professionals such as doctors, dentists,
                                        nurses, pharmacists and allied health
                                        professionals.


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      Locality Pharmaceutical The       Pharmaceutical      Adviser     with
      Adviser                 responsibility for the locality in which the
                              hospital or department is based
      UHMBT                   The University of Morecambe Bay Hospitals
                              NHS Trust
      NCUHT                   The North Cumbria University Hospitals NHS
                              Trust
      NHS Contractors         General practices, community pharmacies,
                              dental practices, opticians, out of hours
                              medical services providers, and any other
                              bodies in Cumbria which contract with the
                              NHS to provide services.
      NMC                     The Nursing and Midwifery Council
      Patient Group Direction A written direction relating to supply and
      (PGD)                   administration, or administration only of a
                              prescription-only medicine to persons
                              generally (subject to specified exclusions)
                              and is signed by a doctor or a dentist, and by
                              a pharmacist.
      Pharmacy staff          Staff employed in the pharmacy department
                              at either NCUHT or UHMBT.

      Medicines Management              Staff    employed   in    the       Medicines
      staff                             Management team by the PCT, either
                                        Prescribing   Support    pharmacists       or
                                        Medicines Managers project facillitators
      Medicines Managers                Employed by Primary Care GP practices
      Prescriber                        A doctor, dentist or non-medical prescriber
                                        registered as such with their professional
                                        body.
      Primary Care Trust (PCT)          CUMBRIA PCT
      or Trust


19.     REFERENCES

        NMC Standards for Records and Record Keeping (2002)
        NMC Standards for medicines management (2007)
        NMC Midwives Rules and Standards (2004)
        Standards of Proficiency for Nurse & Midwife Prescribers (2006) (www.nmc-
        uk.org/aArticle.aspx?ArticleID=2021)
        GMC Good Medical Practice Guide
        RCN Advance preparation of insulin syringes for patients to administer at
        home (2006)
        The Medicines Act – 1968 and subsequent regulations
        The Misuse of Drugs Act – 1971 and subsequent regulations
        The Safe and Secure Handling Of Medicines - A Team Approach (The Royal
        Pharmaceutical Society Of Great Britain (RPSGB)) - 2005.

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        Department of Health (2003) Confidentiality: NHS Code of Practice. Available
        at:
        http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Patientc
        onfidentialityandcaldicottguardians/DH_4100550
        Standards for Better Health: Core standard C04d: Healthcare organisations
        keep patients, staff and visitors safe by having systems to ensure that
        medicines are handled safely and securely
        Marsden Clinical Guidelines
        http://nww.intranet.cumbria.nhs.uk/ClinicalTools/MarsdenGuidelines/Home.as
        px
        HSC 2000/026 Patient Group Directions
        Security of prescription forms guidance. February 2008. Business Services
        Authority
        http://www.cfsms.nhs.uk/doc/sms.general/security_prescriptions.pdf
        Medicines Reconciliation: A Guide to Implementation. National Prescribing
        Centre
        http://www.npci.org.uk/medicinesmanagement/safety/reconcil/library/guide
        reconciliation.php
        Technical patient safety solutionsfor medicines reconciliation on admission of
        adults to hospital. NICE/NPSA/2007/PSG001 December 2007.
        http://www.nice.org.uk/nicemedia/pdf/PSG001Guidance.pdf
        Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted
        and delayed medicines in hospital safety/?entryid45=66720
        http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/medication-
         Policy for Confirmation of Nasogastric Tube Position in Adult Patients
        http://nww.staffweb.cumbria.nhs.uk/acute/policies/m_s/naso%20gastric.pdf
        Guidelines for the Nursing Management of Patients with Percutaneous
        Gastrostomy Tubes (PEG)
        http://nww.staffweb.cumbria.nhs.uk/acute/policies/m_s/peg.pdf
        NHS North Cumbria Palliative Care website.
       http://www.gp-palliativecare.co.uk/?c=clinical&a=syringe_drivers
       “The supply of unlicensed relevant medicinal products for individual patients”.
       www.mhra.gov.uk/Publications/Regulatoryguidance/index
       Policy for management of incidents including management of serious incidents
       CPCT0005/011
       http://www.cumbria.nhs.uk/docstorage/PoliciesAllActive/PolicyUpload/Manage
       mentofIncidentsApril+09-April10%5b1%5d.pdf
       Hand Hygiene policy for Healthcare Workers
       http://www.cumbria.nhs.uk/docstorage/PoliciesAllActive/PolicyUpload/HandHy
       giene.pdf




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20.      APPENDICES

         20.1 Appendix 1 – Standard Operating Procedures

         SOP 1 - Medicines Reconciliation
         (Read in conjunction with Section 4.1)

         Responsibilities

         Nursing staff responsibilities
           • Nursing staff are responsible for ensuring that all patients medication
               brought into hospital is available for assessment by the admitting
               clinician, pharmacist or pharmacy technician.

         Admitting clinician responsibilities
           • Admitting clinicians have a responsibility to ensure that a record is
                made of all medication brought into hospital by the patient, that the
                medication is verified, clarified and reconciled.

         Medicines Management responsibilities
           • Medicines Management has a responsibility to undertake medicines
               reconciliation as soon as possible after admission.

         Procedure
      1. Document the completion of a drug history on the front of the prescribing and
         administration chart, and/or the clerking in proforma, including the source of
         information, signature and date.

      2. It is important that any non-prescribed medicines are documented when
         taking a drug history. A full drug history must include the following:
         • All prescribed medicines
         • All over-the-counter medicines
         • All hormonal and contraceptive medicines
         • All herbal, vitamin & homeopathic preparations
         • All clinical trial medicines
         • Smoking cessation products
         • Any medicines recently stopped, started, changed e.g. antibiotics, steroids,
           possible side effects


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    3. For each category, administration by any route must be considered including
       • Topical
       • Insulin
       • Inhalation/nebuliser
       • Eye preparations
       • Depot injections

    4. The following are useful sources of information
       • Patients and their carers
       • GP surgery – date of issue and quantity; Repeat or Acute; other specialities
         e.g. psychiatry may be separate. (Medicine Manager good point of contact in
         preference to asking reception staff)
       • GP letter – care with out of hours service
       • Copy of current prescription
       • Patient Medication Chart, including Pain chart and other supplementary
         charts
       • Patient’s own drugs – patient may take different from the label; date of issue
         (non-compliance or stopped)
       • Medication Administration Record Sheets (MAR charts) – Care Homes
       • Nursing home or referral letter
       • Community pharmacy
       • Old hospital notes – watch dates
       • Steroid card / warfarin card

    5. Document in medical notes any reasons for differences e.g. GI bleed –
       NSAIDs, hypotensives

    6. Record the specific source of information in the notes, especially if obtained
       from different sources

    7. Where there are differences between the medication histories obtained from a
       variety of sources, advice from a pharmacist should be sought.

    8. Document all medicine allergies/sensitivities, whether of minor or major
       significance, in the patient’s notes and on the prescribing and administration
       chart. Any potential allergic reactions must be considered when prescribing
       medicines.

    9. Check any noted allergies /sensitivities are transposed when the prescribing
       and administration chart is re-written.

    10. Where there is no known sensitivity “none known” must be written on the
        prescribing and administration chart to indicate that the question has been
        asked. Sign and date appropriately.

    11. If the allergy history cannot be established (notes unavailable; patient
        unconscious) then “history unable to be obtained” must be written in the
        allergy box and entry signed.


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    12. Any allergy or reaction which develops during a patient’s hospital stay must
        be recorded on the patient’s prescribing and administration chart and a full
        report made in the patient’s notes.

    13. A brief description of the reaction (e.g. upset stomach, rash) as well as the
        medicine name should be documented to enable informed decision making to
        occur.

    14. All relevant metal and food allergies (e.g. eggs, nuts) must be noted in the
        patient’s notes and on the prescribing and administration chart. Signed and
        dated.

    15. Any allergy/sensitivity to latex or elastoplast must be noted in the patient’s
        notes and on the prescribing and administration record chart. Signed and
        dated.

    16. Patient’s who give a history suggesting latex allergy must be treated as being
        latex-allergic no matter what the result of any screening.

    Tips for collecting an accurate medication list:

            • Collect the best list you can. Learn why the list is not complete and work
              on how to address these gaps.
            • List the source of information: this may be useful in determining the
              reliability of the medication list.
            • Defer to the person who is in the best position to collect this information
              —nurses, pharmacists, pharmacy technicians or clinicians.
            • Involve pharmacists with high-risk patients or those with complex
              medication regimens.
            • Adapt for individual patients - one process may not work for all
            • In all cases, interview the patient to confirm the dose and the frequency
              for each medication the patient is taking.
            • If a patient has a carer, interview that individual to obtain a medication
              history.
            • Use PMH (previous medical history) to establish any gaps e.g. asthma –
              no inhalers.


        SOP 2 - Prescribing Medicines
        (Read in conjunction with Section 4.2)
        BEFORE PRESCRIBING
        New or existing drugs consider
        •   Need / indication
        •   Patient concordance issues including religious or belief systems
        •   Tests/monitoring required
        •   Evidence for the drug choice or efficacy

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        •   Adverse effects including side effects and drug interactions
        •   Risk reduction /possible cause of admission
        •   Simplification / switches to improve compliance or cost effectivity

Prescriptions must be written in black indelible ink.

       A valid prescription must:
        •   Be legible and unambiguous.
        •   Specify the patient’s name, date of birth, and their address or unique
            hospital number (in-patient prescribing only)
        •   Specify the approved name and form of the drug.
        •   Specify any allergies in the space provided (write No Known Allergies or
            ‘NKA’ if there are no known allergies) – applicable to completion of drug
            charts only.
        •   State the dose written clearly in the metric system. Avoid the unnecessary
            use of decimal points. “Micrograms” and “nanograms” must NOT be
            abbreviated.
        •   The dose of liquid medicine should be expressed as mg rather than mls
            e.g. Priadel 520mg/5mls the dose to be written as 520mg
        •   State the frequency and times of administration. BNF approved
            abbreviations may be used.
        •   State the administration route. Only the following abbreviations may be
            used:
                       IV            Intravenous
                       IM            Intramuscular
                       SL            Sublingual
                       TOP           Topical
                       PR            Per Rectum
                       INHALE        Inhalation
                       SC            Subcutaneous
                       NEB           by Nebulisation
                       PV            Per Vaginum
            Other routes of administration must be written in full, e.g. oral.
        •   State the duration of treatment or quantity to be supplied.
        •   Specify any additional instruction(s) in writing.
        •   Be signed and dated by the prescriber. ONLY authorised prescribers
            registered with the PCT may write a prescription. Medical students are not
            authorised to prescribe. If not already printed on the prescription, the
            prescriber’s name and contact number must be clearly added where
            possible.
        •   In in-patient areas the above information should be written on a drug
            prescription and administration record (drug chart), issued by the NHS or
            approved by the PCT

        For drug charts only the prescriber must:



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        •     Affix a patient identification label or fill in all the information normally
              printed on the label and annotate the chart with the ward.

        •     Document patient’s current drug history in the patients case notes

        •     Document known drug hypersensitivities in the section allocated for Drug
              Allergy/Sensitivities

        •     Document the age and weight (in kilograms) of the patient on the
              prescription chart

        •     Tell the registered nurse-in-charge whenever new prescriptions are
              written, in order that supplies can be obtained at appropriate times

        •     Must write prescriptions in black indelible ink

        •     Re-write the entire chart in accordance with the SOP for prescribing
              (Appendix 1) when the administration record is full.

        •     Specify duration of treatment for Take Home medication.


        1. Name and form of medicine

        The name of the medicine should be written in block capitals. Abbreviations
        (e.g. ISMN) and chemical formulae (e.g. FeSO4) are not acceptable. Generic
        names must be used except for:

        •     a compound preparation, e.g. Rimactazid

        •     a preparation with specific pharmacokinetic properties, e.g. a specific
              slow release preparation where the BNF states that prescribing should be
              by brand

        •     Solid dose oral forms of medication will be given unless another form is
              indicated. For liquids the strength must be stated, wherever possible. For
              topical preparations, the strength and form must be stated


        2. Dose of Medicine

        •     The dose must be expressed in metric units avoiding decimal places
              wherever possible.

        •     Do not use decimal points that are unnecessary e.g. 3mg not 3.0mg

        •     Where use of a decimal point is unavoidable a zero should be written in
              front of the decimal point where there is no other figure e.g. 0.5ml not
              .5ml
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        •     The word “micrograms” and “nanograms” must be written in full and not
              abbreviated to mcg or g or ng to avoid confusion with milligrams (mg)

        •     “g” is a permitted abbreviation for gram

        •     “mg “ is a permitted abbreviation for milligram

        •     Only standard liquid preparations that cannot be expressed by
              concentration e.g. 5mg in 5ml, should be prescribed as volume alone e.g.
              lactulose. Other preparations must be prescribed by weight or units e.g.
              amoxicillin syrup 500mg or dalteparin 5000units

        •     The word unit must be written in full rather than abbreviated to “U” or “IU”

        •     The blood unit symbol        must not be used as an abbreviation for
              prescribing units of medicines as it can frequently be confused with a “0”
              (zero) and may lead to 10 times the dose of insulin or heparin being
              administered in error

        •     Roman numerals or other symbols, for example ”ii” are also the cause of
              medication errors and must not be used. If there is no obvious or practical
              tablet/capsule strength e.g. senna, the number of tablets to be
              administered should be expressed in numbers e.g. “2” tabs not “ii”


        3. Route of Administration

        The route should be specified.
        The following abbreviations are permitted:
IV                    Intravenous           PR                    Per Rectum

IM                       Intramuscular         PV                 Per Vagina

ID                       Intrademal            INH                Inhalation
SC                       Subcutaneous          ORAL               By Mouth

IP                       Intraperitoneal       NEB                Nebuliser

SL                       Sublingual            TOP                Topical

NG                       Nasogastric           NJ                 Nasojejunal tube

PEG                      Percutaneous          PEJ                Percutaneous
                         endoscopic                               endoscopic
                         gastrostomy tube                         jejunostomy tube


        Other instructions should be written in full to avoid confusion e.g. intrathecal
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        Preparations used for the eye, ear and nose indications must state in full the
        intended site of application i.e. “Right Eye”


        4. Prescribing multiple routes in the same prescription

        The practice of writing more than one route of administration, for example
        “O/IM” in the same box should be avoided and separate prescriptions should
        be written out for each route stating either/or. This is because there are a
        number of medicines that have very different pharmacokinetic profiles and
        hence doses and routes are not always safely interchangeably and can lead
        to over or under dosing. In addition there is the risk that both routes may be
        used simultaneously.


        5. Times of administration

        The Prescriber should ring the specified time at which the medicines are to be
        administered.
        If the medicine is to be administered at non-standard times the prescriber
        should:

        •   Delete the nearest stated time, add and ring the new time in the space
            next to it

        •   Point out the changes on the chart to the registered nurse-in charge for the
            shift

        •   For a 24 hour infusion make a ring around all the times


        6. Starting date for administration

        The ORIGINAL starting date should be carried forward if the prescription is to
        be rewritten on a new chart.


        7. Indication

        The indication for the medicine and course length should be specified on
        the prescription chart. This must always apply to antibiotics.


        8. Legibility.

        THE PRESCRIBER MUST SIGN THE PRESCRIPTION LEGIBLY i.e. it
        should be recognisable to pharmacy staff and the health professional
        responsible for administering the medicine to the patient. The prescriber
        should print his/her name and contact number at least once on the
        prescription, to facilitate ease of contact if a query arises.
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        9. The prescriber should not normally write on the administration record
        except:
        • To indicate that an individual dose should be missed by blocking in the
           appropriate square with a cross.

        •   To terminate treatment. Other lines drawn across the administration record
            may cause confusion.


        10. Medicine Allergy/Sensitivities

        •   All prescribers are responsible for entering any relevant known allergy,
            including complementary/alternative medicines and latex, on the front of
            the prescription chart. This information must be transferred to subsequent
            prescription charts.

        •   It is not acceptable to leave the allergy box blank. State “None Known” or
            “NKA” if there is no known allergy

        •   After completion, the allergy box should be initialled and dated by the
            prescriber. The information must also be clearly stated in the patient’s
            notes.

        •   Registered nurses, midwives, pharmacists and medicine management
            technicians are authorised to complete the allergy box of a prescription
            chart but should state qualifications after their signature. This is not just
            the responsibility of medical staff.


        11. Intravenous Medication

        •   Intravenous fluids must be prescribed on the IV fluid chart or appropriate
            section of the prescription. The prescription should state the nature,
            strength and volume of the fluid, any additives required, the duration or
            rate of administration and should be signed by the prescriber. Any
            additives other than electrolytes should also be prescribed on the
            prescription chart.
        •   The prescription of IV fluids in anaesthesia should be noted on the
            anaesthetic chart which should be filed in the patient’s notes.
        •   Medicines to be given intravenously as discrete bolus injections should be
            prescribed on the standard prescription chart following the requirements in
            detailed in the Standard Operating Procedure for the Prescribing and
            Administration of IV Medicines. (Appendix 1; SOP 3)


        12. Once only prescriptions


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        These should be written in the appropriate section of the prescription chart
        and the time of administration specified in writing.



        13. As required prescriptions

        The indication and the minimum interval between doses or maximum daily
        dose must be specified in the ‘additional instructions’ section. Only medicines
        which can be given at the discretion of a registered nurse (e.g. analgesics,
        antiemetics, night sedation) should be written up in this way.


        14. Warfarin should be written on the regular prescription chart in the section
        identified for its use which contains guidance on initiation of therapy and
        monitoring arrangements.


        15. Length of Treatment

        Prescriptions for antibiotics should normally be written for a limited period with
        an automatic stop on the prescription made 7 days after initiation of therapy.
        Longer term antibiotic course should only be prescribed if stated in
        local Trust antimicrobial guidelines for the infection being treated or if
        an extended course has been discussed and recommended by
        Microbiology.


        16. Ambiguous or Illegible Charts

        If the prescription is illegible, unclear, ambiguous or incomplete it will be
        presented to the prescriber by the health professional administering the
        medicine or pharmacist for re-writing or clarification before administration of
        the medicine in question. Pharmacists may make minor clarifying
        amendments to the chart but must consult the prescriber first if the original
        intention is unclear.


        17. Verbal Orders

        •   In accordance with NMC Standards for Medicines Management a verbal
            order may only be accepted in cases of exceptional circumstances. The
            prescriber may make a telephoned request to a registered nurse; this
            should only be a last resort, if no other options are available (for example,
            delivery of prescription by courier or taxi). The request MUST be confirmed
            by fax or email, which should be attached to the prescription chart, MAR
            chart or Care Plan, before the medication is administered. This should be
            followed up by a new prescription signed by the prescriber who sent the
            fax/email confirming the changes within normally 24 hours (72 hours
            maximum – Bank Holidays and weekends). (see policy 8.12)
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        •   Controlled drugs must never be given or prescribed as a verbal order.
        •   A Pharmacist may receive verbal authority from the original prescriber to
            alter or add a prescription item for example, following an intervention. All
            alterations must be endorsed “PC” and the name of the prescriber stated
            and the prescription should be signed and dated by the Pharmacist. The
            Pharmacist must read the alteration or addition back to the prescriber who
            must then confirm it.




        18. Cancellations and Alterations to Prescriptions

        To cancel a prescription:
        • Fill in the Stop date section.
        • A vertical line should be drawn at the end of the last day that a medicine is
           required to be administered and a bold cross ( X ) across the remainder of
           the administration section;
        • If some of the ordered doses are not to be given, they should be cancelled
           individually by filling in the individual boxes with a cross;
        • The cancellation must be signed and dated by the prescriber.
        •   A medicine may be discontinued by a pharmacist at the request of the
            prescriber and be signed and dated by the pharmacist with reference to
            the prescriber authorising it.
        •   A single line through drug being deleted is good practice. Do not deface or
            render the original prescription unreadable.




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        SOP 3 – Prescribing, Preparation, and Administration of IV Drugs
        (Read in conjunction with Sections 4.1.1 & 8.7)


        1. Prescribing

        Prescribing of IV therapy must follow the standards set out in the PCT Policy
        for the Safe & Secure Handling of Medicines & The Intravenous Therapy
        Quickguide (Appendix 15)

        All prescriptions for injectable medicines must specify the following:

             • patient’s name and either their address or unique hospital number as
                well as their date of birth
             • prescriber’s signature
             • the approved medicine name
             • the dose and frequency of administration
             • compatible flushes to be administered (the when required section must
                be used e.g. indication should state “before and after IV administration
                of “……….” insert drug name)
             • the route of administration
             • the start date of treatment
             • the allergy status of the patient

        Where relevant, the prescription must also specify the following:

             • formulation of the medicine
             • concentration or total quantity of medicine in the final infusion container
                or syringe
             • name and volume of infusion fluid
             • rate and duration of administration
             • the weight of the patient
             • the age and weight of any patient under 16 years of age
             • date on which treatment should be reviewed/stopped

        2. Prescribing Information

        Information about a drug should be found from the online version of the
        Summary of Product Characteristics www.medicines.org.uk. Other useful
        sources of information are the current BNF and the Intravenous Drug
        Quickguide (Appendix 15) which should be stored on the ward/department
        treatment area. The kind of information which may be required in order to
        prescribe and administer an injectable are

             • the dose and indications of the medicine
             • cautions, contra-indications and adverse effects that may be caused
             • presentation of the medicine

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             • concentration or total quantity of medicine in the final infusion container
                or syringe
             • name and volume of diluent and/or infusion fluid
             • compatible flushes NEED TO BE PRESCRIBED
             • rate and duration of administration
             • stability information to determine the expiry date of the final product
             • type of rate-control pump or device(s) to be used
             • compatibility information
             • special handling requirements
             • technical information such as sodium content, osmolarity and pH


        3. Before administering an injection

        Administration of IV therapy must follow the standards set out in The PCT
        Policy for the Safe & Secure Handling of Medicines & the NMC Standards for
        Medicines Management.

        In an inpatient setting (e.g. Community Hospital), a second authorised person
        (qualified nurse, midwife, doctor or pharmacist) must be involved in the
        preparation, checking and administration of all IV preparations. This process
        also includes the double checking of calculations, and ensuring the rate
        setting is correct when initiating infusion pump devices. This double check
        should be documented on the prescription chart and, if appropriate, on the
        label.

        Registered nurses employed by the PCT working alone in patient’s homes
        may administer medicines alone without a second check, in accordance with
        NMC guidance, and in line with policies within individual services and the
        relevant NPSA Safety Alerts, however, it is good practice to obtain a second
        check wherever possible, even if it is the patient or carer.

        In home situations prescribers must be asked to provide signed, written
        confirmation of a request for a nurse to administer in a patient’s home, and
        this written confirmation should be provided on a PCT-approved
        administration form. (see Appendix 17 – Criteria for IV Administration in Home
        Environment)

        Check all the following:

             • patient’s name, hospital/NHS number or date of birth or address
             • that the prescription is clearly written and unambiguous
             • prescriber’s signature
             • the approved medicine name
             • the dose and frequency of administration
             • the date and route of administration
             • the allergy status of the patient
             • prescription start and stop dates

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        Also check, where relevant:

             • normal dose, expected effects, adverse reactions, contra-indications
                and drug interactions
             • brand name and formulation of the medicine
             • concentration or total quantity of medicine in the final infusion container
                or syringe
             • name and volume of diluent and/or infusion fluid
             • rate and duration of administration
             • type of rate-control pump or device(s) to be used
             • the age and weight of any patient under 16 years of age
             • date on which treatment should be reviewed/stopped

        Check that the medicine is due for administration at that time and has not
        already been given.

        Assemble everything you need including any flushing solution(s) needed. The
        flush used must be checked for compatibility.

        Explain and discuss the procedure with the patient.

        Check any infusion already in progress. It must be free of haziness, particles
        and discolouration.

        Infusion fluids must only be administered for a maximum period of 24 hours.

        Check that an appropriate access device is in place and is safe to use i.e. it
        has been in place for less than 72 hours (unless under exceptional
        circumstances). (Appendix 15 - Peripheral IV Cannula Observation Chart )

        Ensure cannula site is assessed using the Visual Infusion Phlebitis (VIP)
        score prior to access. (Appendix 15)

        Complete the Peripheral Intravenous Cannula Observation Chart as
        appropriate. (Appendix 15)

        Clean the bung/hub prior to access using 2% Chlorhexidine in 70% Isopropyl
        Alcohol and allow to dry.

        Flush the cannula with a compatible flush solution immediately before and
        after administration of a medicine, and between doses of different medicines
        administered. A suitable flush may be 5ml of sodium chloride 0.9% given in a
        10ml syringe.


        4. Preparation - General

        Read all the prescription details carefully and confirm that they relate to the
        patient being treated.

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        Preparation should take place in an area dedicated to this process if
        possible.

        Ensure that the area in which the medicine is to be prepared is visibly clean
        (surfaces must be decontaminated with detergent wipes/detergent and water
        and surfaces allowed to dry), uncluttered and as free from interruption and
        distraction as possible. In a home situation, using a sterile field as a working
        surface on which to place your tray is appropriate.

        Assemble all materials and equipment as follows:

             • sharps container for disposal of medicine and sharps waste only (not for
                any paper/other clinical waste generated)
             • medicine ampoule(s)/vial(s)
             • diluents
             • syringe(s)
             • needle(s)
             • disposable apron and non sterile gloves
             • 70% alcohol wipes
             • Clean plastic re-usable or disposable tray (re-useable trays must be
                decontaminated before and after each use with detergent wipes or
                detergent and water and allowed to dry).

      Check the following on all equipment:

             • expiry dates
             • damage to containers, vials or packaging
             • that medicines were stored as recommended, e.g. in the refrigerator

        Beware of the risk of confusion between similar looking medicine packs,
        names and strengths. Read all labels carefully.

        Check that:
           • the formulation, dose, diluent, infusion fluid and rate of administration
              correspond to the prescription and product information
           • the patient has no known allergy to the medicine
           • you understand the method of preparation

        Calculate the volume of medicine solution needed to give the prescribed
        dose. Write the calculation down and obtain an independent check by the
        second authorised person (qualified nurse, midwife, doctor or pharmacist)
        involved in the procedure.

        Prepare a label if appropriate. See Section 10.

        Decontaminate your hands using detergent and water or if visibly clean, an
        alcohol based hand rub following the hand hygiene policy for Healthcare
        workers
        Put on a pair of disposable protective gloves.
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        Use a 70% alcohol wipe or spray to disinfect the surface of the plastic tray,
        and/or preparation surface.

        Assemble the syringe(s) and needle(s) leaving the needle sheathed. Peel
        open wrappers carefully and arrange all ampoules/vials, syringes and needles
        neatly in a plastic or disposable tray.

        Use an aseptic non-touch technique (ANTT), i.e. avoid touching areas where
        bacterial contamination may be introduced, e.g. syringe-tips, needles and vial
        tops.
        NOTE: Never put down a syringe attached to an unsheathed needle.

        In an in-patient setting, all medication to be administered by injection must be
        double checked by a second authorised person (qualified nurse, midwife,
        doctor or pharmacist) involved in the preparation, checking and administration
        of all IV preparations. This check must be carried through to administration.

        Prepare the injection using one of the following procedures.


        5. Withdrawing solution or suspension from an ampoule into a syringe

        Tap the ampoule gently to dislodge any medicine in the neck.

        Wipe the neck of the ampoule/vial with a 70% alcohol wipe. Allow to dry for at
        least 30 seconds.

        Snap open the neck of the ampoule (use an ampoule snapper if required).

        If the ampoule contains a suspension rather than solution, it should be gently
        swirled to mix the contents immediately before they are drawn into the
        syringe.

        Attach a needle to a syringe and, using an ANTT draw the required volume of
        solution into the syringe. Tilt the ampoule if necessary. (Filter needles may be
        used if available).

        Invert the syringe and tap lightly to aggregate the air bubbles at the needle
        end.

        Expel the air carefully.

        Remove the needle from the syringe and place it safely into a yellow topped
        sharps container. Using an ANTT fit a new needle or sterile blind hub.

        Label the syringe, if appropriate. See Section 10.

        Keep the ampoule and any unused medicine until administration to the patient
        is complete (this will enable further checking procedures to be undertaken).
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        NOTE: The neck of some plastic ampoules are designed to connect a luer slip
        syringe directly without the use of a needle, after the top of the ampoule has
        been twisted off.


        6. Withdrawing a solution or suspension from a vial into a syringe

        Remove the tamper-evident seal from the vial and wipe the rubber septum
        with a 70% alcohol wipe. Allow to dry for at least 30 seconds.

        With the needle sheathed, draw into the syringe a volume of air equivalent to
        the required volume of solution to be drawn up.

        Use an ANTT.

        Remove the needle cover and insert the needle into the vial through the
        rubber septum.

        Invert the vial. Keep the needle in the solution and slowly depress the plunger
        to push air into the vial.

        Release the plunger so that solution flows back into the syringe.

        If the vial contains a suspension rather than solution it should be gently
        swirled to mix the contents immediately before they are drawn into the
        syringe.

        If a large volume of solution is to be withdrawn, use a push-pull technique:
        repeatedly inject small volumes of air and draw up an equal volume of
        solution until the required total is reached. This ‘equilibrium method’ helps to
        minimise the build-up of pressure in the vial.

        With the vial still attached, invert the syringe. With the needle and vial
        uppermost, tap the syringe lightly to aggregate the air bubbles at the needle
        end. Push the air back into the vial.

        Fill the syringe with the required volume of solution then draw in a small
        volume of air. Withdraw the needle from the vial.

        Expel excess air from the syringe. Remove the needle from the syringe and
        place it safely into a yellow topped sharps container. Fit a new needle or
        sterile blind hub.

        Label the syringe, if appropriate. See Section 10.

        The vial(s) and any unused medicine must be kept until administration to the
        patient is complete.



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        7. Reconstituting powder in a vial and drawing the resulting solution or
        suspension into a syringe

        Remove the tamper-evident seal from the vial and wipe the rubber septum
        with a 70% alcohol wipe. Allow to dry for at least 30 seconds.

        Follow guidance in Section 5 to withdraw the required volume of diluent (e.g.
        water for injections or sodium chloride 0.9%) from ampoule(s) into the syringe.

        Using an ANTT inject the diluent into the vial. Keeping the tip of the needle
        above the level of the solution in the vial, release the plunger. The syringe will
        fill with the air which has been displaced by the solution (if the contents of the
        vial were packed under a vacuum, solution will be drawn into the vial and no
        air will be displaced).

        If a large volume of diluent is to be added, use a push-pull technique (see
        Section 6).

        With the syringe and needle still in place, gently swirl the vial(s) to dissolve all
        the powder, unless otherwise indicated by the product information. This may
        take several minutes.

        Withdraw the required volume of solution from the vial into the syringe.
        Remove the needle from the syringe and place it safely into a yellow topped
        sharps container. Fit a new needle or sterile blind hub.

        Label the syringe, if appropriate. See Section 10.


        8. Adding a medicine to an infusion

        Prepare the medicine in a syringe using the appropriate method described in
        Sections 5, 6 and 7.

        Check the outer wrapper of the infusion container (fluid bag or bottle) is
        undamaged.

        Remove the wrapper and check the infusion container (fluid bag or bottle)
        itself in good light. It must be intact and free of cracks, punctures or leaks.

        Check the infusion solution, which must be free of haziness, particles and
        discolouration. NOTE: not all solutions are colourless. Invert the infusion
        solution, any particles present will move across the bag or fall to the bottom,
        bubbles will move upwards.

        Where necessary, remove the tamper-evident seal on the additive port
        according to the manufacturer’s instructions and wipe the rubber septum on
        the infusion container or the exposed additive port with a 70% alcohol wipe
        and allow to dry for at least 30 seconds.

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        Lay the bag flat on the previously cleaned surface.

        If the volume of medicine solution to be added is more than 10% of the initial
        contents of the infusion container (i.e. more than 50ml to a 500ml or 100ml to
        a 1litre infusion), an equivalent volume must first be removed with a syringe
        and needle via the additive port.

        Using an ANTT inject the medicine into the infusion container through the
        centre of the injection port, taking care to keep the tip of the needle away from
        the side of the infusion container.

        Withdraw the needle and invert the container at least five times to ensure
        thorough mixing before starting the infusion.

        Safely place the syringe and needle into a yellow topped sharps container.

        Check the appearance of the final infusion for absence of particles, cloudiness
        or discolouration. NOTE: not all solutions are colourless.

        Do not add anything to any infusion container when it is hanging on the
        infusion stand since this makes adequate mixing impossible.

        Label the infusion. See Section 10.

        Label the giving set with the date and time.

        Check that the rate of administration is set correctly on the device before
        priming the administration set and starting the infusion device. This must be
        checked by a second authorised person (qualified nurse, midwife, doctor or
        pharmacist).


        9. Diluting a medicine in a syringe for use in a pump or syringe-driver

        Prepare the medicine in a syringe using one of the methods described in
        Sections 5, 6 and 7.

        Draw the diluent into the syringe to be used for administration by a pump or
        syringe-driver. Draw in some air (slightly more than the volume of medicine
        needed) and remove the needle. Dispose of the needle safely in a yellow
        topped sharps container.

        Stand the diluent syringe upright. Insert the needle of the syringe containing
        the medicine into the tip of the diluent (administration) syringe and add the
        medicine to it.

        Alternatively, a disposable sterile connector may be used to connect two
        syringes together directly.



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        Check the following:
              • the total volume of injection solution in the syringe is as specified in
                 the prescription and that the infusion can be delivered at the
                 prescribed rate by the administration device chosen
              • the rate of administration is set correctly on the administration device
                 and according to the manufacturer’s instructions

        Fit a blind hub to the administration syringe and invert several times to      mix
        the contents.

        Remove the blind hub using an ANTT, tap the syringe lightly to aggregate the
        air bubbles at the needle end. Expel the air and refit the blind hub (if sterility
        of the blind hub is questioned then a new hub must be used)

        Carefully check the syringe for cracks and leaks and then label it (see Section
        10), noting the requirements specific to syringe drivers.

        Check that the rate of administration is set correctly before starting the
        infusion device, if appropriate. This must be checked by a second authorised
        person (qualified nurse, midwife, doctor or pharmacist).


        10. Labelling injection and infusion containers

        All injections and infusions, including flushes, must be labelled immediately
        after preparation, except for syringes intended for immediate push (bolus)
        administration by the person who prepared them.

        Under no circumstances must an operator be in possession of more than one
        unlabelled syringe at any one time, nor must an unlabelled syringe be fitted to
        a syringe driver or similar device. Infusions must always be labelled.

        Labels used on injectable medicines prepared in clinical areas must contain
        the following information:
                • name of the medicine
                • strength
                • route of administration
                • diluent
                • final volume
                • patient’s name
                • expiry date and time
                • name of the practitioner preparing the medicine
                • name of the practitioner checking the process


        11. General

        Ensure the time and date of the cannula insertion is documented. (Appendix
        15)

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        Check infusions. They must be free of haziness, particles and discolouration.

        Use an ANTT at all times.

        Attach administration sets to infusion containers carefully, on a flat
        decontaminated surface and using the technique appropriate to the type of
        container.

        Label administration sets with the time and date.

        Flush the cannula with a compatible flush solution immediately before and
        after administration of a medicine, and between doses of different medicines
        administered.

        Prime the access device immediately before starting an infusion.

        The double checking procedure must be followed through to administration to
        the patient and must be documented on the label, if appropriate, and the
        prescription chart.


        12. Administration

        Place the final syringe or infusion and the empty ampoule(s)/vials(s) in a clean
        plastic tray with the prescription for taking to the patient for administration.

        Before administration clean the cannula bung/hub with a 2% Chlorhexidine in
        70% Isopropyl Alcohol wipe and allow to dry for at least 30 seconds.

        After completion of an intermittent infusion, flush the access device with a
        compatible flush solution.

        Ask the patient to report promptly any soreness at the injection site or
        discomfort of any sort. More frequent checks of the site must be made if the
        patient is unable to notify discomfort themselves.

        Using the Trust Peripheral Intravenous Cannula Observation Chart record
               • size and type of device used
               • site location and description
               • condition of the site
               • site care provided
               • dressing changes
               • site changes
               • patient consent
               • flushes administered
               • replacement of administration sets

        If complications arise i.e. VIP score above 2, follow the guidance given on the
        Peripheral Intravenous Cannula Observation chart:
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                   • document the signs and symptoms
                   • patient complaints
                   • name of doctor notified
                   • remove the cannula
                   • resite the cannula if still required
                   • take a swab of the cannula site
                   • blood cultures should be done if the patients temperature is above
                      380
                   • treatment ordered

        Discard the empty ampoules/vials from which the injection was prepared and
        any unused medicine in a yellow topped sharps container. Ampoules or vials
        must never be used to prepare more than one injection unless specifically
        labelled by the manufacturer for ‘multi-dose’ use.

        Re-check the administration site for signs of leakage, infection or inflammation
        and continue to monitor the patient, contents of the infusion container and the
        rate of infusion.

        Check that arrangements for monitoring fluid balance or clinical parameters
        have been made.

        The fluid balance chart must be regularly updated e.g. if infusing 1000mls
        over 8 hours every hour the chart should be annotated with 125ml given.

        When administering an infusion regularly check and document the progress
        e.g. if using an infusion device check the infusion rate setting, if a device is
        not required the volume remaining may be estimated using the graduations on
        the infusion bag.

        Document the administration on the drug chart.

        When documenting the discontinuing IV therapy specify:
               • time and date
               • reason for discontinuing therapy
               • assessment of device site before and after therapy
               • any complications, patient reactions, and other nursing
                  interventions
               • integrity of venous access device on removal
               • follow-up actions e.g. restarting the IV in another extremity




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        SOP 4 – Transcribing
        (Read in conjunction with Sections 4.5)

        This detailed framework provides clear instruction about the physical
        transcription process (writing medicines, but not prescribing them, onto a
        prescription chart) but also prompts the nurse to think logically about what is
        being prescribed for that patient and challenges them to critically appraise,
        based on their knowledge of medicines, the accuracy and appropriateness of
        the medicines being transcribed and sets out guidance on what actions to
        take if a prescription needs to be reviewed.

        1. Before you start transcribing familiarise yourself with what you can find out
           about the patient’s clinical history – use this information as you start
           transcribing. Think about the accuracy of the prescription you are reading
           and think about the appropriateness of the prescription for that patient.

        2. You can transcribe a prescription record either:
           • on admission for a new patient
           • during their inpatient stay

        3. Highlight any controlled drugs, which the independent prescriber must
           prescribe directly onto the prescription form. These medicines cannot be
           transcribed. Inform the prescriber at the earliest possible opportunity of
           this.

        4. The patient’s name, address, date of birth, NHS number, ward and
           hospital, should be clearly written, in block capitals on the drug chart
           An addressograph sticker may be used.

        5. Clearly document any known allergies (e.g. drug, food, latex) or record as
           ‘none known’, if appropriate.

        6. The front of the chart should indicate date, including the year, it was
           rewritten.

        7. The medication should be transcribed observing good prescribing practice
           as laid out in NHS Cumbria PCT Medicines policy. Drug names must be
           written clearly, in capital letters, with black ink. Strength of doses must be
           specified clearly.

        8. If you have any problems reading a prescription, or have concerns about
           the accuracy or appropriateness of a prescription, you must resolve the
           situation by contacting either the documented independent prescriber or
           another independent prescriber to clarify the issue identified. At no point
           can you amend the prescription to what you think is correct – this is in
           effect you writing a prescription for which you are not covered.

        9. Accepted abbreviations to be used on drug charts include:
           • g = gram
           • mg = milligram
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            •    ml = millilitre
            •    TOP = topical
            •    INH = Inhaler
            •    NEB = nebulised
            •    SL = sublingual
            •    PR = per rectum
            •    PV = per vagina
            •    NG = via nasogastric tube
            •    PEG = via Percutaneous endoscopic gastrostomy tube
            •    IV = intravenous
            •    SC = subcutaneous
            •    IM = intramuscularly
            •    L = Left
            •    R = Right
            •    Must specify clearly if drug to be applied to a particular body area e.g.
                 R Leg, L Eye
        Micrograms and nanograms must not be abbreviated - must be written
        in full.

        10. State the date that regular therapy was commenced (start date in hospital)
            not the date that the drug chart is rewritten.

        11. Drugs must state the names (and brand where important), strength (and
            form if necessary), route, dose, frequency and duration of treatment if
            appropriate (if not patient pack dispensing). All drugs must be identical to
            that stated on the drug chart.

        12. Clearly circle the times that drugs are to be administered.

        13. Copy any details that clearly specify the duration of therapy, e.g. stop date,
            review date, or reducing doses. If this is not clear, the transcriber should
            discuss the details with the prescriber. The prescriber should then make
            the relevant changes on the drug chart.

        14. Copy any previous endorsements on drug chart e.g. ‘take after food’; ‘do
            not lie down after taking for 60 mins and take with a full glass of water’.

        15. If the patient requires more than one drug chart, clearly mark on the front
            of each drug chart, in the ‘TOTAL NUMBER OF CHARTS IN USE’ section
            i.e. “1 of 2”, “2 of 2” etc.

        16. A second authorised registered nurse MUST check the rewritten chart
            against the original.

        17. Cancel the old drug chart by drawing a diagonal straight line across each
            page, and writing ‘Discontinued’ on the front. Sign & Date.

        18. The rewritten chart MUST be signed by a prescriber as soon as possible,
            and before the medicine is administered
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        SOP 5 – Ordering and Receipt of Medicines from Pharmacy
          (Read in conjunction with Section 6.2, 6.3 & 6.4)

        1.    Health professionals with authorised signatures are responsible for
              ordering stock items.

        2.    Nurses, or a member of the pharmacy or medicines management staff
              using the top-up system, are responsible for ordering ward stock items.

        3.    Orders must only be made on the official order books supplied by the
              pharmacy department specifically for this purpose.

        4.    Check cupboard(s) for current stock.

        5.    If required order stock using stock order form.

        6.    Do not order more than current stock level on list – may only be required
              in exceptional circumstances when several patients on same medication.

        7.    If excess stock in cupboard do not order until level decreased.

        8.    When ordering items not on stock list order as original pack.

        9.    All medicines must be delivered to a designated area and an authorised
              health professional informed of their arrival.

        10. Authorised health professional must sign for receipt of the medicines.

        11. Medicines must then be put in the appropriate safe storage.

        12. Items to be stored in the fridge must be put away immediately.

        13. All delivery notes for stock must be checked by a designated member of
            staff, signed and stored appropriately.

        14. Discrepancies must be reported as soon as possible to the pharmacy
            department.

        15. All medicines should be of the quantity and quality expected and the
            receiving member of staff must ensure that they are assured that
            deterioration has not occurred (e.g. breakage of cold chain).




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        SOP 6 – Use of Patients’ Own Medicines
        (Read in conjunction with Sections 6.5)

        1.    On admission, ask for all the medicines that the patient has with them,
              including any that may be in their handbag or pockets. Specifically ask
              about items that patients may not see as significant, such as eye drops,
              creams, inhalers, the pill and any medication bought OTC (over the
              counter) including herbal remedies. Explain that for safety reasons,
              patients cannot keep medicines with their other belongings, except for
              specific items such as GTN spray and bronchodilator inhalers. (Any
              medicines remaining at home should, if possible, be brought in by
              relatives at the next visit).

        2.    The drugs should then be locked in the patient’s drawer/cabinet. All
              medicines, including creams, eye drops, the pill etc. MUST be locked
              away AT ALL TIMES, following hospital policy, except under special
              circumstances, e.g. GTN spray.

        3.    Explain the Patient Own Drugs (POD) scheme to the patient.

        4.    Tell the patient that you need their consent to use their own medicines,
              and that they will be provided with more medicines as and when required
              during their stay, as well as adequate supplies of medicines on
              discharge. Inform them that it is in their own interest to allow unwanted
              medicines to be safely disposed of, and that you need them to consent to
              this as well.

        5.    Answer any queries and be satisfied the patient understands.

        6.    Obtain signature on consent form (Appendix 6), or document implied
              consent, whether for consent or refusal to consent.

        7.    File consent form in the patient’s nursing notes.

        8.    Ensure that patient’s own medicines are assessed as suitable for use
              before you administer them by either contacting the PCT pharmacist to
              arrange POD assessment, or when, pharmacist not available, follow the
              algorithm (see Appendix 7).

        9.    Return suitable medicines to the patient to be locked in the medicine
              drawer/cabinet, and separate any unsuitable medicines, explaining this to
              the patient.

        10. Unsuitable drugs should be destroyed, following any local procedures.

        11. Never store a patients’ own medicine with stock supply.

        12. Always transfer POD’s with the patient if they are moved to another ward.



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        13. Never allow a patient to have a medicine if it has not been prescribed,
            even if they insist they always take it. Get the prescriber to prescribe it
            first.

        14. Be careful that the prescription and the POD match. If they do not,
            discuss this with the prescriber. If the change is deliberate, the POD will
            no longer be suitable and arrangements should be made to destroy as
            per policy.

        15. NEVER alter a label by hand.

        16. Only POD’s that have been assessed as suitable for use can be given
            back to the patient, unless they have signed informed non-consent.
            These must be stored in a suitable locked cupboard until patient
            discharged.

        17. Any POD’s not given back to the patient when they leave must be
            disposed of as per policy.

        18. Ensure that no medicines are given to a patient to leave the hospital
            unless they have been checked against a discharge prescription by an
            authorised member – a pharmacist, GP or two registered nurses.

        19. Additional medicines required for discharge may be obtained from an
            Approved supplier (Policy 6.1)

        20. It is important to remember that any item supplied during the hospital stay
            is not patient’s property, unless supplied on a FP10 prescription.

        21. If required, The Medication Information Card (WQG457:06/04 REV 1) will be
            completed by a registered nurse, and checked by either another
            registered nurse or the PCT pharmacist, before discharge.

        22. Patients’ own Controlled Drugs should be stored in the ward Controlled
            Drug cabinet as per Controlled Drug policy.




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        SOP 7 – Discharge Medication
        (Read in conjunction with Sections 6.6)

        A discharge medication summary must be written for all patients.
        Discharge summary should include
           • Complete and accurate patient details i.e. full name, date of birth,
           • weight if under 16 years, NHS/unit number, consultant, ward, date
              of admission, date of discharge
           • The diagnosis of the presenting condition plus co-morbidities,
           • Procedures carried out
           • A list of all the medicines prescribed for the patient on discharge
              from hospital (and not just those dispensed at the time of discharge)
           • Dose, frequency, formulation and route of all the medicines listed
           • Medicines stopped and started, with reasons
           • Length of courses where appropriate (e.g. antibiotics)
           • Details of variable dosage regimens (e.g. oral corticosteroids, warfarin,
              etc.)
           • Known allergies, hypersensitivities and previous drug interactions
           • Any additional patient information provided such as corticosteroid
              record cards, anticoagulant books, etc.
            This information should be clear, unambiguous and legible and should
            be faxed to the patient’s GP on day of discharge.

        Medicines to be dispensed by hospital pharmacy

            1. Encourage the early prescribing of discharge prescriptions so that
               these may be dispensed by pharmacy during normal opening hours.

            2. Discharge / leave prescriptions should be notified to pharmacy at least
               one working day before they are required.

            3. Any previously dispensed individual patient’s medicines, including
               patient’s own medicines, must be assessed and checked, either by a
               prescriber and a registered nurse, or by two registered nurses, as to
               their fitness to supply to the patient for discharge. Medicines
               Management pharmacist may also be involved.

            4. A discharge prescription must be written.

            5. If sufficient supply of patient’s own medicine annotate prescription with
               ‘patients own drugs’ to indicate dispensing not required.

            6. Discharge prescription faxed to pharmacy department, then sent in
               internal mail.

            7. Discharge medication will be returned on the next available internal
               transport after the original prescription has been received in the
               pharmacy.


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            8. Medication delivered to ward should be received as SOP 5.


        Medicines to be dispensed by Community pharmacy

            1. A discharge medication summary must be written, for sending to
               patient’s surgery as complete record of discharge medication.

            2. Any previously dispensed individual patient’s medicines, including
               patient’s own medicines, must be assessed and checked, either by a
               prescriber and a registered nurse, or by two registered nurses, as to
               their fitness to supply to the patient for discharge. Medicines
               Management pharmacist may also be involved.

            3. Where a new drug is required then a prescriber may write an FP10 for
               the medicine to be obtained at a community pharmacy.

            4. A separate FP10 for Controlled Drugs, if required, should be written.

            5. FP10 prescription sent to local pharmacy, complying with local hospital
               procedures.

            6. Medication delivered to ward should be received as SOP 5.

        Prior to discharge

            1. Medication must be checked against discharge summary.

            2. If required, a Medicine Information Card is completed for the patient.

            3. Explain medication to patient including potential side effects,
               interactions, new or discontinued treatments.

            4. Provide patient with any support material required e.g. written
               information, contact details, compliance aids etc.

            5. Ask patient for permission to dispose of any medication no longer
               prescribed.

            6. If permission not received explain the risk of confusion and possibility
               of over/under dosing holding onto discontinued medication.

            7. Fax discharge summary to patients GP and Community pharmacy, if
               applicable.

            8. If patient was self-medicating on the ward ensure key is returned to
               Nurse in charge.




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Safe and Secure Handling of Medicines   Page 83 of 154
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        SOP 8 – Administration of Medication to Patients
        (Read in conjunction with Section 8.3)

        Medicines administration procedure should be as follows; local Trust
        procedures may allow deviation from this process. These should be approved
        by the ward manager/team leader and pharmacist.

        •   For in patients check if any patients are absent from the ward – these
            charts should be separated from the other charts until the end of the
            administration process.

        •   Assemble cups, water, medicines pots, measures, spoons, oral syringes.

        •   When administering to more than one patient, assemble all charts for
            patients who are present.

        •   Administer to patient one at a time.

        For each patient:

        1. Check the prescription has been written and signed by an authorised
           practitioner.

        2. Be aware of patient’s care plan/pathway.

        3. Check from the times on the chart, which medicines are required to be
           administered at that time.

        4. Check that the medicines have not already been administered.

        5. Check no contra-indications to administration of the prescribed medicine,
           including allergy to medication.

        6. Read name of first medication, dose, and route.

        7. Select the medication.

        8. Check medicine name, dose, frequency, route, dilution where appropriate
           and date for administration are consistent with the prescription, Patient
           Group Direction, Drug Chart or Standing Order.

        9. Check Expiry date (if it exists).

        10. Ensure clean hands, avoid touching medication and provide a glass of
            water to swallow tablets/capsules.

        11. Remove/measure the correct dose into a measuring pot.

        12. Continue for each medicine prescribed at that time.

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        13. Request the patient attend, or take the medicine and chart to the patient
            (the trolley should be locked if left unattended).

        14. Confirm patient’s identity.

        15. Inform patient which medicines they are being offered.

        16. Check patient has a clear understanding of the dose, frequency, main
            effects and main side effects of the medicine that has been prescribed.
            Administration may not proceed without this clear understanding.

        17. If necessary, obtain advice or information about a medicine so that they
            gain a clear understanding.

        18. Obtain patient consent to administer the medicine.

        19. Observe the patient taking the medicine and advise them to drink half a
            glass of water or administer by injection or other prescribed route.

        20. Make immediate record of all medication administered, intentionally
            withheld or refused by the patient. Where medication not given the reason
            for doing so MUST be recorded.

        21. Return medicine packs to trolley or cupboard.

        22. Continue for other patients.

        23. Check if any prescribed medications will have been missed by patients
            who are absent and who have not had leave medicines dispensed. Make
            arrangements for these patients to have their medication when they return,
            if appropriate. If in doubt about the time elapsing since prescribed time and
            time of administration, check with prescriber.

        24. Report any adverse incidents (as per the Policy for the management of
            incidents including management of serious incidents CPCT 0005/011).

        If another nurse, or another healthcare professional is assisting in the
        administration of the medication, they should follow the same checking
        procedure above as the first registered nurse.




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        SOP 9 – Self-administration of Medication
        (Read in conjunction with Section 8.5 )

        1.    Give the patient a Patient Information Card (Appendix 9) and explain the
              scheme

        2.    Answer any queries and be satisfied the patient understands the scheme

        3.    Ensure there is a signature on Re-use and Disposal of Medicines
              Consent form (Appendix 6), or implied consent is documented

        4.    File consent in patient’s nursing notes

        5.    Assess patient for suitability for inclusion in the self-medication scheme,
              using the Self Administration of Medicines Assessment Form (Appendix
              8). The Medication Risk Assessment Form (Appendix 10) is a useful tool
              to assist in assessment.

        6.    Determine Level of self-administration

        7.    Sign and date the Assessment form and file in nursing notes

        8.    Counsel the patient with respect to their medication and provide a
              medication reminder/information card where appropriate.

        9.    Clearly document in patients notes or care plans regarding self-
              medication, including Level

        10. Contact pharmacist, if available.

        11. Pharmacist who sees the patient will countersign the form and make
            record in medical notes that patient will be self-administering medicines
            and at what Level

        12. Document the Level in the comments section of the prescription chart

        13. Ensure patient has an accurate drug chart

        14. Ensure, if appropriate, patient has an accurate Medicines Information
            Card (do not forget to update this if there is a change to regime)

        15. Provide clearly labelled medication and compliance aids if assessed as
            appropriate


        16. Provide patients with appropriate information regarding the correct use of
            their medicines. This should include
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                •   The name of the drug
                •   The purpose of the drug
                •   The dose and frequency of the drug
                •   Any special instructions
                •   Possible side effects
                •   Duration of the course

        17. Assess patients daily for their ability to continue on the scheme. This
            means:
              • At an appropriate time, the nurse must directly communicate with
                 the patient and determine if the patient is coping with self-
                 administration
              • Check the drug chart for changes. Any changes will require
                 amendment to the Medicine Information Card and discussion with
                 the patient
              • Determine if there is any change in the appropriate level of self-
                 administration, e.g. is the patient coping? Or can they progress to
                 another level? Any changes should be documented in the
                 comments section on the back of the prescription chart
              • Document the outcome of this communication and any other
                 observations in the patient nursing notes
              • Endorse the drug chart using the appropriate code to indicate if the
                 nurse has administered a drug, or if the patient has self-
                 administered

        18. Repeat risk assessment as necessary with review of self-medication if
            needed.
              • Be aware of how the patient is coping with self-administration.
                Forgetting doses, or not storing medicines safely, may require
                reduction to level amber or red
              • Patients who are improving in their health status maybe eligible for
                inclusion into the programme, or suitable to start self-administrating
                at level green instead of amber
              • Document any change in self-administration level on the drug chart

        19. The nurse should document any change               to   self-administration
            programme, with reason, in nursing notes

        20. The pharmacist must document any change, including reasons, in the
            medical notes

        21. Secure storage of medication in a place accessible to the patient.




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October 2010
        SOP 10 – Pre-loading and Administration of Insulin
        (Read in conjunction with Section 8.11)


           Pre loading of insulin should only be considered when alternative methods
           of delivery are not possible.

           Registered Nurses should be aware of the alternative injection devices
           available and discuss the patient’s needs and preferred options with the
           Diabetes Specialist Nurse or General Practitioner.

           Pre loading of insulin should only begin following a full written risk
           assessment and the ruling out of alternative methods of administration. A
           thorough assessment of the patient’s understanding of the insulin regime,
           their ability to manage it, and the support available to the patient between
           community nurse visits, must be undertaken. (Appendix 18 – Assessing
           risk)

           A patient should always be consulted about their insulin administration and
           informed consent obtained regarding the care to be provided.

           The MHRA clearly states that insulin should be drawn up and should be
           administered within 24 hours.

           All patients will receive a visit within 24 hours to draw and check pre-
           loaded insulin syringes.

           Nursing teams can reduce the frequency of their visits in response to
           exceptional circumstances such as severe weather conditions, flu outbreak,
           except where patients are prescribed glargine insulin and every effort
           should be given to maintain those visits.

           However, nursing teams should ensure that there is appropriate emergency
           support in administering pre-loaded insulin.

           Correct storage - pre-filled syringes should be stored, with needle end
           slightly elevated, in a labelled protective container in the main body of the
           fridge (away from the freezer section or the back of the fridge) between 2 –
           8 degrees centigrade. (RCN 2006)

           Where insulin is to be administered at different times of the day (unless
           same dose and insulin type) then separate containers, which are easily
           distinguishable, must be used.

           When each new insulin vial is opened, the date and time must be recorded
           on the vial and on the patient’s notes. Patients should have a vial in use
           and a back up vial at all times to ensure that vials are used methodically.

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           The patient/carer should have the community nursing team contact
           telephone numbers and if appropriate the diabetes nurse specialist contact
           number should they wish to discuss any issues with their insulin regime.

           Patients must have appropriate storage conditions for their insulin i.e.
           refrigerator and be advised of the correct storage recommendations,
           reinforced by a patient leaflet.

           Patients in residential care must have their pre-loaded insulin stored in a
           clearly marked container as above in a locked fridge. If more than one
           patient requires preloaded insulin in a residential home, separate containers
           must be provided and syringes must be individually labelled.

           Where more than one patient requiring pre-loaded insulin resides in a
           residential home each syringe must be labelled individually stating name,
           type of insulin, date, dose, signature of person drawing up insulin, in
           addition to labelling the outer container.

           Arrangements must be made to ensure the monitoring of diabetes control is
           undertaken. Diabetes monitoring may be undertaken by the patient
           themselves, a family member/friend or by an interim visit by a member of
           the community nursing team. Arrangements for this being based on a full
           written risk assessment.

           Regular re-assessment of the patient and plan of care must be undertaken
           and documented. (3 monthly or sooner if patient’s circumstances change)

           The pre-loading of insulin should only be undertaken by nurses who have
           the appropriate knowledge and competence.

        Contra – indications
         Insulin which is not suitable for pre loading:
         • Short Acting (Soluble) insulin
         • Long acting Analogues e.g.Glargine
         Unstable diabetic condition
         Lack of satisfactory storage facilities in the patient’s home
         Unpredictable mental state or declining cognitive ability

     Practical process of pre-loading insulin

        Equipment required:
          • Plan of care
          • Gloves
          • Sharps Box
          • Insulin Syringes 30, 50 or 100 unit syringes (depending which is most
            appropriate for the dose), needle length should be no more than 8
            millimetre (mm).
          • Relevant prescribed Insulin Vial
          • Labelled Container(s) provided by patient for storage of pre filled syringes
          • Mediswab
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           Read and check plan of care. Check for allergies/contra-indications. Check
           all previous pre loaded syringes have been administered and safely
           disposed of.
           Explain procedure to patient, ensuring consent obtained.
           Prepare clean working surface and collect equipment required; check
           insulin for expiry date and against instructions of care plan.
           Wash Hands.
           Prepare equipment and re-suspend insulin, by inverting vial at least 10
           times if using cloudy insulin.
           Draw up insulin in presence of patient as follows for each syringe using a
           clean procedure to prevent contamination:-
             • Swab insulin vial with a mediswab and allow to dry.
             • Remove needle cover and pull back plunger to measure an amount of
                air equivalent to the amount of insulin prescribed.
             • With insulin vial standing upright, insert the needle through the centre
                of the rubber cap and push down plunger.
             • Invert the insulin vial
             • Pull back plunger until slightly more than correct dose is drawn up.
             • Expel any air bubbles back into vial.
             • Recheck correct prescribed dose has been drawn up and remove
                needle from vial.
             • Carefully re-sheath needle (there is no risk of contaminated needle
                stick injury as needle is sterile – in the event of a needle stick injury the
                syringe must be safely discarded).
           Store pre-filled syringes with needle end slightly elevated, within a labelled
           protective container in main body of the fridge (away from freezer section or
           the back of the fridge). For twice-daily injections, with different doses, a
           method of identification for the containers must be negotiated with the
           patient and recorded in the care plan, taking into account the patient’s
           preferences and capabilities.
           Dispose of clinical waste and wash hands.
           Complete nursing notes ensuring date, time, insulin type/dose and number
           of insulin syringes drawn up are recorded.

        Advise patient re:-
           • Timing of their injections.
           • Re-suspending all pre-loaded insulin, by inverting vial, at least 10 times
              prior to injection, if using cloudy insulin.
           • Correct disposal of sharps.
           • Ensure arrangements are in place, based on the risk assessment, for
              patient support and monitoring. Ensure patient is aware of Community
              Nursing Team contact number.
           • Ensure plan of care meets patient’s needs, and ability, by regular
              review and reassessment (3 monthly or sooner if patient’s
              circumstances change). Liaise with Diabetes Specialist Nurse as
              required.



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20.2 Appendix 2 – Assessment of Competency to Transcribe

        Name_________________________________________________________

        Has successfully:

    •   Completed an assessment of their understanding of the Medicines Policy and
        the transcribing framework.

    •   Completed an assessment of ‘transcribing’ in practice, which will be marked –
        pass mark 100% (and assessed annually against the transcribing audit tool,
        see below).

        This has been verified by the nurse consultant who has signed this
        authorisation.
        The person named can undertake the transcribing role within their clinical
        position within the Trust. They are supported by the locality matron and (when
        appropriate) their manager and are confident and willing to undertake this
        activity as a key part of their role.
        The line manager is responsible for ensuring that transcribers are registered
        with Medicines Management.
        This record must be held in the staff member’s personal file and reviewed
        annually as part of their Individual Performance review.

        FULL NAME (Print)………………………………………………………

        SIGNATURE……………………………………………………………..

        POSITION…………………………………………………………….….

        QUALIFICATIONS…………………………………….………………..

        WARD. ……………………………………………………………………

        HOSPITAL……………………………………………………………….

        LOCALITY MATRON NAME……………………………………………..

        LOCALITY MATRON SIGNATURE…………………………………………….

        LINE MANAGER’S NAME & SIGNATURE     ……………………………………

        DATE…………………………………………………………………….


Safe and Secure Handling of Medicines                               Page 91 of 154
October 2010
20.3 Appendix 3 – Theoretical Knowledge Assessment of Transcribing for
Adults

        NAME of Nurse




        1. Define what ‘Transcribing’ is…




        2. What are the benefits and risks of Transcribing?




        3. What transcribing situations does this policy cover?

            •

            •

            •


        4. Which health care professionals does this policy cover?




        5. To undertake the transcribing role, how does the nurse demonstrate
           competency?




Safe and Secure Handling of Medicines                                Page 92 of 154
October 2010
        6. When transcribing a medicine what general rules does the Trust require
           you to adhere to?




        7. What must you do if the prescription you are transcribing from is unclear?




        8. If you think a prescription needs amending, what do you do?




        9. What medicines should not be written on prescription record, except by the
           independent prescriber?




        10. Who is responsible for the prescription of medicines?




        11. What is the transcribing practitioner accountable for?




        Signed by
        practitioner………………………………………………………………………

        Date……………………………………………………………………………………

        Signed by Locality Matron
        Date……………………………………………………………………………………



Safe and Secure Handling of Medicines                                Page 93 of 154
October 2010
20.4 Appendix 4 – Competency Assessment Framework and Annual
Transcribing Audit Tool

        Aim

        To assess the safety of transcribing of the practitioner within the PCT and to
        ensure that transcribers are adhering to the detailed framework outlined in the
        Safe and Secure Handling of Medicines policy, Transcribing SOP.


        Method

        •   6 patients drug charts to be audited from within the last 12 months for new
            transcribers/annually          for           existing          Transcribers

        •   Completed        audit      form   to   be   returned   to   the    line    manager

        •   Tick or cross against each point of the framework for every drug chart


        Date of Audit: ……………………………………………………………………….

        Name of Auditor: …………………………………………………………………...



      Audit criteria                                                 1   2     3    4     5   6
      Transcriber Name




       Is the patient’s name on the drug chart?
       Is there a date of birth?
       Is there a NHS number?
      Is the ward identified?
      Is it legible?
      Are allergies noted?

Safe and Secure Handling of Medicines                                        Page 94 of 154
October 2010
      Has the Transcriber signed and dated each
      medication transcribed and indicating that this is
      transcribed?

      Are drug names written in capital letters?

       Is black ink used?
       Are doses clearly written?
      Are accepted abbreviations used on the drug charts?

      These are: g, mg, ml, TOP, INH, NEB, SL, PR, PV,
      NG, PEG, IV, SC, IM, L, R. Must specify clearly if
      drug to be applied to a particular body area e.g. R
      Leg, L Eye
      mcg is not acceptable and must be written in full
      i.e. micrograms

      Is the start date as per the old drug chart?
      Are the drug names identical to those on the old drug
      chart?
      Are the times for administration clearly circled?
      Are specified instructions clearly written (e.g. stop
      date, review date)?
      Are multiple drug charts clearly identified e.g. ‘1 of 2’,
      ‘2 of 2’?
      Was the old drug chart cancelled by drawing a
      diagonal line across each page, with discontinued
      clearly written on the front?
       Any schedule 2 or 3 medicines, any controlled drugs
      or any trial medications have not been transcribed,
      but have been prescribed by an independent
      prescriber.
      Has the prescriber signed the chart within specified
      timescale?

      TOTAL SCORE PER CHART




Safe and Secure Handling of Medicines                              Page 95 of 154
October 2010
20.5 Appendix 5 – Signature Requirements for Transcribing

        To:     Authorised ‘transcribers’

        Dear Colleague,

        In order to comply with PCT Policy, the transcribing of medicines in the
        Community Hospitals (Cumbria PCT) may only be undertaken, in exceptional
        circumstances, by an authorised practitioner. Medicines Management,
        Cumbria PCT is therefore required to maintain a list of names and signatures
        of all authorised practitioners before any medicine can be dispensed or
        administered to a patient. This is also a requirement of the Internal Audit
        department.
        Please complete the form below and send it to Gillian Johnson, Non-Medical
        Prescribing Lead (NMP), Medicines Management Administration, Cumbria
        PCT, Wavell Drive, Rosehill, Carlisle, Cumbria CA1 2SE. A copy should be
        filed in your personal records.
        A further copy will be held by the Matron in charge of unit.

        To: Gillian Johnson, NMP Lead, Cumbria PCT
           …………………………………………………………………………………

        FULL NAME……………………………………………………………………..
        (Print)

        Ward …………………………………………………………………………………


        Usual Full Signature………………………………………………………………


        Date……………………………………………………………………

        The above member of staff is authorised to transcribe in accordance with PCT
        Policy for the Safe and Secure Handling of Medicines, transcribing standard
        operating procedure on the inpatient unit at Community Hospital

        Signed ………………………………………………………………….

        Name…………………………………………………………………………………
        Designation………………………………………………………
        Date …………………………………………………………………………



Safe and Secure Handling of Medicines                              Page 96 of 154
October 2010
20.6 Appendix 6 – Medication Re-use and Disposal Consent Form


                     MEDICATION RE-USE AND DISPOSAL CONSENT FORM
          Dear Patient

          At this hospital we operate a policy of continuing to use your own medicines from home.
          This allows you to continue with familiar tablets, eye-drops and other treatments and avoids
          waste. We will give you new supplies when needed. Of course, if your medicines are
          changed while you are here, we may need to dispose of any you don’t need.

          Please tick the appropriate boxes if you are in agreement:

Date                  Tick

                                I am happy for my own medicines to be used for my
..................
                                own personal use whilst I am in hospital.

                                I am happy for my own medicines to be safely disposed if I
..................              no     longer     require them     or    if   they   are
                                unsuitable to use.

                                I am willing to take part, if appropriate, in the Self
                                Administration Scheme. Before I do so, I will have read the
..................              Self Administration Information card. I understand that I may
                                withdraw my consent at any time by informing my named
                                nurse.

          Please sign below:

                                                                      (Stick patient’s printed label here)
SIGNED:                ............................................

DATE:                  ............................................

WITNESSED: ............................................


          If you do not agree to being able to re-use the medication you are currently on, please
          sign below. I agree to have the hospital supply all my medication whilst I am in hospital
          and accept full responsibility for the condition of my medication and the fact there may be
          discontinued medicines that are left my possession.
          SIGNED: ........................................... DATE: ……………………………….

          WITNESSED: ....................................



Safe and Secure Handling of Medicines                                                  Page 97 of 154
October 2010
     20.7 Appendix 7 – Patient Own Drugs (PODS)
           Assessment Checklist for Administration by Nurses

             PODS assessment checklist for ADMINISTRATION by NURSES
                     Use this flowchart to decide whether it is appropriate to use a medicine,
                                   for a nurse to administer against a drug chart,
                                prior to the medicine being assessed by pharmacy.
                     DO NOT use it to assess suitability for self-administration or discharge.

                     Medicines must comply with all aspects listed in the relevant box.
                        If in doubt, DO NOT USE, but organise alternative supply.

ORIGINAL BLISTER PACK
Is the drug packed in a sealed blister that is
        clearly marked with the name of the drug?                                         NO
        clearly marked with the strength of the drug?
        clearly marked within expiry date?
        Reasonably clean and in good condition?                     NO


EYE, EAR, NOSE PREPARATIONS
Is the medicine an eye, nose or ear preparation which
                                                                                           NO
                                                                                                        D
       has been opened/dispensed in the last four weeks or has not been opened
       and is within manufacturers expiry
       is clean and able to be sealed
                                                                                                        O
MEDICINES IN A BOTTLE


                                                                                                        N
Is the medicine tablets or capsules which are contained in a bottle and                    NO
       the label on the bottle clearly shows the name and strength of the medicine
       the markings or appearance of the contents cause no concern about the

                                                                                                        O
       identification of the contents compared to the label details
       the contents are of a uniform appearance, e.g. tablets all the same
       the bottle and medicine are in reasonably clean condition


INHALERS
                                                                                                        T
                                                                                           NO
     Is the inhaler in reasonably good, clean condition, and appear to be in
     working order?
     If it is possible, can it be checked to ensure that it is not empty?

INSULIN
                                                                                           NO
                                                                                                        U
     Can it be reasonably assumed that the insulin has been stored correctly so
     far?
     Is the product in a reasonable condition and in working order?
                                                                                                        S
                                                                                                        NO


ALL OTHER PRODUCTS                                                                         NO
                                                                                                        E
Is the product acceptable – in a suitable container, clean and dry with no visible
signs of deterioration and in good working order?




     Safe and Secure Handling of Medicines                                             Page 98 of 154
     October 2010
20.8 Appendix 8 – PODS Assessment Checklist for Self-administration or
Discharge


       PODS assessment checklist for SELF-ADMINISTRATION OR DISCHARGE
      Patients Own Drugs (PODS) must meet ALL criteria for re-use. If in doubt DO NOT USE.



                                                                                                     D
   Is the label legible and typed, bearing the correct patient name and details without       No
                                 handwritten alterations?         NO

                                                  Yes


                                                                                                     O
                                                                                             No
           Is the dispensers name and address identifiable on the packaging?


                                                  Yes                                        No
    Do the product, strength, instructions and dosage match the doctors prescription?

                                                  Yes
                                                                                             No


                                                                                                     N
  Products in tamper-evident packaging (i.e. a blister pack) match the label on the box,
                       and are within expiry date (if identifiable)?
                                                    NO
                                                 Yes                                         No



                                                                                                     O
    Products in a bottle can be reasonably assumed to be as described on the label?

                                                  Yes
                                                                                              No


                                                                                                     T
  Is the product acceptable – in a suitable container, clean and dry with no visible signs
                       of deterioration and in good working order?

                                                  Yes
                                                                                               No
    Have eye drops or ointments, ear drops or nose drops been dispensed within the
                                  LAST 4 WEEKS?

                                                  Yes
                                                                                               CD


                                                                                                     U
                         The product is NOT a Controlled Drug?
                                                  Correct                                     Pre-
                                                                                              pack
 The medicines are NOT in a compliance device, e.g. dosette box, Venalink, Medidos?

                                                  Correct
          Are you satisfied with the general condition, packaging and labelling?
                                                                                              No     S
                                                  Yes

                      SUITABLE FOR USE IN A SELF-ADMINISTRATION
                                                                                                     E
                   PROGRAMME OR AGAINST A DISCHARGE PRESCRIPTION




Safe and Secure Handling of Medicines                                              Page 99 of 154
October 2010
        20.9     Appendix 9 – Self-administration of Medicines – Information Card


                            INFORMATION CARD (FRONT)

                          SELF-ADMINISTRATION OF MEDICINES


               A self-administration programme is used on this ward to allow
               patients, where possible, to be responsible for taking their own
                                          medicine.


         Self-administration is designed to improve your knowledge about your
           medicines so you are better able to cope with them when you go
                                         home.


          Patients on this ward are assessed by nursing staff in order to see if
                     self-administration is suitable for their needs.


          Self-administration is not compulsory and you need not feel that you
                          have to take part in it, even if asked.


          If you agree, then before starting a trained nurse will explain which
         medicines you need and why, the dosage, any special directions and
                           some of the possible side effects.


                You will be given a card to keep as a reminder of the above
                                        information.


            Your own medicines from home will be used where suitable. Any
            other medicines you require will be given to you from the hospital
             pharmacy. They will have on them your name, the name of the
                  medicine and instructions on how often to take them.




Safe and Secure Handling of Medicines                                 Page 100 of 154
October 2010
                             INFORMATION CARD (BACK)

                                        PLEASE REMEMBER


              It is your responsibility to keep your medicines in the medicine
                      drawer/cabinet and keep the key in a safe place.


                                 Do not exceed the stated dose.


           If you forget the number of tablets or when to take them, or if you
          have any questions regarding your medicines, please ask one of the
                               nursing or pharmacy staff.


           Remember that if not used properly, medicines can be dangerous.


         If any visitor or patient tries to take your medicines, please tell a nurse
                                          immediately.


              It is very important that your medicines are checked by the
           pharmacist before you leave the hospital. You may need to wait a
                  short time once the doctor has said you can go home.


           Please remember to give the key to your nurse before going home.




Safe and Secure Handling of Medicines                                  Page 101 of 154
October 2010
         20.10 Appendix 10 – Self-administration of Medicines – Patient
               Assessment Form

             SELF-ADMINISTRATION OF MEDICINES PROGRAMME
                      PATIENT ASSESSMENT FORM

 LOCATION
 PATIENT NAME                            (AFFIX LABEL HERE)



 ADDRESS

 DATE OF BIRTH

1)    MEDICATION RISK ASSESSMENT SCORE (if applicable)
      A score of more than 7 will require a judgement on behalf of the nurse/carer and pharmacist
      whether self-administration is possible at this point. A score of 16 or more is likely to exclude a
      patient from the programme.
2)    DOES THE PATIENT HAVE A HISTORY OF DRUG OR ALCOHOL ABUSE?
      YES/NO
      If YES, it would not be advisable to allow self-administration. Only proceed with
      the express permission of all parties, including GP.
3)    CAN THE PATIENT PHYSICALLY ACCESS THEIR MEDICATION?                                      YES/NO
      (I.E. OPEN FOIL PACK, OPEN BOTTLE)

4)    IS THE PATIENT ABLE TO READ THE MEDICINE LABELS?                                         YES/NO

5)    AFTER EXPLANATION, DOES THE PATIENT KNOW HOW AND WHEN                                    YES/NO
      TO TAKE THEIR MEDICINES?

If the answer to any of the above three questions is NO, self-administration is not advisable. Further
education, compliance aids, or other assistance may be required before self-administration is achieved.

PATIENT ASSESSED BY
(SIGN AND PRINT NAME)
DATE
LEVEL OF SELF-ADMINISTRATION                              RED               AMBER                    GREEN
(CIRCLE ASSESSED LEVEL)
PHARMACIST COUNTERSIGNATURE
AND DATE

IF PATIENT IS CONSIDERED SUITABLE FOR INCLUSION, ENSURE THE
FOLLOWING:
     PATIENT HAS HAD THE SCHEME EXPLAINED, BEEN GIVEN AN INFORMATION FORM, AND GIVEN
     CONSENT FOR INCLUSION?
     GIVE THE PATIENT A MEDICATION INFORMATION CARD AND GO THROUGH THE REGIMEN WITH
     THEM.
     CHECK: HAS THE PATIENT’S PARTNER OR SIGNIFICANT OTHERS BEEN INCLUDED IN THE
     PROCESS?
Safe and Secure Handling of Medicines                                              Page 102 of 154
October 2010
                             20.11 Appendix 11 – Self-administration of Medicines – Medication Risk
                                   Assessment Form

                                                       MEDICATION RISK ASSESSMENT FORM

 PATIENT NAME

                                                                        DATE/INITIALS
                                                            SCORE
                                                                            ADMISSION         WEEK     WEEK      WEEK       WEEK      DISCHARGE
                            Very confused/ psychiatric
                                     illness                    4
 MENTAL
 STATE




                              Muddled/ disorientated            3
                               Occasionally forgetful           2
                             Fully alert and orientated         1
                                      6 or more                 4
NUMBER OF
 MEDICINE




                                        4 or 5                  3
  ITEMS




                                        2 or 3                  2
                                       1 or less                1
                                    Alone, no help              4
ARRANGE-




                            Alone, some help– not daily         3
 MENTS
 LIVING




                                   Alone, daily help            2
                            Living with others – home or
                                      res. care                 1
                             Very ill/ severely disabled/
   PHYSICAL CONDITION




                              severe hearing or visual          4
                                       difficulties
                           Unwell - poor hearing/vision.
                               Partially disabled               3
                            Weakness of limbs/ hands.
                               Poor co-ordination               2
                                   Physically able              1
                            Disinterested or unhappy
                           about medication - unable to         4
                                  recall regimen
 ATTITUDE/




                              Reluctant to talk about
  ABILITY




                                   medication
                                                                3
                               Limited knowledge of
                                    medication
                                                                2
                             Interested - can recall and
                               understand medication            1
                                                             TOTAL
                                                                                              L/M/      L/M/     L/M/
                                                              RISK           L/M/H                                         L/M/H        L/M/H
                                                                                               H         H        H

                                         MEDICATION
                        SCORE
                                            RISK            ACTION
        Less than 6                              Low        Check understanding. May benefit from medication chart and more information.
                                                            May need physical help with administration. May need to refer to Pharmacist. Will benefit
                        7 to 12            Moderate         from medication chart. May need to discuss with community pharmacist assistance available
                                                            e.g. easy-open tops, large print labels, other aids.
                                                            Refer to Pharmacist. Will need regular help and medication reviews. May need to inform GP
                        13 to 20              High          and/or community pharmacist.

 Safe and Secure Handling of Medicines                                                                              Page 103 of 154
 October 2010
        20.12 Appendix 12 – Self-administration of Medicines – Audit Tool

SELF- ADMINISTRATION OF MEDICINES
STANDARD STATEMENT                                   Yes    No       Comments
Statement 1 Are all staff aware of policy guidance
            and SOP for Self–Administration of
            medicines?
Statement 2 Have all relevant staff been trained on
            Self- Administration of medicines?
Statement 3 Does every patient who is self-
            administering medicines have a
            signed consent form?
Statement 4 Does every patient who is self-
            administering medicines have an
            assessment form completed and filed
            in nursing notes?
Statement 5 Do     patients    who      are    self-
            administering medicines have an
            entry from the pharmacist in the
            medical notes documenting this and
            at what level?
Statement 6 Is there daily observation and
            determination of appropriate level of
            self-administration documented in the
            nursing notes for each patient self-
            administering?
Statement 7 Do all patients who are self-
            administering have the key kept
            safely      and      the     medicines
            cupboard/drawer locked?
Statement 8 Do all self-medicating patients have
            medicines in their drawer which are
            suitable for use and appropriately
            labelled?




Safe and Secure Handling of Medicines                        Page 104 of 154
October 2010
        20.13 Appendix 13 – Formulary Exception Request Form




                       FORMULARY EXCEPTION REQUEST
         must be completed fully for any non-formulary medicine requested
 Medicine requested                     Patient name                       Ward



 Continuation/Initiation                Formulary alternative              Consultant
 For continuation, specify GP



 Reason for request to be completed by prescriber




 Prescriber signature                                                      Date

                                For Pharmacy Use Only
 Dose/ Instructions                       Pharmacist sig/ clinical check    Disp by
                                                                           Check
                                                                           Date
                                                                           Date
 Ordered by                             Ordered from


 Received on


                                                                           Date
 Sent to ward/ pt by


 Cost
 Formulary alternative cost
 Difference




Safe and Secure Handling of Medicines                                      Page 105 of 154
October 2010
        20.14 Appendix 14 – NHS Cumbria Waste Medicines Disposal Procedure

        Procedure for disposal of waste medicines direct from Community
        Hospitals and clinics (Appendix 6 Waste Management Policy
        CPCT/005/020)

        Pharmaceutical waste should no longer be sent for disposal to the pharmacy
        at either of the North Cumbria University Hospital Trust (NCUHT) hospital
        sites. Pharmaceutical waste must now be consigned as waste from the
        premises where it is declared as waste.

        Pharmaceutical waste for disposal may comprise –

        a) Hazardous and non-hazardous medicines i.e.
        • Out of date stock medicines e.g. those originally supplied by NCUHT
        • Refused medication or medication potentially contaminated prior to
           administering e.g. dropped pills.
        • Controlled drugs (schedules 2 & 3) that have been denatured in
           accordance with Trust policy – Safe and Secure Handling of Controlled
           Drugs (Community Hospitals).
        • Empty containers (bottles, aerosols etc.) that previously contained
           pharmaceutical products.
        • Patient’s own medication brought in at the time of admission in connection
           with their treatment but no longer required. This includes patients own “in
           date” medication that has become obsolete due to a change in treatment.
           No other medication should be accepted for disposal from patients or
           visitors.

        b) Non- pharmaceutically active waste possessing no hazardous properties
        • Saline IV fluid bags

        Only non-pharmaceutically active waste possessing no hazardous properties
        can be disposed of by emptying into a sink or sluice. The empty containers
        may be disposed of as domestic waste. All other waste must be disposed of
        to a waste management contractor.

        Some pharmaceutical waste may be deemed hazardous containing cytotoxic
        or cytostatic agents. This description includes many hormonal preparations
        since the definition (within the Hazardous Waste Regulations 2005) includes
        medicines that have one or more of the following hazardous properties: Toxic,
        Carcinogenic, Mutagenic or Toxic for Reproduction. These must be
        segregated from other non-hazardous pharmaceutical waste prior to disposal.

        Hazardous pharmaceutical waste (i.e. cytotoxic or cytostatic as described
        above) should be identified by checking the type of medication against
        NCUHT’s “List of Recognised Cytotoxic and Cytostatic Medicines – December
        2008”. This list will be updated by NCUHT pharmacy department at least
        annually.

Safe and Secure Handling of Medicines                             Page 106 of 154
October 2010
        Hazardous and non-hazardous medicines must be placed in separate and
        appropriately identified pharmaceutical waste containers for subsequent
        collection by an authorised waste management contractor for disposal by
        incineration. Hazardous waste should be placed in yellow containers with a
        purple lid or purple stripe. Non-hazardous waste should be placed in all yellow
        containers. Leak proof waste containers should be used for the disposal of
        liquid pharmaceutical waste.

        A range of suitable containers for pharmaceutical waste are available from
        NHS Supply Chain catalogue.

        The outer (secondary) packaging may be removed from the waste medicines
        to reduce waste volume. If the outer packaging has any patient identifiable
        details ensure it is disposed of as confidential waste i.e. shredded sufficiently
        to ensure no personal information can be read.

        Pharmaceutical waste should be disposed of in its original primary packaging
        (blister packs, vials etc.). Medicines should not be removed from blister
        packaging. Any liquid waste must remain in its original container.

        All pharmaceutical waste not in its original primary packaging e.g. dropped or
        refused medication, should be treat as hazardous waste.

        Aerosols, full or empty, up to a total volume of 2 litres that are likely to contain
        flammable liquids may be placed in a container with other pharmaceutical
        waste. Larger quantities of aerosols must be segregated into a separate
        container and the container identified as highly flammable.

        All pharmaceutical waste containers must be kept secure, in a locked
        cupboard or room, until consigned to the waste disposal carrier.
        Pharmaceutical waste should be consigned at regular intervals, typically
        monthly to avoid the build up of waste medicines. For premises producing
        very small quantities of waste medicines, Intervals should not exceed six
        months.

        Hazardous pharmaceutical waste must be consigned to the waste contractor
        on a hazardous waste consignment note. This can normally be included on
        the same consignment note provided by the contractor for the regular clinical
        waste collections. Non-hazardous pharmaceutical waste can also be included
        on this consignment note.

        The quantity of any waste medicines brought in by patients should be
        separately identified by approximate weight to the classification codes below.
        Where this is not practical, waste medicines should be assumed to be from
        hospital provision.

        The following waste classifications and hazard codes should be used to
        consign pharmaceutical waste. These will normally be pre printed on any
        consignment note.

Safe and Secure Handling of Medicines                                  Page 107 of 154
October 2010
         Waste item                                      Classification   Hazardous
                                                                          properties
         Cytotoxic/cytostatic waste medicines from       18 01 08*        H6, H7, H10,
         hospital provision.                                              H11

         Cytotoxic/cytostatic waste medicines            20 01 31*        H6, H7, H10,
         brought in by patients.                                          H11

         Non-hazardous waste medicines from              18 01 09
         hospital provision.

         Non-hazardous waste medicines brought in        20 01 09
         by patients.




Quick guide to procedure



                                  Pharmaceutical waste




       Non-pharmaceutically                              Pharmaceutically active
           active waste                                         waste



      Waste into sink or sluice          Hazardous cytotoxic                  Non-hazardous
                                           cytostatic waste                pharmaceutical waste
                                         Dropped/refused pills


                                         Yellow container with             Yellow container with
                                               purple lid                        yellow lid




Safe and Secure Handling of Medicines                                           Page 108 of 154
October 2010
        20.15 Appendix 15 – Intravenous Drug Quickguide




INTRAVENOUS DRUG QUICKGUIDE
GENERAL NOTES

NEVER GIVE A DRUG UNLESS YOU ARE CONFIDENT THAT YOU ARE COMPETENT TO DO SO, ARE FAMILIAR WITH THE DRUG AND ITS SIDE-
EFFECTS, ARE FOLLOWING ALL RELEVANT TRUST POLICIES AND HAVE THE CORRECT FACILITIES AND EQUIPMENT TO PREPARE AND
ADMINISTER THE DOSE CORRECTLY. INCLUSION ON THIS LIST DOES NOT CONSTITUTE APPROVAL FOR USE IN COMMUNITY, IN FACT MAY
BE USEFUL TO DETERMINE NON-SUITABILITY.

PREPARING A DOSE

If the dose to be given is the same as the vial dose, then unless otherwise indicated in the product leaflet, add the precise volume of correct diluent as stated,
then draw up the entire vial contents once it is fully dissolved. Always dilute further if directed.

FRACTIONAL DOSES
If a fractional dose is to be taken from a vial, make up the solution by adding the precise volume of diluent as stated, then calculate the volume to draw out
from the vial as follows:

volume to           dose required (mg)                          volume of           displacement
draw      =                                          X          diluent       +        volume
from vial              mg in vial                                added                  for vial

e.g. giving a 1000mg dose of benzylpenicillin from a 1.2g vial, 1000/1200 x (8+0.8) = 7.3ml. Therefore 8ml added to 1.2g vial and draw up 7.3ml, then dilute
further to around 20ml (at least 1000/1200 x 20 = 17ml) = 1000mg

COMPATIBILITY
Always administer each drug separately (but metronidazole bags are compatible with cefuroxime or cefotaxime). ALWAYS FLUSH BEFORE, AFTER AND
BETWEEN DRUGS.

Safe and Secure Handling of Medicines                                             Page 109 of 154
October 2010
SINGLE-USE : Always use a freshly-prepared solution immediately, and use each vial ONCE ONLY, unless the vial specifically states that it is a multi-dose
vial.

RISK FACTOR LEVEL
Risk reduction strategies are required for HIGH (RED) (SCORE 6-8) risk products. Risk reduction strategies are recommended for MODERATE (AMBER)
(SCORE 3-5) risk products. Risk reduction strategies should be considered for LOW (GREEN) (SCORE 0-2) risk products,

QUERIES
THIS GUIDE IS AN AIDE MEMOIRE ONLY, AND SHOULD NOT REPLACE YOUR PROFESSIONAL REQUIREMENT TO USE MANUFACTUER’S
LICENSED INFORMATION TO INFORM YOUR PREPARATION AND ADMINISTRATION OF MEDICATION. Remember you can always contact pharmacy
for advice on any aspect of IV drugs.

ABBREVIATIONS: NaCl = sodium chloride         WFI = water for injections




Safe and Secure Handling of Medicines                                        Page 110 of 154
October 2010
       TABLE FOR PREPARATION AND ADMINISTRATION OF IV MEDICATION (page1/4)


                   Typical Adult dose       Displacement                              Suitable volume
                                                                 Suitable diluent                                                                                          Risk
 Medication         and dose interval          volume                                    for diluting      Speed of bolus injection     Suitable fluid
                                                                    for initial                                                                            Speed of       Factor
                      (assumes no         (to be taken into                             powder/final       (bolus often preferred if   and volume for
                                                                reconstitution of                                                                          infusion       Score
generic name          renal/hepatic          account for                             volume for bolus             possible)               infusion
                                                                     powder                                                                                              (NPSA)
                       impairment)        fractional doses)                            administration
                                                                                      10ml per 250mg
                       5mg/kg               Negligible, also                                                  NOT FOR BOLUS             500mg/100ml
   aciclovir                                                       NaCl 0.9%         then must dilute to                                                  60 minutes       5
                    EVERY 8 HOURS         comes ready-mixed                                                  ADMININSTRATION             NaCl 0.9%
                                                                                       at least 5mg/ml
                                               0.2ml/250mg
                        500mg-1g                                                      5ml per 250mg
                                                                                                                                         NaCl 0.9%
  amoxicillin            EVERY            Draw up entire vial         WFI                  e.g.                  3-4 minutes                             30-60 minutes     1
                                                                                                                                         50-100ml
                       6-8 HOURS           contents for full                           20ml for 1g
                                                dose
                                          Draw up entire vial                                                                            NaCl 0.9%
                     1-2g EVERY 6, 8
  aztreonam                                contents for full          WFI                  10ml                  3-5 minutes             50-100ml        20-60 minutes     1
                      OR 12 HOURS
                                                dose                                                                                      per 1g
                                                                                                            DOSES >1.2g MUST BE
                                              0.4ml/600mg                                                                                Doses over
                                                                                                             GIVEN BY INFUSION
                        600mg-3g                                                                                                        1.2g must be
                                                                    WFI or                                   At least 2 minutes per
benzylpenicillin    (or can be higher)    Draw up entire vial                         4ml per 600mg                                        infused       30-60 minutes     2
                                                                   NaCl 0.9%                                        600mg.
                   EVERY 4-6 HOURS         contents for full                                                                             NaCl 0.9%
                                                                                                           Preferred 10ml per 600mg
                                                dose                                                                                      50-100ml
                                                                                                            given over 5-10 minutes
                                                                       WFI
                       1g EVERY 12             0.5ml/1g vial
                                                                solution is straw-
                          HOURS
                                                                    coloured           1g vial– 4ml                                      NaCl 0.9%
  cefotaxime       (though can be up to   Draw up entire vial                                                    3-5 minutes                             20-60 minutes     2
                                                                    (okay to           2g vial– 10ml                                     50-100ml
                      12g daily in 3-4     contents for full
                                                                reconstitute with
                          doses)                dose
                                                                 Minibag Plus)
                       1g EVERY 8
  ceftazidime
                        HOURS or
(see leaflet for                                                                        5ml/500mg
                      2g EVERY 12                                   WFI or                                                               NaCl 0.9%
   specific                                   0.55ml/500mg                              10ml/1-2g                3-5 minutes                             20-60 minutes     2
                         HOURS                                     NaCl 0.9%                                                             50-100ml
reconstitution                                                                           15ml/3g
                     but can be up to
  guidance)
                          6g/day




      Safe and Secure Handling of Medicines                                               Page 111 of 154
      October 2010
      TABLE FOR PREPARATION AND ADMINISTRATION OF IV MEDICATION (page2/4)


                   Typical Adult dose      Displacement                           Suitable volume                                                                    Risk
                                                               Suitable diluent
 Medication         and dose interval         volume                                 for diluting    Speed of bolus injection     Suitable fluid
                                                                  for initial                                                                        Speed of       Factor
                      (assumes no        (to be taken into                          powder/final     (bolus often preferred if   and volume for
                                                              reconstitution of                                                                      infusion       Score
generic name          renal/hepatic         account for                           volume for bolus          possible)               infusion
                                                                   powder                                                                                          (NPSA)
                       impairment)       fractional doses)                         administration
                   750mg-1.5g EVERY
                    8 HOURS (or can                                                  6ml/750mg                                     NaCl 0.9%
 cefuroxime                                   0.54ml/750mg          WFI                                    3-5 minutes                             20-30 minutes     2
                           be inc                                                    15ml/1.5g                                     50-100ml
                        to 6-hourly)
                    500mg EVERY 12          reconstituted                           10ml/500mg          NOT FOR BOLUS              NaCl 0.9%
clarithromycin                                                      WFI                                                                             60 minutes       3
                          HOURS          solution = 50mg/ml                       then must dilute      ADMINISTRATION               250ml
                                                                                                                                   NaCl 0.9%
                     Can be up to 3g                                                                                              Must not be      Minimum 10
                                                                                                        NOT FOR BOLUS
 clindamycin         divided into 2-4         Ready-mixed       Ready-mixed             n/a                                        more than        minutes for      2
                                                                                                        ADMINISTRATION
                       doses daily                                                                                               18mg/ml, e.g.     every 300mg
                                                                                                                                 600mg in 50ml
co-amoxiclav       1.2g EVERY EIGHT
(Augmentin)           HOURS (can be                                                                                         NaCl 0.9%
                                              0.5ml/600mg        WFI        10ml per 600mg           3-4 minutes                                   30-40 minutes     2
 (contains a       increased to every 6                                                                                  50ml per 600mg
  penicillin)              hours)
                         250mg-1g                                                                                        (Doses over 2g
                                                                                              (Doses of 2g must be given
                     EVERY 6 HOURS                                                                                       must be infused)
 flucloxacillin                               0.2ml/250mg        WFI         5ml per 250mg           by infusion)                                  20-60 minutes     1
                      (can be up to 2g                                                                                      NaCl 0.9%
                                                                                                     3-5 minutes
                       every 6 hours)                                                                                       50-100ml
                    3-4mg/kg daily in 8-
                        hourly doses
                                                                            no need to dilute                               NaCl 0.9%              less than 20
                            OR                Ready-mixed     Ready-mixed                            3-5 minutes
 gentamicin                                                                     for bolus                                less than 100ml             minutes         3
                       5mg/kg ONCE
                           DAILY
                                         *MAY REQUIRE BLOOD LEVEL MONITORING, SEEK PHARMACY ADVICE as depends on dosage schedule*




      Safe and Secure Handling of Medicines                                           Page 112 of 154
      October 2010
     TABLE FOR PREPARATION AND ADMINISTRATION OF IV MEDICATION (page3/4)


                  Typical Adult dose       Displacement                             Suitable volume
                                                                Suitable diluent                                                                                           Risk
 Medication        and dose interval          volume                                   for diluting        Speed of bolus injection     Suitable fluid
                                                                   for initial                                                                             Speed of       Factor
                     (assumes no         (to be taken into                            powder/final         (bolus often preferred if   and volume for
                                                               reconstitution of                                                                           infusion       Score
generic name         renal/hepatic          account for                             volume for bolus              possible)               infusion
                                                                    powder                                                                                               (NPSA)
                      impairment)        fractional doses)                           administration
                  20-250mg at a rate                                                                                                      NaCl 0.9%
                     not exceeding                                                                                                     any volume, but
                      4mg/minute,                                                   no need to dilute                                       1mg/ml       not more than
  furosemide                                 Ready-mixed         Ready-mixed                                not more than 4mg/min                                          2
                    repeated usually                                                    for bolus                                       preferred, but     4mg/min
                    under consultant                                                                                                    not more than
                       supervision                                                                                                         10mg/ml
                                                                                                                                          NaCl 0.9%
                   100-500mg up to                                                  no need to dilute
hydrocortisone                               0.05ml/100mg        Ready-mixed                                     1-10 minutes           or glucose 5%    30-40 minutes     1
                    four times daily                                                    for bolus
                                                                                                                                            100ml
                  500mg-1g EVERY 8                                                                                                        NaCl 0.9%
 meropenem                                   0.22ml/250mg            WFI             5ml per 250mg                5 minutes                              15-30 minutes     1
                        HOURS                                                                                                              50-200ml
                    Short courses of
  methylpred -                                                                       Only doses up to                                   over 250mg
                   high dose (1g daily                         add all of diluent                                up to 250mg
   nisolone                                   negligible                            250mg suitable for                                  NaCl 0.9%         30 minutes       2
                  for 3 days) used for                            ampoule                                         5 minutes
(Solu-medrone)                                                                            bolus                                           100ml
                          MS
                                                               Ready-mixed Do
                                                               Not Add Anything
                   500mg EVERY 8                                    Except                                    NOT FOR BOLUS
metronidazole                                    n/a                                       n/a                                          Ready-mixed      20-30 minutes     0
                      HOURS                                     Cefuroxime or                                 ADMINISTRATION
                                                                 Cefotaxime

                                                                                     The contents of
                       One pair of
                                                                                     ampoules 1 & 2
                  ampoules every two
                                                                                      must be both                                         Infusion
                      weeks after        Draw up entire vial
                                                                                      drawn up and                 10 minutes          preferred: NaCl
   Pabrinex         haemodialysis –       contents for full      Ready-mixed                                                                              30 minutes       2
                                                                                       mixed in the         (but infusion preferred)         0.9%
                   other uses would            dose
                                                                                     syringe, or both                                       100ml
                   not be appropriate
                                                                                      added to the
                     in community
                                                                                       infusion bag




     Safe and Secure Handling of Medicines                                               Page 113 of 154
     October 2010
      TABLE FOR PREPARATION AND ADMINISTRATION OF IV MEDICATION (page4/4)



                     Typical Adult                                               Suitable volume
                                          Displacement           Suitable
                    dose and dose                                                   for diluting          Speed of bolus                                             Risk
Medication                                   volume             diluent for                                                     Suitable fluid
                        interval                                                   powder/final               injection                             Speed of        Factor
                                        (to be taken into          initial                                                       and volume
                     (assumes no                                                    volume for         (bolus often preferred                       infusion        Score
generic name                               account for        reconstitution                                                     for infusion
                     renal/hepatic                                                     bolus                if possible)                                           (NPSA)
                                        fractional doses)       of powder
                      impairment)                                                 administration
    Tazocin
 (piperacillin/
                     4.5g EVERY 8               0.7ml/1g         WFI or           20ml per 4.5g                                  NaCl 0.9%
 tazobactam)                                                                                                3-5 minutes                           20-30 minutes      2
                        HOURS                 (3.15ml/4.5g)     NaCl 0.9%              vial                                      50-100ml
  (contains a
   penicillin)
                                           Draw up entire                                                                                           6 HOURS
                    500mg THREE                               use 10ml diluent                          NOT FOR BOLUS              500ml
Sodium fusidate                           vial contents for                            n/a                                                          (or 2h via       3
                    TIMES DAILY                                   supplied                              ADMINISTRATION           NaCl 0.9%
                                               full dose                                                                                           central line)
                                                                                   do not shake,
                      200-400mg         Draw up 3ml from                              roll until
                                                               use all diluent                                                   NaCl 0.9%
  teicoplanin         EVERY 24          200mg or 400mg                               dissolved               5 minutes                             30 minutes        2
                                                                 supplied                                                        50-100ml
                       HOURS                  vial                                and stand until
                                                                                  foam reduces.
                                                                                                                                                   Give over not
                                                                                                                                                    less than 60
                                                                                                                                  NaCl 0.9%
                   500mg EVERY 6                                                                                                                  minutes and at
                                           Draw up entire                          20ml per 1g                                  not more than
                      HOURS or                                                                          NOT FOR BOLUS                             least 10mg per
 vancomycin                               vial contents for         WFI             then dilute                                    5mg/ml                            3
                    1g EVERY 12                                                                         ADMINISTRATION                              minute, e.g.
                                               full dose                              further                                   e.g. give 1g in
                       HOURS                                                                                                                        give 500mg
                                                                                                                                    250ml
                                                                                                                                                       over 60
                                                                                                                                                      minutes




      Safe and Secure Handling of Medicines                                          Page 114 of 154
      October 2010
           20.16 Appendix 16 – IV Cannula Observation Chart

Surname:
First name:
Date of birth:                                                            Peripheral Intravenous
Hospital number:                                                        Cannula Observation Chart
Patient details or ID label

Insertion of peripheral cannula
 Ward         A&E    Theatre        Xray       Other        Date & Time of Insertion               Date of Removal


   Please commence new observation chart at each cannula insertion/reinsertion
      INSERTION                                         VISUAL INFUSION PHLEBITIS SCORE
 Gauge         24
                                            Observation                    VIP                  Actions
               22
               20                    IV Site Appears Healthy                0             No signs of phlebitis
               18                                                                          Observe cannula
               16
               14
                                 One of the following evident:              1     Possible first signs of phlebitis
                                      - Slight pain near I.V site                          Observe cannula
 Lot No………….……..
                                      - Slight redness near I.V site
 No. of attempts.……..
 Insertion reason
                                 Two of the following is evident:           2           Early stages of phlebitis
                                      - Pain near I.V site                                  Resite cannula
 NBM                                  - Erythema
 IV Antibiotics                       - Swelling
 Theatre                         All of the following are evident:          3         Medium stages of phlebitis
 Blood                           - Pain along the path of cannula                           Resite cannula
                                 - Erythema
 Other………………………                                                                           Consider treatment
                                 - Induration
 ………………….
   Insertion Actions             All of the following are evident and       4     Advanced stage phlebitis or start of
                                 extensive:                                              thrombophlebitis
 Hand Hygiene (HII2a)            - Pain along the path of cannula
 Gloves & Aprons                 - Erythema                                                 Resite cannula
 used (HII2a)                    - Induration                                             Consider treatment
 Skin Prep (HII2a)               - Palpable venous cord
 Dressing (HII2a)
 Successful flush post
                                 All of the following are evident and       5              Advanced stage of
                                 extensive:                                                 thrombophlebitis
 insertion                       - Pain along path of cannula
 Aseptic technique               - Erythema                                                Initiate treatment
        Consent                  - Induration                                               Resite cannula
                                 - Palpable venous card
 Informed
                                 - Pyrexia (+/- WCC, HR)
 Implied
 Unable                               Please indicate                                REMOVAL
 Inserted by:                       insertion site below:      Removal Reason
                                                               Not required
 Designation & bleep no.                                       Phlebitis
                                                               Other………………………………………………
                                                               Cannula in place
                                                               < 72 hours
                                                               > 96 hours
                                                               Removed by:
                                                               Designation:


  Safe and Secure Handling of Medicines                                              Page 115 of 154
  October 2010
                               Cannula Daily Assessment & Monitoring
              Please enter tick / cross in appropriate box and initial column (min every shift )
                                Day 1                     Day 2                    Day 3                   Day 4
Clinical location:

Date:




                                                  night




                                                                           night




                                                                                                   night




                                                                                                                        night
Time:



                                          pm




                                                                  pm




                                                                                           pm




                                                                                                                   pm
                                 am




                                                          am




                                                                                   am




                                                                                                             am
Do clinicians require
ongoing peripheral
venous access? (HII2b)

Does the cannula need
to be replaced?
Infection Prevention (see High Impact Interventions 2b Ongoing Care (HII2b)
Hand Hygiene (HII2b)
Administration set
replacement (HII2b)
(ensure all lines are
dated)
Cannula access – (HII2b)
chlorhexidine wipe prior
to access
Assessment of Dressings and Lumen Potency
Dressing dry and intact
(HII2b)

Dressing soiled, damp
or loose – changed
Cannula flushed

Risk Assessment score
VIP Score (HII2b)
Action Taken if VIP 2 or above
Cannula removed
Cannula resited
Medical staff informed
Swab of cannula site
Blood cultures taken if
temp above 38º
Other (documented in
notes)
          Initials

    High Impact Intervention (HII2b) – Ongoing care actions
        •    Hand hygiene
        •    Continuing clinical indication
        •    Site inspection (signs of infection)
        •    Dressing (transparent, dry, intact)
        •    Cannula access (chlorhexidine 2%)
    Safe and Secure Handling of Medicines                                                  Page 116 of 154
        •    Administration set replacement (please ensure all lines are dated)
    October 2010
        •    Routine cannula replacement
        20.17 Appendix 17 – Criteria for IV Drug Administration in the Home
        Environment



Criteria for the suitability of IV Drug Administration (excluding chemotherapy) in
the Home Environment following discharge from Acute Hospital

    •   Scheme appropriate for adult patients only

    •   The patient lives within the Cumbria Primary Care Trust area

    •   Review has confirmed a continuing need for IV drug administration

    •   Patient is medically stable with uncomplicated condition and can cope with
        activities of daily living

    •   Prior communication regarding discharge planning, review and agreement to
        accept patient referral has taken place between ward staff, GP and District Nurse;-
                  - suitable home environment
                  - community team has sufficient numbers of IV trained staff to provide
                     drug administration
                  - community team has appropriate equipment eg drip stands if
                     required
                  - monitoring requirements specified and can be conducted in patients
                     home
                  - Care plan includes nurses responsibilities, length of treatment etc
                  - full course of treatment (IV medication and administration supplies)
                     supplied by the acute trust
                  - Prescribing responsibility remains with the hospital doctor.

    •   Medication is prescribed by the hospital doctor on the green community
        medication chart (supplies on ward areas)
    •   Ensure both the GP and the caseload holding nurse have both accepted prior to
        discharge
    •   Consultation with the patient and agreement and consent has taken place

    •   Ensure there is access to a telephone or mobile phone in the home environment.
        Establish an effective signal via a mobile phone can be obtained in the area. If not,
        clarify the route of communication in the event of a medical emergency




Criteria for IV Drug Administration (excluding chemotherapy) in the community
hospitals, Primary Care Assessment Centres and Step Up Step Down units


Safe and Secure Handling of Medicines                               Page 117 of 154
October 2010
    •    GPs and non-medical independent prescribers can prescribe flucloxacillin or
         clarithromycin as defined in the Cellulitis Care pathway
.
    •    IV trained nurses can administer IV flucloxacillin and clarithromycin in accordance
         with the Cellulitis Care pathway

    •    All other IV medication can only be administered by an IV trained nurse if
         prescribed by a specialist eg microbiologist

For discharge of patient to home environment - follow the Criteria for the suitability of
IV Drug Administration (excluding chemotherapy) in the Home Environment
following discharge from Acute Hospital




Cumbria PCT IV steering group
Reviewed September 2009
Next review September 2010




Safe and Secure Handling of Medicines                                Page 118 of 154
October 2010
        20.18 Appendix 18 – Assessing Risk: The pre-loading of Insulin

The pre-loading of insulin should be considered as a last resort and only following a risk
assessment. Its aim is to promote patient independence not as a means of saving
nursing time.

Contra-indications
  • Insulin which is not suitable for pre-loading
          o Short-acting (soluble) insulin
          o Long-acting analogues e.g. Glargine
  • Unstable diabetic condition
  • Lack of satisfactory storage facilities
          o Fridge in working order
          o Protective container(s) to store syringes
  • Patient suffers from an unpredictable mental state or declining cognitive ability
  • Patients in a Care Home without his/her own individual private storage facilities

No contra-indications then a positive response to all of the following is required before
the pre-loading of insulin can commence

1) Has the patient shown that he/she understands their insulin              Yes / No
    regime?
2) Has the patient been provided with education and support                 Yes / No
    regarding the drawing up of insulin but remains unable to do this
    accurately and independently?
3) Has the patient shown that he/she is able to administer insulin          Yes / No
    correctly and independently at the appropriate time?
4) Does the patient know how to dispose of the used syringes                Yes / No
    safely?
5) Has advice been sought from the Diabetes Specialist Nurse                Yes / No
    Team?
6) Have alternative methods of insulin administration been                  Yes / No
    considered/tried without success?
7) Can the patient monitor diabetes control independently or are            Yes / No
    arrangements in place for monitoring to be undertaken?
8) Is the patient aware of the nursing team’s contact details and           Yes / No
    available support between nurse’s visits?
9) If on twice daily insulin dose will the patient be able to distinguish   Yes / N/A
    between a.m. and p.m. dose?
10) Does clinical judgement support the use of preloading of insulin        Yes / No
    for the patient?
11) Would pre-loading of insulin promote patient independence and           Yes / No
    meet patient need?
12) Will arrangements be put in place (and documented) for the              Yes / No
    regular reassessment of the plan of care (3 monthly or sooner if
    patient’s circumstances change)?




Safe and Secure Handling of Medicines                                 Page 119 of 154
October 2010
        20.19 Appendix 19 – Safe and Secure Handling of Medicines: Self
              Assessment Checklist

SELF ASSESSMENT CHECKLIST

Yes / No

1. ORDERING AND TRANSPORT OF MEDICINES
(a) Designated person responsible for ordering: Name: _______________________
(b) Satisfactory Receipt & Security of delivered orders
(c) Delivery note/picking ticket always signed, dated and one copy returned to the supplying
pharmacy
(d) Current order forms are used for pharmacy orders

2. STORAGE
(a) Room with limited access to key holders
(b) Keys for medicine cupboard held by a designated person.
Name …………………………
(c) Locked drug cupboards
(d) Separate cupboard for each discipline
(e) Adequate storage space available
(f) Drug cupboards are solely for storage of Pharmaceutical supplies
(g) Drug cupboards are fixed to a solid permanent wall
(h) Internal medicines/external medicines and disinfectants separated
(i) Pharmacy fridge is locked when it is not in use
(j) Temperature of the fridge is monitored regularly using a min-max thermometer

3. STOCK CHECK
(a) Satisfactory arrangement of stock within cupboards
(b) Regular stock/date check by clinic staff
(c) Regular rotation of stock
(d) Satisfactory stock levels
(e) Anaphylactic shock packs in date
(f) Medicines belonging to patients are accepted and used only as in policy

4. DISPOSAL
(a) Appropriate sharps and waste bins are used according the Infection Control Policy and Waste
Management Policy.

5. ACCESS TO POLICY DOCUMENTS:
(a) Medicines Policy
(b) Anaphylaxis treatments guidelines
(c) Infection Control Policy
(d) Other relevant policies and guidelines

6. STANDARD OPERATING PROCEDURES (SOPS)
(a) Accountability record for SOPs completed


Name and signature: ____________________________            date:______


Hospital/ dept: _____________________________________

Safe and Secure Handling of Medicines                                   Page 120 of 154
October 2010
        20.20 Appendix 20 – SOPs Accountability Record


The undersigned have read and understood the relevant SOPs (list the numbers)
and will work to them and any future updates of this SOP



Date                           Name      Number (s) of    Signature
                                         SOPs




Safe and Secure Handling of Medicines                    Page 121 of 154
October 2010
APPENDIX 20 - MEDICATION FRIDGE TEMPERATURE MONITORING CHART

    Ward/unit/team base…………………………………Month…………………Year……….

                    Date                Current    Minimum          Maximum                Initials

                      1
                      2
                      3
                      4
                      5
                      6
                      7
                      8
                      9
                     10
                     11
                     12
                     13
                     14
                     15
                     16
                     17
                     18
                     19
                     20
                     21
                     22
                     23
                     24
                     25
                     26
                     27
                     28
                     29
                     30
                     31

            o Reset min/max after daily temperature readings have been recorded
            o Record when defrosting has been carried out, if applicable
            o Fridge temperature for medication storage should be in range 2 – 8 C.
            o If temperature outside range, report to manager, adjust thermostat if possible and
              return after 1 hour to recheck current temperature. If continues to be outside range,
              report fault and move medication to another fridge. Seek advice from pharmacy for
              medication which has been outside of range.
            o Keep monitoring chart on ward for 2 years.




Safe and Secure Handling of Medicines                                    Page 122 of 154
October 2010
         POLICY TITLE:
           POLICY FOR THE SAFE AND SECURE HANDLING OF MEDICINES
           STANDARD STATEMENT                               Yes       No      Comments
           Statement 1 All staff have access to medicines
                       policies and know how to access
                       them on the intranet. An up-to-date
                       BNF is available.
           Statement 2 Adherence to SOPs form signed by
                       all relevant members of staff.
           Statement 3 All medicines cupboard keys are
                       stored securely and there is a named
                       health professional responsible for
                       key security
           Statement 4 All medicine cupboards meet BS2881
                       standard
           Statement 5 Temperatures of drug fridges are
                       monitored on a daily basis
           Statement 6 Prescriptions pads are kept in a
                       locked cupboard/drawer when not in
                       use
           Statement 7 PGDs are available in the relevant
                       clinical areas
           Statement 8 Emergency drugs are available and in
                       date
           Statement 9 Regular stock checks are carried out

           Statement 10 Arrangements are in place for the
                        safe destruction of expired and
                        unwanted medicines




Safe and Secure Handling of Medicines                       Page 123 of 154
October 2010
             21.     ASSOCIATED DOCUMENTATION

             21.1 Template 1 – Training Needs Analysis and Training Plan

             To be completed following discussion with the Training Manager

             OVERVIEW
             The Trust has a Document Development Policy to provide a framework and
             guidance for staff responsible for the development and management of procedural
             documentation.
             STATEMENT

             All policies will provide clear analysis of the amount of training required to ensure
             compliance. Policy authors will be asked to complete the following table to support
             submission to the Policy Monitoring Group.

Training Assessed at     For which staff group:
Level:
                                                              Suggested cost
Please refer to key                                           implications
below                    Please identify approximate number
                         Admin & Clerical              NO
                                                              Costs covered by In-
                         Allied Health Professionals   YES    Service training
Statutory    Yes         Central Functions/Corporate   NO                                   YES/NO
                         Services (HR, Finance)
                         Information                   NO
                         Ancillary/Maintenance         NO     Departmental Costs:
                         Registered Nurses and         YES
                         Midwives
                         Health Care Assistant         YES
Mandatory
                         Social Care Support Staff
                         General Management
                         Medical/Dental
                         Other please specify
                         Does this apply to
                                                              Comments – Policy Aim:
Best                     Corporate
Practice                 PCT
                         Provider
                         Both
Method of delivery                                            Awareness raising of
                                                                                            YES/NO
                                                              Policy by manager
                                                              Length of session
Frequency
Handouts                 YES/NO

Redesign & reuse of
existing training time

     Safe and Secure Handling of Medicines                                Page 124 of 154
     October 2010
Reference Policy Document available http://nww.staffweb.cumbria.nhs.uk/cumbriapct/Policies/Home.aspx




     Safe and Secure Handling of Medicines                                Page 125 of 154
     October 2010
        Training Key

        Statutory – large scale training implications. A policy will be designated for this
        required level of training if the policy is felt to present high risk to the Trust.

        Mandatory – specified training programme required for defined group of
        staff. A policy will be designated for this required level of training if the policy is
        felt to present medium risk to the Trust.

        Best Practice – awareness and local discussion only. A policy will be
        designated for this required level of training if the policy is felt to present minimal
        risk to the Trust.

        It is acknowledged that all staff must be aware of new and reviewed policies.

        Equality & Diversity

        This applies to all staff working within the trust, employees, contractors and staff
        from other organisations working on trust premises irrespective of age, race,
        colour, religion, disability, nationality, ethnic origin, gender, sexual orientation or
        marital status, domestic circumstances, social and employment status, HIV status,
        gender reassignment, political affiliation or trade union membership. All
        employees will be treated in a fair and equitable manner and reasonable
        adjustments will be made where appropriate (e.g. interpreter or signing provision,
        access arrangements, induction loop, etc).




Safe and Secure Handling of Medicines                                 Page 126 of 154
October 2010
        21.2 Template 2 – Document Implementation Effectiveness Audit Tool

        Audit Statement

     The Trust will work towards effective governance systems. To demonstrate effective
     care delivery and compliance, regular audits must be carried out. Policy authors are
     required to attach an audit tool to all policies, which will be used to question the
     systems in place, as outlined in the policy.

        Policy                                                                     Author




Safe and Secure Handling of Medicines                            Page 127 of 154
October 2010
        21.3     Template 3 – Initial Equality Impact Assessment

        Please refer to the guidance notes available on the NHS Cumbria website:
        http://www.cumbriapct.nhs.uk/pct/about/trustboard/2007/Guidance%20.doc

         Title of Existing/Reviewed/Proposed Policy/Change in Service:
         SAFE AND SECURE HANDLING OF MEDICINES POLICY
         Department:
         MEDICINE MANAGEMENT
         Name of person completing this assessment
         Date
         1. Identify the main aims of the Policy/Change
         A. What is the purpose of the policy/change? (Aims and objectives)
         This policy will ensure that :
                   •    Information is available to enable an authorised practitioner correctly and appropriately prescribes medicines.
                   •    Medicines are accurately and appropriately supplied, stored and transported.
                   •    Medicines are accurately, appropriately and safely administered.
                   •    Medicines are correctly controlled and recorded to prevent the loss, inappropriate access and misuse by patients,
                        residents, staff or any member of the general public.
                   •    Practitioners involved in the delivery of care are responsible for their actions.
                   •    Incidents and errors involving medicines are minimised.

         B. What are the intended benefits of the proposed policy/change? How will they be
         measured?

         The Trust will work towards safe and secure handling of medicines in all settings ensure patient safety. To demonstrate effective
         care delivery and compliance regular audits will be carried out.


         C. What mechanisms will be/are in place to ensure it works/is working as intended?

         The compliance to the policy will be audited


         2. Assess the Likely Impact
         A. Could this have a negative impact on the following groups?
                                        Yes No                             Yes No
         Disabled                               x   Age                         x
         Race                                   x   Religious Groups            x
         Gender                                 x   Sexual Orientation          x
         B. Will the policy damage relations between the different groups?
                                        Yes No                             Yes No
         Disabled                               x   Age                         x
         Race                                   x   Religious Groups            x
         Gender                                 x   Sexual Orientation          x
         3. Is there a public or staff concern that this function or policy may be
         discriminatory?
         Public                                     Staff
         No                                                               No
         4. Consider the evidence (see appendix )
         A. Do you have monitoring data on the number of people who are using or will be
         impacted by the policy?
         Number of people with a disability 97706 Gender                       487607

         Black & Ethnic Minorities (BEM)    3549  Age                          487607

         Sexual Orientation                 no

Safe and Secure Handling of Medicines                                                           Page 128 of 154
October 2010
         Religious Groups:
         Christians                              400578    Sikhs                        48

         Muslims                                 747       Hindus                       222

         Others                                  1755

         B. What is the percentage of persons in the above categories according to local
         census data?
         Disabled                                          Gender
         Black & Ethnic Minorities (BEM)                   Age
         Sexual Orientation
         Religious Groups:
         Christians                                        Sikhs
         Muslims                                           Hindus
         Other
         C. Is there evidence to support that some minority groups are not adversely affected?
                     Yes                                           No
         If yes, what is the evidence that this might be/is the case? Consider:
         Research findings
         Consultations and/or surveys
         Equality monitoring data
         Analysis of complaints
         Inspection and/or audit reports
         Information from voluntary and/or community groups
         5. If in your judgement the proposed service/policy does have an adverse
         impact, can that be justified? What are the benefits to that group and on balance
         do you still proceed bearing in mind the negative impact?


         6. Are there simple steps you can take to address any justified impact?


         7. How will you monitor the effect of this change/policy on the equality target
         groups?


         8. Does this policy need to be fully impact assessed? Please give reasons



         Name                                        Service
         Signed                                      Dated
         Equality Steering Group Review/Approval     Date


        This form to be completed and returned to Policy Co-Ordinator




Safe and Secure Handling of Medicines                            Page 129 of 154
October 2010
        21.4    Template 4 – Full Equality Impact Assessment (if applicable)

         1. Stakeholder Engagement
         A. Identify all the groups likely to be affected by the policy

         B. Decide what method of engagement is more likely to succeed
         Disabled
         BEM
         Gender
         Age
         Sexual Orientation
         Religious Groups
         C. Encourage participation by hard to reach groups
         Gypsies/Travellers
         Asylum Seekers
         and Immigrants
         BEMs in rural
         environments
         D. What steps will you take to make information understandable and accessible to all
         groups?

         2. Decide whether to adopt the policy
         A. Does the assessment show that the policy will have an adverse impact on
         particular groups/individuals?
                                        Yes   No                                Yes No
         Disabled                                  Age
         BEMs                                      Religious Groups
         Gender                                    Sexual Orientation
         B. Will the proposal make it difficult to promote equal opportunity and/or good
         relations between different groups?
                                        Yes   No                                Yes No
         Disabled                                  Age
         BEMs                                      Religious Groups
         Gender                                    Sexual Orientation
         C. What weight should be given to evidence gained by stakeholder engagement?
                                        High   Med   Low                             High   Med   Low
         Disabled                                          Age
         BEMs                                              Religious Groups
         Gender                                            Sexual Orientation
         D. Consider Alternatives:
                                                                                            Yes   No
         D1 Are there any aspects of the policy which could be changed?
         D2 Can you remove or reduce the adverse impact?
         D3 Can you justify the policy?
         D4 Can you find alternative means of achieving policy aims?
         E How will the decision-making process be structured, and how will the decision be
         recorded?


Safe and Secure Handling of Medicines                                     Page 130 of 154
October 2010
         3. Make Monitoring Arrangements
         A. Who will be responsible for monitoring the effects of this policy?

         B. How often and by whom will the policy be reviewed?
         Annually          Semi-annual                   Quarterly                Monthly
         By whom?
         C. Draw up a formal monitoring programme

         4. How will results be published?


         Name                                          Service
         Signed                                        Dated
         Equality Steering Group Review/Approval       Date

        This form to be completed if appropriate and returned to Policy Co-Ordinator




Safe and Secure Handling of Medicines                                Page 131 of 154
October 2010
        21.5    Template 5 – Glossary of Terms

        Insert a list of words and their definitions appropriate to this document




Safe and Secure Handling of Medicines                                Page 132 of 154
October 2010
        21.6    Template 6 – Consultation Circulation List

    •   Insert details of groups and individuals who have been consulted about this
        document.
    •   Medicine management Team
    •   Locality general managers
    •   Governance group
    •   IV strategy Group
    •   Non medical Prescribers group
    •   Professional Leads (health visitors, children’s nursing, school of nursing)
    •   Extended scope practitioners
    •   Patient Voice Group




Safe and Secure Handling of Medicines                        Page 133 of 154
October 2010
21.7    Template 7 – Consultation Checklist for Individual Use

       Title of document being            Yes/No/                                  Author’s Response
                                                  Comments
       reviewed:                          Unsure
1.     Cover Sheet
       Is the title clear and
1.1
       unambiguous?
       Is it clear whether the document
1.2    is a guideline, policy, protocol
       or standard?
2.     Rationale
       Are reasons for the
2.1    development of the document
       stated?
       Is there a clear Statement
2.2    which summarises the purpose
       of the document?
       Policy Document Control
3.
       Sheet
       Is the method described in
3.1
       brief?
       Are people involved in the
3.2
       development identified?
       Do you feel a reasonable
       attempt has been made to
3.3
       ensure relevant expertise has
       been used?
Safe and Secure Handling of Medicines                            Page 134 of 154
October 2010
       Title of document being             Yes/No/                              Author’s Response
                                                   Comments
       reviewed:                           Unsure
       Is there evidence of
3.4    consultation with stakeholders
       and users?
4.     Content
       Is the objective of the document
4.1
       clear?
       Is the target population clear
4.2
       and unambiguous?
       Are the intended outcomes
4.3
       described?
       Are the statements clear and
4.4
       unambiguous?
       Are other relevant policies
4.5
       cross referenced?
5.     Evidence Base
       Are sources of evidence to
5.1    support the development of this
       document identified explicitly?
5.2    Are key references cited?
5.3    Are the references cited in full?
       Are supporting documents
5.4    referenced?


Safe and Secure Handling of Medicines                         Page 135 of 154
October 2010
       Title of document being           Yes/No/                              Author’s Response
                                                 Comments
       reviewed:                         Unsure
6.     Approval
       Does the document identify
6.1    which Committee will approve
       it?
       If appropriate, has the
       document been approved by
6.2
       the Joint Negotiating and
       Consultative Committee?
       Dissemination and
7.
       Implementation
       Is there an outline/plan to
7.1
       identify how this will be done?
       Has the plan been submitted to
7.2    the Training Manager for
       Training Needs Analysis?
8      Document Control
       Does the document identify
8.1
       where it will be held?
       Have archiving arrangements
8.2    for superseded documents
       been addressed?




Safe and Secure Handling of Medicines                       Page 136 of 154
October 2010
       Process to Monitor
9.     Compliance and
       Effectiveness
       Are there measurable
       standards of KPIs to support
       the monitoring of compliance
9.1    with and effectiveness of the
       audit?


       Is there a plan to review or
9.2    audit compliance with the
       document?
       Is the lead person for
9.3
       audit/review identified?
10.    Review Date
10.1 Is the review date identified?
       Is the frequency of review
10.2
       identified? If so is it acceptable?
       Overall Responsibility for the
11.
       Document
     Is it clear who will be
     responsible for co-ordinating
11.1 the dissemination,
     implementation and review of
     the documentation?



Safe and Secure Handling of Medicines        Page 137 of 154
October 2010
12.    General Comments




Individual Approval
If you are happy to approve this document please return to the document author within two weeks of receipt with an electronic
signature
Name                                                                            Date

Signature




Safe and Secure Handling of Medicines                        Page 138 of 154
October 2010
        21.8    Template 8 – Consultation Checklist for Patient Voice Group
        To be completed for all policies reviewed by the Public Engagement Group
CONSULTATION CHECKLIST FOR PATIENT VOICE GROUP
To be completed for all policies reviewed by the Public Engagement Group

Comments from the patients perspective on                                                          Author’s Response
Policy for safe & secure handling of medicines


Thanks for the chance to see the update to this important policy. Most of us found it clear to
follow, concisely written and well laid out. We have relatively few major
comments/suggestions to make. These are:

We appreciate the references to informing and involving patients and ensuring their                All NHS staff work under the NHS
understanding and consent. However, we would ask that confidentiality is also highlighted as       code of confidentiality as part of
there are occasions when decidedly sensitive information is being recorded/faxed etc and we        their contract . We could add
think there should be reminders to staff about this (see appendix 10, page 129, and section        something to reassure the patient if
16 for example). Patients do need some reassurance about where such forms are stored, and          necessary I have added the
staff reminded about confidentiality please. Are the references to faxing this info in line with   confidentiality policy as reference
the PCT’s I.G policies (e.g. p.108)?                                                               Yes all should have secure fax

We would also mention that English is not always the first language of patients and not all are Link added to applied language
literate. What systems are in place to manage these concerns?                                   solutions

Should there not be a section at the end listing all the Trust policies which have been cited – List reviewed and updated
and their Trust policy number included? Some have these noted, and others do not (e.g. Management of incidents policy
p.112 point 24). Also there are a number of other policies in existence which relate to this referenced
one and they must at least be cross-referenced or there is potential for confusion.

There are a number of places where we have included comments with reference to nursing
and care homes. Under C2H there are going to be more PCT staff involved here and our NHS staff and                     nhs contracted
Safe and Secure Handling of Medicines                              Page 139 of 154
October 2010
concern is that standards are upheld right across the county, for the safety of the patient.        staff agree to work under the policy
                                                                                                    wherever their place of work . For
Specific textual comments:                                                                          private organisations such as care
                                                                                                    homes they would have their own
                                                                                                    policies which are regulated by the
                                                                                                    Care Quality Commision

Table of contents still requires correct pages inserting but appreciate we were sent non-           Done
finalised version.
Page 9, section 2 Purpose of policy – 4th bullet point – should “and recorded” be added?            Done
Page 10 – section 3.2 last para – who is responsible for pointing out the need for
discrepancies to be pointed out?                                                                    Done
          - section 4 – “in” needs deleting from 5th line (Prescribing for patients…)
Page 13 – section 4.3 – if this is the first time the Nursing and Midwifery Council is mentioned,
it should be in full with acronym                                                                   Done
            (NMC) in brackets.
          - 2nd to last para on the page, line 3/4 – suggest “must” be inserted for clarity after   Done
              “must not transcribe and”
                                                                                                    Done
Page 15 – section 5.1.1 – suggest inserting (LASCA) after it is first mentioned here
Page 18 - 6.5 - good to see this as previously patients under the age of 60 have been
reluctant, for cost reasons, to part with their own drugs.
          - 6.6.1 – while we appreciate it is not always possible to notify pharmacy that far in True
              advance, the situation with unacceptable delays at pharmacy often leads to
              family members or even transport drivers becoming restless and even
              unpleasant.

Page 19 – - 4th para - FP10 – we would suggest that community pharmacy dispensing                   But neither do hospital pharmacies
practices do not have 24/7 availability
Page 20 – section 7.1.1. – 4th para – should “lockable” be inserted between ‘separate’ and          Done
‘drug’?
Page 21 – 7.2. – should something be added about local police force normally notified if            Have added in accountable officer
controlled or schedule drugs lost (or is this dealt with elsewhere eg CD policy?) and staff key     for CDs Investigations may or may
holders interviewed?                                                                                not involve these measures
Safe and Secure Handling of Medicines                               Page 140 of 154
October 2010
Page 22 – section 7.3.1. – this is a welcome addition to the policy - should there be a               depends on the appropriateness
statement about who is responsible for informing patients about the details of their holding
keys to their own meds? It is also worth saying that patients who adhere strictly to medication       Covered in missed dose section?
time regimes at home may find it distressing in hospital where drug rounds do not always run
to time.
Page 23 – 7.4. – we do not know if this is the place but would point out that guidelines for          As they would if the patient were in
nursing home care are also becoming more stringent and we believe NHS policies will shortly           their own home
be introduced in some. This will mean GPs leaving prescriptions to include CDs and night
sedation. Any volunteer may then collect these.                                                       Reference to cold chain policy
Page 24 – 7.4.1. – there used to be a policy for community staff transporting vaccines with           added
particular concern in protecting the ‘cold chain’ – this should therefore be cross-referenced if it   Done
still exists. Last para here would benefit from reference to gaining patient consent.                 Done
Page 26 – 8.2. training competency – Is level 2 training for HCAs ward or training day based?         Training day based with work place
HCAs have no regulated Board unlike the RNs who are answerable to the NMC. The RCN                    competency assessment
are trying to address this for this vulnerable group of staff – the recent closure of 2 care          This is the responsibility of the
homes in Cumbria through medication errors reflects this concern. We would point out that             home and is covered by the CQC
the results are neglect in patient care, as well as being devastating for staff.                      registration
Page 28 – 8.3.1. – the list starting with “Anti-infectives” – this might be clearer if indented or    Done
bulleted.
Page 29 – 8.4 – last sentence again would benefit by mentioning explanation to the patient.           Added
            - 8.5. – a good clear explanatory section – in 8.5.5. the need for explanation to the     Covered in 8.5.4.
               patient is under-stated.                                                               0.5 s documentation only
Page 35 – 8.5.11 – 1st para – who will discuss this with the registered manager – GP,                 Could be any therefore         HCP
pharmacist, nurse?                                                                                    inserted
Page 35-37 – references to Marsden guidelines might benefit from reminder where to find
these? Not found in references.                                                                       Done
Page 41 – 8.13 – last para - should this not also mention recording, and informing patient?
Page 45-49 re unlicensed drugs and PGDs. While all NHS staff are well covered, will this be
the case when RNs are transferred out of the PCT into nursing/care homes? Will they have              Yes if they are NHS staff    or via
access to Royal Marsden guidelines?                                                                   internet Have added link
Page 46 – 14.3 – is it enough/adequate to just record this in the notes, is there not a specific      Don’t think so
form?
Page 52 – are the performance indicators still to be inserted here?                                   Done
            - excellent list of definitions
Safe and Secure Handling of Medicines                                Page 141 of 154
October 2010
Page 54 – references – will all nursing and care homes have to have computers now for Should have
accessing documents on line?
Page 57 – good to see
Page 60 – EIA – please note our question in intro section of this response

Several templates (10 for example) still not completed

Standard Operating Procedures – generally very clear.
SOP 1 – page 83 – top of page B.P – please explain why the bracketed sentence is in – it
helps reinforce the confidentiality thinking!
          - page 84 – 5th bullet point – what will staff understand by “segment” patients? Rephrased

SOP 3 re IV drugs – felt handwashing refs were minimal. Is there another PCT policy which Handwashing policy added
needs cross-referencing here?
SOP 7 – is p.110 intentionally blank?                                                     Reformatted

Appendices 4, 6 and 10– good to see but note our concerns over confidentiality on Appx 10.
Appendix 7 – should PODS be spelt out in full here?
Appendix 16 – delighted to see this!
Appendix 17 – does “adult” mean 16 or 18 here, please? Under Mental Health Act we Over 16?
understand 16 is classed as adult, and in general medicine 16 is the age to give consent.




                                              Yes/No/
      Title of document being reviewed:                  Comments                             Author’s Response
                                              Unsure
1.    Cover Sheet
1.1 Is the title clear and unambiguous?         Yes

      Is it clear whether the document is a     Yes      Policy and standard op. procedures
Safe and Secure Handling of Medicines                           Page 142 of 154
October 2010
                                                 Yes/No/
      Title of document being reviewed:                     Comments                          Author’s Response
                                                 Unsure
      guideline, policy, protocol or standard?
2.    Rationale
      Are reasons for the development of the
2.1                                              Implied
      document stated?
    Is there a clear Statement which
2.2 summarises the purpose of the                  Yes
    document?
3.    Policy Document Control Sheet
      Is there evidence of consultation with
3.1                                              Yes but    Template not complete as to who   Completed
      stakeholders and users?
4.    Content
4.1 Is the objective of the document clear?        Yes
      Is the target population clear and
4.2                                                Yes
      unambiguous?
4.3 Are the intended outcomes described?         Unsure
    Are the statements clear and
4.4 unambiguous?                                   Yes      Mostly – see our comments


      Are other relevant policies cross           Not all
4.5                                                                                           Updated
      referenced?                                 listed
5.    Evidence Base

5.1 Are sources of evidence to support the         Yes
    development of this document identified
Safe and Secure Handling of Medicines                             Page 143 of 154
October 2010
                                                 Yes/No/
      Title of document being reviewed:                     Comments               Author’s Response
                                                 Unsure
      explicitly?
                                                 Yes but
5.2 Are key references cited?                                                      Updated
                                                  not all
5.3 Are the references cited in full?              No
5.4 Are supporting documents referenced?          Not all
6.    Dissemination and Implementation
      Is there an outline/plan to identify how     Not
6.1
      this will be done?                         complete
      Does the plan include the necessary
6.2
      training/support to ensure compliance?
7     Document Control
      Does the document identify where it will
7.1                                                No
      be held?
    Have archiving arrangements for
7.2 superseded documents been
    addressed
      Process to Monitor Compliance and
8.
      Effectiveness
      Is there a plan to review or audit
8.1                                                Yes
      compliance with the document?
9     Review Date
9.1 Is the review date identified?                 No

Safe and Secure Handling of Medicines                            Page 144 of 154
October 2010
                                                Yes/No/
      Title of document being reviewed:                   Comments                                Author’s Response
                                                Unsure
    Is the frequency of review identified? If
9.2 so is it acceptable?


      Overall Responsibility for the
10.
      Document
      Is it clear who will be responsible for
      co-ordinating the dissemination,
                                                  No                                              Head of Medicine Management
      implementation and review of the
      documentation?


Completed by Public Engagement Group
I understand that this document has not yet been ratified by Cumbria Teaching PCT, and agree to keep any
sensitive information contained within the document confidential.
Name            Ailsa Benson, Ella Cullen,                                 Date          17/08/10
                Janet Pitman, Viv Stucke
Signature


This form to be returned to the Policy Co-ordinator within two weeks of receipt of the document




Safe and Secure Handling of Medicines                             Page 145 of 154
October 2010
21.9    Template 9 – Author’s Summary of Consultation Comments (for Author Use Only)

       Title of document being            Yes/No/
                                                  Comments
       reviewed:                          Unsure
1.     Cover Sheet
       Is the title clear and
1.1
       unambiguous?
       Is it clear whether the document
1.2    is a guideline, policy, protocol
       or standard?
2.     Rationale
       Are reasons for the
2.1    development of the document
       stated?
       Is there a clear Statement
2.2    which summarises the purpose
       of the document?
       Policy Document Control
3.
       Sheet
       Is the method described in
3.1
       brief?
       Are people involved in the
3.2
       development identified?
       Do you feel a reasonable
       attempt has been made to
3.3
       ensure relevant expertise has
       been used?
Safe and Secure Handling of Medicines                        Page 146 of 154
October 2010
       Title of document being             Yes/No/
                                                   Comments
       reviewed:                           Unsure
       Is there evidence of
3.4    consultation with stakeholders
       and users?
4.     Content
       Is the objective of the document
4.1
       clear?
       Is the target population clear
4.2
       and unambiguous?
       Are the intended outcomes
4.3
       described?
       Are the statements clear and
4.4
       unambiguous?
       Are other relevant policies
4.5
       cross referenced?
5.     Evidence Base
       Are sources of evidence to
5.1    support the development of this
       document identified explicitly?
5.2    Are key references cited?
5.3    Are the references cited in full?
       Are supporting documents
5.4    referenced?


Safe and Secure Handling of Medicines                         Page 147 of 154
October 2010
       Title of document being           Yes/No/
                                                 Comments
       reviewed:                         Unsure
6.     Approval
       Does the document identify
6.1    which Committee will approve
       it?
       If appropriate, has the
       document been approved by
6.2
       the Joint Negotiating and
       Consultative Committee?
       Dissemination and
7.
       Implementation
       Is there an outline/plan to
7.1
       identify how this will be done?
       Has the plan been submitted to
7.2    the Training Manager for
       Training Needs Analysis?
8      Document Control
       Does the document identify
8.1
       where it will be held?
       Have archiving arrangements
8.2    for superseded documents
       been addressed?




Safe and Secure Handling of Medicines                       Page 148 of 154
October 2010
       Process to Monitor
9.     Compliance and
       Effectiveness
       Are there measurable
       standards of KPIs to support
       the monitoring of compliance
9.1    with and effectiveness of the
       audit?


       Is there a plan to review or
9.2    audit compliance with the
       document?
       Is the lead person for
9.3
       audit/review identified?
10.    Review Date
10.1 Is the review date identified?
       Is the frequency of review
10.2
       identified? If so is it acceptable?
       Overall Responsibility for the
11.
       Document
     Is it clear who will be
     responsible for co-ordinating
11.1 the dissemination,
     implementation and review of
     the documentation?



Safe and Secure Handling of Medicines        Page 149 of 154
October 2010
12.    General Comments




Approval by Local Specialist Group/Committee
If you are happy to approve this document please return to the document author within two weeks of receipt with an electronic
signature
Name                                                                            Date

Signature



Approval by Policy Advisory Group
If you are happy to approve this document please return to the document author within two weeks of receipt with an electronic
signature
Name                                                                            Date

Signature


Safe and Secure Handling of Medicines                        Page 150 of 154
October 2010
Approval by Standards and Quality Committee
If the Committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for
disseminating and implementing the document, and to the Policy Co-ordinator, for inclusion on the PCTs database of approved
documents
Name                                                                                 Date

Signature




Safe and Secure Handling of Medicines                            Page 151 of 154
October 2010
        21.10 Template 10 – Implementation Template

        Plan for the Dissemination of Policy/Procedural documents

Title
Policy number
Date finalised
Policy statement
Dissemination lead

        Training assessed as            Statutory    Mandatory            Best Practice
        (please circle)

        Key Points:

            a)   ..
            b)   ..
            c)   ..
            d)   ..
            e)   ..
            f)   ..
            g)



Disseminated to:            Date                    Paper or   Comments
                                                    electronic

Corporate:
Business Manager
Associate Directors
Existing Policy
Provider:
General Managers
Existing Policy
Authors
        Date added to PCT Register:

        Review Date:




Safe and Secure Handling of Medicines                                Page 152 of 154
October 2010
        21.11 Template 11 – Policy Advisory Group Checklist

Policy Advisory Approval Process

Name of Document

Author of Document

Contact details for Author

Does the policy meet the
document standards?

Is the Policy Document Control
Sheet complete with
stakeholder/consultation
information?

Does the Reviewer feel any
stakeholders have been omitted
from the consultation process –
please state

Has a summary of Template 9 –
comments and authors response
from consultation process been
provided?

Has Template 2 Audit
Arrangements been completed
satisfactorily (check against
NHSLA requirements)

Has Template 1 Training Needs
Analysis been completed
satisfactorily?

Have Templates 3 and 4 (where
appropriate) Equality & Diversity
Impact assessment been
completed satisfactorily?

Has Template 10 –

Safe and Secure Handling of Medicines                         Page 153 of 154
October 2010
Implementation Plan been
completed satisfactorily?

Has the author indicated a clear
need for this policy?

General Comments on content of
document – indicate where
revision is required




Assessment of Merit

Grading           Description                                    Please
                                                                 tick

1                 Proceed without any revision. Document to be
                  recommended for approval to:
                  Standards and Quality Committee
                  Resources Committee

2                 Document revised as indicated by      Policy
                  Advisory Group – returned to author

3.                Document deemed to be in-appropriate/not
                  necessary – returned to the author

        Email this form back to:
        Policy Co-ordinator




Safe and Secure Handling of Medicines                        Page 154 of 154
October 2010

				
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