Trust Medicines Policy 2016
Version:
6.1
Ratified By:
Clinical Policy Working Group
Date Ratified:
21st February 2017
Date Policy Comes Into Effect:
28th June 2017
Author:
Deputy Director of Pharmacy - Clinical
Responsible Director:
Medical Director
Responsible Committee:
Drug and Therapeutics Committee
Target Audience:
Nurses,
Doctors,
Pharmacists
and
Pharmacy staff, Clinical staff, Audit staff
Review Date:
2 years (December 2019)
Equalities Equality Impact Assessment
Assessor: Shubhra Mace
Date: 13.10.2016
HRA Impact Assessment
Assessor: Shubhra Mace
Date: 13.10.2016
This policy document is subject to South London and Maudsley copyright. Unless expressly indicated on the
material contrary, it may be reproduced free of charge in any format or medium, provided it is reproduced
accurately and not used in a misleading manner or sold for profit. Where this document is republished or
copied to others, you must identify the source of the material and acknowledge the copyright status
Medicines Policy, version 6.1 – June 2017
Document History
Version Control
Version
Date
Summary of Changes
Major (must go to
Author
No.
an exec meeting)
or minor changes
October
1
N/A
N/A
D. Taylor
2005
March
Required full review and new NHSLA
2
Major
D. Taylor
2008
Standards
February
3
New NHSLA Standards
Major
D. Taylor
2010
Required full review and new NHSLA
4
2012
Major
D. Taylor
Standards
5
2014
Required full review
Major
S. Mace
6
Dec 2016
Full review
Minor
S. Mace
RT policy updated
6.1
June 2017
Covert administration policy updated
Minor
S. Mace
To include new recommendations
b
Consultation
Stakeholder/Committee/
Date
Changes Made as a Result of Consultation
Group Consulted
Senior Pharmacy Staff and
November
Policy changes incorporated
Heads of Nursing
2013
Nursing Leads; Pharmacy
December
1 clarification of CDs; policy changes incorporated
staff; Rosemary Peregrine-
2013
Jones; Barry Huckstep, Mike
Cummins, Mike; Cliff Bean;
Middleton, Anne
As above
January
Policy amended according to comments received from
2014
December consultation
Medicines Policy, version 6.1 – June 2017 Page 2 of 316
As above
March
Policy amended according to comments
2014
CAG Clinical Directors;
April 2014
Wider consultation. Final version to be circulated as
D&TC committee members;
shown
patient safety team;
performance team
representatives; pharmacy;
nursing team; director of
nursing; medical director
CAG Clinical Directors;
May 2016
Wider consultation. Final version to be circulated as
D&TC committee members;
shown
patient safety team;
performance team
representatives; pharmacy;
nursing team; director of
nursing; medical director
Drug and Therapeutics
April 2017 Both policies approved by Drug and Therapeutics
Committee
Committee
Service
Users/Carers Date
Changes Made as a Result of Consultation
consulted
N/A
Plan for Dissemination of Policy
Audience(s)
Dissemination Method
Paper
Person
or
Responsible
Electronic
All clinical staff
Trust intranet. Email link to
Electronic
S. Mace
staff
Clinical audit and
Trust intranet. Email link to
Electronic
S. Mace
performance management
staff
teams
Key changes to policy:
Implementing CAS alerts for medicines
Non-medical prescribing policy
Policy compliance with the MHA
HTT Older Adults
Covert administration policy consistent with NICE and recent court ruling
RT policy Consistent with NICE and include guidance of use and monitoring of zuclopentixol
acetate
Guidance on:
Monitoring clinic room temperatures
Transport of medicines in community
Reporting lost and stolen prescriptions
Naloxone in community Drug and Alcohol teams
Home Office Guidance on licence for ordering CDs
Medicines Policy, version 6.1 – June 2017 Page 3 of 316
Contents
Section
Page
1.
INTRODUCTION
12
2.
DEFINITIONS
12
3.
PURPOSE AND SCOPE OF THE POLICY
13
4.
ROLES AND RESPONSIBILITIES
14
5.
COURSE OF ACTION REQUIRED
16
6.
CONSULTATION
16
7.
PRESCRIBING
7.1 Who can prescribe in the Trust?
17
7.2 Who can prescribers prescribe for?
17
7.3 The Role of the Prescriber
17
7.4 Self Prescribing and Administration of Medicines by Staff
17
(for personal use)
7.5 Prescription Writing
18
7.6 Prescription Writing Standards
18
7.7 Drug Discontinuation
19
7.8 Changes to Prescription
19
7.9 Prescriptions on Transfer between Trust Clinical Units
19
7.10 Destruction of Old Prescriptions
19
7.11 Allergy Status Determination and Documentation
19
7.12 Medicines Reconciliation
20
7.13 Medicines Adherence
20
7.14 Information for Patients on Prescribed Medicines
21
Medicines Policy, version 6.1 – June 2017 Page 4 of 316
Section
Page
7.15 Discharge or Transfer from the Service
21
7.16 Prescribing PRN (when necessary) medication
22
7.17 Prescribing and Use of Patients’ Own Drugs (PODs)
22
7.18 Prescribing Complementary Medicines
22
7.19 Prescribing Medicines For Use in Clinical Trials
23
7.20 Prescribing Controlled Drugs (CDs)
23
7.21 Prescription of Unlicensed Medicines or Licensed Medicines
24
for Unlicensed Indications
7.22 Process for Ensuring the Accuracy of Prescription Charts
24
8.
ADMINISTRATION OF MEDICINES IN CLINICAL AREAS
8.1 General Principles
25
8.2 Who can Administer Medicines in the Trust?
25
8.3 Consent to Treatment
26
8.4 Aims of Medicines Administration
26
8.5 Verbal Messages
26
8.6 Administration Procedure
26
8.7 Identification of the Patient
27
8.8 Administering PRN (when necessary) medication
27
8.9 Administration of CDs to Patients on the Ward/ Unit/ Clinic
27
8.10 Self Administration of Medicines by In-Patients
28
8.11 Self Administration of CDs by Patients
28
8.12 Covert Administration
28
8.13 Other Administrations
28
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Section
Page
8.14 Administration of Medicines Under a Patient Group Direction
28
8.15 Recording of Medicine Administered or Omitted
28
8.16 Omission of Critical Medicines
29
8.17 Hazardous substances
29
9.
ORDERING MEDICINES FROM PHARMACY
9.1 General Principles
30
9.2 Pharmacy Opening Hours and Out-of-Hours Services
30
9.3 Prescriptions Used for Ordering Medicines
30
9.4 Ordering Stock/ Community Clinic Stock/ Temporary Stock
31
Items
9.5 Ordering Individual Patient Items (non-stock) for In-Patients/
31
Out-Patients and Community Patients
9.6 Ordering medicines out-of-hours
32
9.7 Ordering Take-Away Medicines for Leave or Discharge
32
(TTAs)
9.8 Planned Leave or Discharge
32
9.9 Unplanned Leave or Discharge
32
9.10 Order Controlled Drugs (CDs) from Pharmacy
33
9.11 CDs for Administration to Patients on the Ward/ Unit or in
33
Community Clinics
9.12 CDs for Patients in Community Teams/ TTAs or Outpatients
33
9.13 Ordering Medicines for Clinical Trial Use
33
10.
RECEIVING MEDICINES IN CLINICAL AREAS
10.1 General Principles
34
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Section
Page
10.2 Receiving Controlled Drugs (CDs)
34
11.
STORAGE AND SECURITY OF MEDICINES IN CLINICAL
AREAS
11.1 General Principles
36
11.2 Storage of Medicines in Clinical Areas
36
11.3 Transportation of medicines in the community, for example,
36
between community teams and patients’ homes
11.4 Monitoring clinic room temperatures
37
11.5 Monitoring fridge temperatures
37
11.6 Keys
37
11.7 Borrowing and Lending medicines between wards
37
11.8 Reporting Loss of Medicine
38
11.9 Reporting the Loss of the Medicines Cupboard Keys
38
11.10 Storage of Controlled Drugs in Clinical Areas
38
11.11 Storage of Clinical Trials Medication in Clinical Areas
38
12.
DISPENSING
AND
SUPPLY
OF
MEDICINES
FROM
PHARMACY
12.1 Definition of Dispensing
40
12.2 Who May Dispense or Supply
40
12.3 Dispensed Medicines
40
12.4 Labelling of Dispensed Medications
40
12.5 Stock Medications
40
12.6 Pre-Packed Medicines
41
12.7 Patient Information Leaflets
41
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Section
Page
12.8 Supply of Controlled Drugs from Pharmacy
41
12.9 Supply of Medicines Under a Patient Group Direction (PGD)
42
12.10 Supply of Clinical Trials Medication from Pharmacy
42
13.
DISPOSAL OF MEDICINES IN CLINICAL AREAS
13.1 Disposal of Medicines
43
13.2 Disposal of Controlled Drugs (CDs) in Clinical Areas
43
13.3 Disposal of Clinical Trials Medication in Clinical Areas
44
13.4 Hazardous Substances
44
14.
ISSUING MEDICINES TO PATIENTS AND THEIR CARERS
14.1 Definition
45
14.2 Who Can Issue Medicines to Patients and Their Carers?
45
14.3 Responsibility
45
14.4 Documentation
46
14.5 Issuing Procedure
46
14.6 Provision of Medicines Information to Patients and Carers
47
15.
ORDERING, STORAGE AND SUPPLY OF CONTROLLED
STATIONERY (CD REGISTERS, CD REQUISITION BOOKS,
FP10HPS AND FP10MDAS)
15.1 Storage of Controlled Drugs (CD) Register and Requisition
48
Books
15.2 Ordering CD Registers and Requisition Books from
48
Pharmacy
15.3 Unused, Lost or Stolen CD Registers and CD Requisition
48
Books
15.4 Ordering FP10HPs/ FP10MDAs/ FP10SS
48
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Section
Page
15.5 Ordering FP10 Forms
48
15.6 Storage and Use of FP10 Forms
49
15.7 Responsibility of the Individual Member of Staff
49
15.8 Responsibility of the Trust
50
15.9 Lost, Stolen or Fraudulent Prescriptions
50
16.
RISK MANAGEMENT
16.1 Recording Allergies and Adverse Drug Reactions
51
16.2 Medicines Reconciliation
51
16.3 Medicines Safety Committee
51
16.4 Error Reporting
51
16.5 Defective Pharmaceutical Products
52
16.6 Recall of Defective Pharmaceutical Products
52
17.
NEW DRUGS, CLINICAL TRIALS AND UNLICENSED
MEDICINES
17.1 Introduction of New Drugs in the Trust
53
17.2 Drugs and Therapeutics Committee
53
17.3 Clinical Trials
53
17.4 Unlicensed Medicines and Off Label Uses of Licensed
53
Medicines
18.
LOCAL POLICIES
54
19.
MONITORING COMPLIANCE
54
20.
ASSOCIATED DOCUMENTATION
55
21.
REFERENCES
55
22.
FREEDOM OF INFORMATION ACT 2000
55
Medicines Policy, version 6.1 – June 2017 Page 9 of 316
Section
Page
APPENDICES
APPENDIX 1:
PATIENTS’ OWN DRUGS (PODs)
56
APPENDIX 2:
STANDARD OPERATING PROCEDURES (SOPS) FOR
62
CONTROLLED DRUGS (CDs)
APPENDIX 3:
NON-MEDICAL PRESCRIBING POLICY
76
APPENDIX 4:
PHARMACY OPENING HOURS AND OUT OF HOURS
94
SERVICE
APPENDIX 5:
NURSE COMPETENCY FRAMEWORKS FOR
103
ADMINISTRATION OF MEDICINES IN THE TRUST
APPENDIX 6:
POLICY FOR SINGLE NURSE DRUG ADMINISTRATION
114
APPENDIX 7:
HOMELY REMEDIES/ SINGLE DOSE ADMINISTRATION
118
APPENDIX 8:
SELF-ADMINISTRATION OF MEDICINES BY IN-PATIENTS
121
APPENDIX 9:
COMPLIANCE AIDS
136
APPENDIX 10: MEDICAL REPRESENTATIVES POLICY
143
APPENDIX 11: DRUGS AND THERAPEUTICS COMMITTEE – TERMS OF
145
REFERENCE AND NEW DRUG REQUEST FORM
APPENDIX 12: UNLICENSED
MEDICINES/
OFF-LICENCE
MEDICINES
149
POLICY
APPENDIX 13: HOME TREATMENT TEAMS (HTT) – not MHOA
155
APPENDIX 14: MEDICINES MANAGEMENT IN INDEPENDENT CARE HOMES
158
AND SUPPORTED HOUSING
APPENDIX 15: COVERT ADMINISTRATION OF MEDICINES WITHIN FOOD
159
AND DRINK
APPENDIX 16: PATIENT GROUP DIRECTION (PGD) POLICY
185
APPENDIX 17: FP10 SECURITY POLICY (FP10SS, FP10HP, FP10MDA)
193
Medicines Policy, version 6.1 – June 2017 Page 10 of 316
Section
Page
APPENDIX 18: POLICY ON NHS PATIENTS WHO WISH TO PAY FOR
200
ADDITIONAL PRIVATE CARE
APPENDIX 19: MEDICINES RECONCILIATION POLICY
215
APPENDIX 20: REPORTING OF MEDICATION AND PRESCRIPTION ERRORS
244
(TAKEN FROM INCIDENT POLICY)
APPENDIX 21: POLICY FOR PHARMACY SUPPORT FOR CLINICAL TRIALS
246
APPENDIX 22: DRUG ALERT PROCEDURE
249
APPENDIX 23: MEDICINES MANAGEMENT POLICY AT LORRAINE HEWITT
254
HOUSE
APPENDIX 24: RAPID TRANQUILLISATION POLICY
257
APPENDIX 25: SUPPLY OF LONG ACTING INJECTIONS BY POLARSPEED
291
APPENDIX 26: TEMPERATURE MONITORING LOG
296
APPENDIX 27: MEDICINES SAFETY COMMITTEE – TERMS OF REFERENCE
299
APPENDIX 28: HOME TREATMENT TEAM – MENTAL HEALTH OF OLDER
301
ADULTS
APPENDIX 29: EQUALITY IMPACT ASSESSMENT
309
APPENDIX 30: HUMAN RIGHTS ACT ASSESSMENT
315
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1.
Introduction
This Medicines Management Policy was developed over the period 2002-2005.
Originally a
Core Medicines Policy was developed and approved by the Trust Policy
Making Committee in 2003. Amendments and additions were made and the updated
policy with supplements was approved by the trust in July 2005. The
Non-Medical
Prescribing Policy was separately approved by the trust (Policy Making Committee and
Governance Executive) in November 2004. In September 2005 these two policies were
combined (with minor further additions) to form this
Medicines Policy.
The standard
operating procedures for Controlled Drugs were approved by the Governance
Executive in May 2007 and are included in this policy. The covert administration and
rapid tranquillisation policies, previously separately approved, and now also incorporated
in this overall Medicines Policy. This policy is required by numerous NHS directives.
This updated Medicines Policy supersedes the old Medicines Management Policy (2012)
2.
Definitions
For the purpose of this policy and local policies throughout SLaM, the definitions are:
Administer/Administration - To give a medicine by either introduction into the
body, (e.g. orally or by injection) or by external application (e.g. cream or ointment).
This includes removal of medication from labelled packaging for patient to take.
BNF - The British National Formulary.
Carer - A person who assists a patient in personal care, whether paid or unpaid, and
may or may not be related to the patient.
Patient/service user - A person receiving services from the trust.
Clinical Unit – A trust clinical facility e.g., ward, clinic, resource centre, day centre,
community mental health team, Home Treatment Team
Clinician – person with responsibility to provide a clinical service to a patient e.g.
doctor, nurse, pharmacist and key worker.
CPN -
Community Psychiatric Nurse/Community Mental Health Nurse.
Dispensing of medication - Medication is prepared by pharmacy staff for a named
patient according to a legal prescription which has been clinically screened by a
pharmacist.
Homely remedies - An agreed list of medicines which give symptomatic relief and
may be administered without individual prescription at the patients request for an
agreed time limit or a specified number of doses. Staff must ensure that there are no
existing factors which contra-indicate the use of the medicine.
Issue/supply of medication - To provide patient (or carer) with medicines which
have been dispensed for the individual patient and labelled with full instructions for
self administration, or to supply medicines to a clinical unit as stock or non-stock
items. Note: this is not the same as administration. See above
Medication - Any medicines or drugs prescribed for the purpose of treatment or
prevention of any condition or disease or illness, including herbal treatments,
homeopathic medicines, over-the-counter medicines, vaccines and homely
remedies.
Off-label use -
Unlicensed use of licensed medicines
. See appendix 12 for the trust
Unlicensed Medicines policy.
Pharmacy - Departments providing a service to patients of the trust.
Prescribe -
To authorise in writing the supply or administration of a medicine.
Prescription chart - The chart or form used to prescribe medication. May also be
known as a prescription form, medication chart or drug chart.
Qualified nurse - A registered nurse currently registered with the NMC and holding
a current PIN.
Self-administration -
See appendix 8 for the trust Self-Administration policy.
Medicines Policy, version 6.1 – June 2017 Page 12 of 316
Supervised administration - Where staff observe self administration.
Supply/issue of medication - To provide medication labelled with patient details
and directions for use or to provide unlabelled medication in the manufacturer’s
original containers for a ward or clinical unit
Team leader -
The responsible person in charge of a service area, ward or
department. The title actually used may differ in individual areas.
The Trust -
South London and Maudsley Foundation NHS Trust.
Unlicensed Medicines - Drugs without a formal Product Licence or used beyond
recognised indications.
Ward manager -
The person in charge of a service area, ward or department. The
title actually used may differ in individual areas.
3.
Purpose and Scope of the Policy
Purpose of the Policy
This document forms the overall Medicines Policy for South London and Maudsley
NHS Foundation Trust.
This policy provides the basis for any local medicines policies for individual service
areas.
This policy will be reviewed every 2 years and revised as necessary.
It is the responsibility of all managers employed by the trust to ensure that staff in
their services know how to access the policy and that staff are familiar with the parts
of the policy which covers their practice.
All staff must ensure that, having read and understood the policy they are in a
position to work in accordance with the policy.
Any failure to adhere to this policy, if it is deemed to have been health- or life-
threatening, jeopardised safety or had other serious consequences, may lead to
enquiries and, if necessary, to disciplinary action.
Specific monitoring requirements are detailed throughout the text of this policy.
Adherence to this policy will be subject to regular audit.
The aim of the policy is to ensure that the medicines management process is safe
and secure and complies with clinical governance and legal requirements.
The trust Drug and Therapeutics Committee holds the overall responsibility for
overseeing this policy.
Objectives of the policy are to:
To define procedures and set standards for the medication process based on current
legislation and professional standards.
To direct where possible to the appropriate policy for specific or local issues.
To take into account the needs of service users.
To define the responsibilities of all staff involved in the medication process working
within South London and Maudsley Foundation NHS Trust, whether employed
directly or indirectly.
Scope of this policy
This policy covers all aspects relating to the procurement, dispensing, prescribing,
administration and destruction of medicines in the trust. The policy also includes the
trust’s non-medical prescribing policy, self-administration policy and rapid tranquillisation
policy and the standard operating procedures for controlled drugs.
Targeted audience
All staff who have any involvement with medicines use in the trust
Audit staff
Medicines Policy, version 6.1 – June 2017 Page 13 of 316
Performance team
Patient Safety team
Targeted patient/user group
This policy is relevant to all service users who are prescribed medicines.
4.
Roles and Responsibilities
4.1
The Chief Executive and Trust Board
The Chief Executive and Trust Board will bear ultimate responsibility for this policy and
will authorise implementation of the Medicines Policy and appendices into the working
arrangements of the Trust. They will maintain an overview of significant risks via the
Drug and Therapeutics and Quality Sub Committee (of the Board) and by monitoring the
trust Assurance Log.
4.2
Accountable Officer for Controlled Drugs
The medical director is the designated Accountable Officer who will have overall
responsibility for all aspects of the safe and secure management of Controlled Drugs.
4.3
Director of Pharmacy and Pathology
The Director of Pharmacy has statutory responsibility as superintendent pharmacist
under the Medicines Act 1968. He is responsible for medicines management throughout
the Trust on behalf of the Chief Executive.
4.4
Deputy Director of Pharmacy
The Deputy Director of Pharmacy will hold the master copies of the Medicines Policy
and will be responsible for ensuring the accuracy of content and will act as a source of
information for enquiries related to the policy content.
Members of Pharmacy staff will promote use of the Medicines Policy in Pharmacy and in
relevant clinical areas.
4.5
Executive Directors and CAG leads
Executive directors and CAG leads will ensure that the Medicines Policy and its
appendices are implemented throughout their divisions with the aim of minimising risks
associated with medicines use.
4.6
Clinical directors and heads of nursing
Clinical directors, heads of nursing and service managers will ensure the policy is
implemented to achieve its aims.
4.7
Team leaders
Team leaders will ensure staff are aware of how to access the policy and ensure day-to-
day adherence to the policy.
4.8
Clinical staff
All clinical staff will ensure they are familiar with all relevant sections of the Medicines
Policy and its appendices and will follow the correct procedure when undertaking any
medicine-related task.
All clinical staff involved in the daily use of medicines must attend mandatory medicines
management training as described in the trust’s mandatory training needs analysis
policy.
Medicines Policy, version 6.1 – June 2017 Page 14 of 316
All clinical staff health professionals involved in the daily use of medicines are expected
to act in accordance with their professional standards and codes of conduct with respect
to medicines use.
4.9
Education and training department
The trust education and training department will advise CAG leads of the training
requirements in relation to this policy. Records of attendees will be collated by the trust
E&T department.
4.10
Role of professions in relation to this policy
a) The role of the pharmacist
To ensure that medication received by patients is safe, effective and appropriate.
To ensure that a supply of the correct medicine is available for the right patient at
the right time.
To ensure that all prescriptions are complete, clear, unambiguous and safe and
appropriate for the patient.
To ensure allergy status of the patient is documented on the prescription before
any medication is supplied
To provide patients and healthcare staff with medicines information.
To provide training for other health care professionals.
To work at all times in a professional manner, following procedures and acting in
the best interests of service users e.g. by following the General Pharmaceutical
Council Standards for Conduct, Ethics and Performance (July 2012)
To ensure that safe and secure systems for the handling of medicines are
established and followed.
b) The role of the nurse
To practice within the NMC Code of Conduct and Standards for Medicines
Management
Qualified nurses to complete mandatory training and undertake the competency
assessment relevant to clinical area
To administer medicines to the patient
To be aware of the patient’s allergy status and co-morbidities before
administration of medicines
To issue medicines to the patients
To observe the clinical effects (benefits and side effects) of medication in the
patient
To have an up-to-date knowledge of the drugs s/he administers including route,
dose range, indications, contraindications and side effects.
To provide information on medication to patients and their carers. Nurses should
be able to reinforce information about medication given to patients by medical
staff.
If the nurse is in any doubt s/he should consult an up-to-date reference source,
e.g. Prescribing Guidelines, formulary, BNF, or a colleague or pharmacist for
clarification prior to making a judgement about administration. If any doubt
remains the nurse should contact the prescriber.
c) The role of social workers, occupational therapists, psychologists and support
workers (see appropriate supplements)
To issue (see definition above) medication to patients and their carers. The role
of these occupational groups in relation to medication concerns the issuing of
Medicines Policy, version 6.1 – June 2017 Page 15 of 316
dispensed medication to patients, for self-administration by the patient. To
support this role the staff involved must be familiar with the trust policy and local
procedures for issuing medication to patients. Staff should have received training
and feel confident to perform this duty.
Support workers in care homes may administer or support the service user to self
administer medication only in strict accordance with trust and local policy. (See
appendix 14 for the Medicines Management in (non-nursing) registered Care
Homes and Supported Housing) The medicines may only be administered to the
person that they were intended for and in accordance with the directions
specified by the prescriber. The medicines must have been dispensed by a
pharmacy for that individual patient and the label must include the specified
directions for use. Staff performing this duty must have received formal training
and obtained a proficiency certificate. A proficiency certificate is only valid for
administration of medication in that specified home/project Service.
5.
Course of Action Required
Ongoing actions in relation to this policy are outlined in the annual Medicines
Optimisation Report and programme.
6.
Consultation
This is an update of the Medicines Policy. A full consultation process has been
undertaken including the trust Nursing, Medical, Pharmacy and Performance and
Clinical Audit teams.
Medicines Policy, version 6.1 – June 2017 Page 16 of 316
7.
Prescribing
7.1
Who can prescribe in the trust?
Registered medical practitioners employed by the trust, which could include GPs
employed via SLA
Healthcare professionals employed by the trust who are approved as independent or
dependent (supplementary) prescribers.
Legal responsibility for a prescription lies with the practitioner signing that
prescription.
7.2
Who can prescribers prescribe for?
Medicines can only be prescribed on trust prescriptions for patients with a valid NHS
hospital number.
All patients should have an ePJS record.
Exceptions include babies on the Mother and Baby Unit.
Contact pharmacy if in doubt
7.3
The role of the prescriber
Before prescribing, to determine (and document in ePJS and on the prescription
where necessary)
- the patient’s allergy status. To note any drug allergies or sensitivities and make a
record on the front of each prescription chart and in the patient’s notes
- the patient’s history of adherence with prescribed medication.
- the patient’s regular prescription before admission/transfer
To select and prescribe medication according to the clinical needs of the patient, in
line with local, regional and national guidance.
To be satisfied that the prescription is appropriate for the individual patient. By
signing the prescription the prescriber is taking legal responsibility for the
prescription,
To make a record in the patient’s notes (Patient Journey System) when medication is
started, changed or discontinued, giving reasons for the choice of treatment or
change in treatment.
To inform the patient and/or carer of the reason for the prescription, the expected
outcome and length of treatment, possible side effects and what to do if they occur,
and when medication will be reviewed.
To review patient medication on in-patient and Home Treatment Teams at least once
a week
To review patient medication in community teams, at least every 3 to 6 months.
To monitor and document in ePJS the effects of treatment (clinical benefits and side
effects, including physical health monitoring)
To refer to GP when appropriate.
To refer to specialist/acute services when appropriate.
7.4
Self prescribing and administration of medicines by staff (for personal use)
Clinical staff are not permitted to take any medication for themselves or another
person for whom it is not prescribed.
Prescribers are not permitted to prescribe, using trust prescriptions or an FP10, any
medication for themselves or another person who is not a SLAM patient. Staff
requiring ‘prescription only medicines’ must see their GP.
Medicines Policy, version 6.1 – June 2017 Page 17 of 316
Staff requiring treatment for minor ailments must be referred to occupational health
or purchase medicines from a local pharmacy.
Medicines can only be supplied legally to patients with an NHS hospital number
.
7.5
Prescription writing
In-patients
Prescriptions must be written on the trust in-patient chart. Supplementary prescriptions
used must be attached to the in-patient chart. All medications, including any prescribed
on supplementary charts, must be prescribed on the in-patient chart
Outpatients and community patients
Trust community prescriptions and FP10s (FP10HP, FP10SS and FP10 MDA) can be
used
See appendix 17 for details of the FP10 Security policy
Prescriptions must comply with legal and professional requirements as well as local
regulations and guidelines.
Prescriptions will be handwritten by the prescriber on a Trust approved prescription
pro-forma, or in an electronic format on a Trust approved computerised prescribing
system.
If prescriptions are not written legibly or legally, or are felt to be unsafe, they are
referred back to the prescriber for clarification.
Prescriptions may only be written for patients registered as patients with the trust
Prescribers should follow local and national prescribing policies. These include NICE
guidance and The Maudsley Prescribing Guidelines.
All prescriptions for children should include the child's age and weight.
Prescriptions for controlled drugs for supply to patients must comply with the legal
requirements of the Misuse of Drugs Regulations 2001 and subsequent
amendments.
Investigational medicines, or medicines being used as part of a research study, may
only be prescribed following approval of the clinical trial protocol by appropriate
research and ethics committees.
Research Ethics Committee and have Regulatory (MHRA) and R&D approval.
Investigational medicines, or medicines being used as part of a research study, may
only be prescribed following approval of the clinical trial protocol by the appropriate
Research Ethics Committee and have Regulatory (MHRA) and R&D approval.
7.6
Prescription writing standards
All medicines must be prescribed according to BNF guidelines and local prescription
writing standards
Trust in-patient and community prescriptions must
Be written legibly in ink and be indelible
Be dated
State the name and the hospital number (trust ID) of the patient
Be signed in ink by the prescriber
Include the patient’s date of birth
Medicines Policy, version 6.1 – June 2017 Page 18 of 316
Include the patient’s allergy status. It is the responsibility of the person signing a
prescription to ensure that the patient’s allergy status is noted on the prescription.
Include a valid start date
Medicines must be prescribed using the approved drug name. Brand names should not
be used unless specific drug products are required
Abbreviations must not be used.
The drug dose and frequency must be stated as metric or international units.
7.7
Drug discontinuation
When medicines are discontinued the prescription for that medicine should be
cancelled by crossing it through with a single line.
The prescription should not be obliterated in such a way that the original prescription
cannot be read.
The date and reason for stopping the medicine must be documented in the patient
notes and on the inpatient drug chart.
7.8
Changes to prescription
Once written a prescription must not be altered in any way. It must be discontinued
and a new prescription written
Correcting fluid e.g. Tippex must not be used on prescriptions
Pharmacists may make amendments to prescriptions following discussion with the
prescriber. The pharmacist should record on the prescription the name of the
prescriber with whom the amendments have been agreed and details of the
amendments. If such an amendment results in the drug being rewritten on the
hospital inpatient chart the new prescription must countersigned by the prescriber
Any additions or changes to prescribed medication must be entered in the patient’s
record (ePJS) under the medication section. Any discontinuation of medication must
also be clearly documented.
7.9
Prescriptions on transfer between trust clinical units
When patients are transferred between trust clinical units the existing prescription
should be transferred with the patient and continue to be used.
Medications should also be transferred
7.10
Destruction of old prescriptions
A prescription should be cancelled by drawing a bold line diagonally across all pages
of the chart. The cancellation must be dated and signed in full by the prescriber.
The old prescription should be scanned into the correspondence section of the
patient’s ePJS record. The paper copy should be shredded after scanning.
7.11
Allergy status determination and documentation
Before prescribing any medication for a patient the prescriber must accurately
determine the patient’s al ergy status.
A note of any drug allergies or sensitivities must be made on the front of each
prescription chart and in the alert section of ePJS. This must include the drug and
the suspected/known reaction to the drug.
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The prescriber must ask the patient about any allergies, adverse reactions or
sensitivities to any previously prescribed (or non-prescribed) medications as well as
consult the patient’s medical notes. It may be necessary to corroborate the
information using other sources. See appendix 19 for the Medicines Reconciliation
Policy.
The prescriber must complete, sign and date the allergy section on the front of the
prescription.
The prescriber must record any allergies (or the absence of them) in the alert section
of ePJS.
The known absence of any allergies must be denoted by NKDA or No known drug
allergies. The record must be signed and dated by the prescriber.
Under no circumstances must the allergy section on the prescription be left blank.
Pharmacy will not supply medication for a patient if the allergy section on the
patient’s prescription is not fil ed in. Nursing staff should not administer medication
unless the allergy section is completed.
On discharge from or transfer to another service the patient’s allergy status must be
communicated to the onward team.
7.12
Medicines Reconciliation
See appendix 19 for the trust Medicines Reconciliation Policy
When a patient is admitted to a trust service or transferred between trust services the
prescriber must ensure that the patient’s regular medication is not inadvertently
omitted from or changed on the prescription. The patient (or their carer) must be
asked for a list of medications (and doses) the patient was taking before admission
to the service. In addition, the patient’s notes must be consulted. Other sources of
information include the patient’s GP, community team and any other specialist
services.
The patient’s allergy status must also be determined and documented on each
admission. See above.
7.13
Medicines Adherence
Before prescribing any medication the prescriber must determine the patient’s
previous history of adherence with prescribed medication and willingness to take
current medication as prescribed.
When choosing a medication above factors must be borne in mind.
Patients must be involved, as far as is reasonable, in the choice of their medication.
Clinicians must assess for individual patients the risk of non-compliance with
medication. Clinicians must evaluate the risk and ensure that both the appropriate
medication is prescribed and that the patient is supported to continue treatment.
Note: Compliance of the medicines Policy with the Mental Health Act, please see
notes below about treatment for patients who may or may not have capacity to
consent to treatment.
Physical intervention may be used in order to administer medication to an unwilling
patient where there is legal authority, whether under the Mental Health Act 1983
(amended by the Mental Health Act 2007) or Mental Capacity Act 2005 or otherwise, to
treat the patient without consent. Physical interventions may not be used to treat an
informal patient who has the capacity to refuse treatment and who has done so.
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Assessment of the patient’s capacity to consent or refuse physical health care must be
made. If the team assesses that the patient lacks capacity to consent to treatment for a
physical health care problem then the team needs to refer to Mental Capacity Act
guidance to assist them in assessing and treating patients for physical ill-health.
If the patient requires emergency treatment and it has not been possible to determine
the patient's mental capacity, urgent treatment can be given in the patient's best
interests under the Mental Capacity Act provided that staff have reason to doubt the
patient's capacity.
7.14
Information for patients on prescribed medicines
The patient should be informed of the following when medication is prescribed:
- The reason for the medication choice
- The aims of treatment
- The likely duration of treatment (i.e. short or long term)
- The commonly recognised adverse effects of treatment and who to
contact if they experience any
- Any serious adverse effects of which the patient should be aware
- Monitoring requirements
A summary of the conversation should be made in ePJS.
The patient should be asked about any concerns they may have about currently
prescribed medication (including any medications that are being considered).
In addition, the patient should be given a Patient Information Leaflet for the
medications prescribed. These are available from pharmacy or on the trust intranet.
The patient should have the opportunity to speak to a pharmacist about prescribed
medications within 2 weeks of starting a medication and thereafter.
7.15
Discharge or transfer from the service
When patients are transferred between trust clinical units the existing prescription
should be transferred with the patient and continue to be used.
Medications should also be transferred
On discharge from or transfer to another service the following patient information
must be communicated to the new service:
- Diagnosis
- current medication
- changes to medication whilst in the service (including any treatment stopped
or started)
- Intended treatment duration
- Monitoring requirements
- Any problems with adherence
- Allergy status
Statutory regulations regarding the prescriber, the medicine and the prescribing
Medicines Policy, version 6.1 – June 2017 Page 21 of 316
7.16
Prescribing PRN (when necessary) medication
All PRN prescriptions should be individualised in the same way that regular
prescriptions are written for individual patients: there should be no routine PRN
prescribing of any drugs.
All PRN prescriptions should specify indication, dose (not a range of doses),
frequency, maximum daily dose, a single route of administration and precise
circumstances in which the drug is to be given.
All PRN prescriptions should be reviewed at least once a week by the prescribing
team. Any prescriptions for PRN antipsychotics should be time-limited, preferably to
a week or less.
The reason for administration must be clearly stated by the nurse administrating.
7.17
Prescribing and use of patients’ own drugs (PODS)
On admission to an in-patient unit, patients are encouraged to bring with them any
prescribed or non-prescribed medication that they take whilst in the community. Please
refer to appendix 1 for more information
a) PODs may be used whilst the patient is an in-patient provided:
The medicine is prescribed on the in-patient medication chart.
It can be easily identified from the backing on the strip pack or markings on the
tablet/capsule.
The medicine has not expired and appears to be in good condition.
Local policy requirements on PODs are satisfied.
b) If the medication is a Controlled Drug, it must be stored in the Controlled Drugs
cupboard and appropriate records made in the Controlled Drugs register.
c) Medicines not appropriate for use on the in-patient unit must be removed from the
ward as per PODS procedure.
7.18
Prescribing complementary medicines
Complementary medicines are therapies that may be used in conjunction with
orthodox medical, nursing and paramedical treatments to enhance patient well-
being, quality of life and symptomatic relief. These may include herbal and
homeopathic medicines as well as essential oils.
If a patient is admitted to hospital and is already taking complementary therapies
then these therapies should be brought to the attention of the multidisciplinary team
and a decision taken as to whether these therapies should continue.
The administration of any alternative/complementary substance (by ingestion or
topical use) must follow this medicines policy, unless a specific approved policy for
that particular therapy is available.
The pharmacist should be asked to investigate whether there are any interactions or
contra-indications with conventional medication, and whether the substances can be
positively identified and assessed as suitable for use (see use of patients own
drugs). If a substance cannot be identified, it may not be prescribed.
Items that have been purchased by patients for their own use (i.e. items not obtained
via a prescription) will not normally be supplied by the hospital pharmacy. If therapy
is to continue then the patient remains responsible for the continuation of supply.
Al complementary medicines must be prescribed on the patient’s medication chart
and recorded according to usual policy.
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Generally speaking, pharmacy will not procure or supply complementary medicines.
Limited supplies may be provided against a prescription in exceptional
circumstances.
7.19
Prescribing medicines for use in clinical trials
For the purpose of this document the term clinical trials includes all research
involving medicinal products
.
See appendix 21
All trials have a specifically designed prescription form. For in-patient trials an in-
patient trust medication chart must also be used. The prescription must make clear
that the medication is intended for clinical trial use.
Medicines must be prescribed in the usual way in accordance with the Trust
Medicines Policy.
7.20
Prescribing Controlled Drugs (CDs)
Please refer to appendix 2.
Prescriptions for controlled drugs for supply to patients must comply with the legal
requirements of the Misuse of Drugs Regulations 2001 and subsequent amendments.
Injectable diamorphine may only be prescribed by prescribers who hold a relevant Home
Office licence.
CDs may be ordered on any trust prescription chart, an FP10HP or an FP10MDA.
Prescriptions for CDs may be computer-generated or hand-written.
The signature must be in the prescriber's own handwriting.
The prescription must be dated. The prescription is valid for 28 days.
The prescription must state the name and address (or hospital number/Trust ID) of
the patient and the dose (and directions), form, strength and total quantity of the
required CD. The total quantity of the CD to be supplied must be stated in words as
well as figures. A total quantity need not be stated for CDs prescribed for
administration to in-patients.
A pharmacist may amend the prescription if it specifies the total quantity only in
words or in figures or if it contains minor typographical errors. These changes need
to be indelible and signed by the pharmacist.
The supply quantity should not exceed 30 days. In exceptional circumstances where
a supply of more than 30 days is necessary and not thought to pose a risk to the
patient, the prescriber must make a note in the patient's medical records. The
pharmacist must check that the prescriber intended the supply to be more than 30
days.
When patients are admitted to an in-patient unit, the prescriber must determine the
dose and supply quantity of opiate substitutes in each individual case. Note, some
patients may be on a daily supervised administration regime. Care must be
exercised when prescribing medication on discharge. If in doubt, confirm with the
patient’s community drug and alcohol team.
All patients of the community drug and alcohol teams who use or who have ever
used opiates are at risk of relapse or overdose and should be provided with take
home naloxone kits and overdose management training. All clinical staff working in
Addictions should be trained and competency assessed to issue kits and provide
overdose training. Since October 2015 there has been no legal requirement for a
PGD or prescription for this to be done (however, this only applies to recognised
drug
treatment
services).
Naloxone
can
also
legally
be
issued
to
carers/friends/family members of people at risk of opiate overdose, including staff of
relevant agencies such as probation and hostel staff who may witness an overdose.
Medicines Policy, version 6.1 – June 2017 Page 23 of 316
Staff should regularly check whether kits have been used, lost or expired.
Replacement kits should be re-issued regularly.
Prescribing of CDs by non-medical prescribers (NMPs) – see appendix 3 for further
details.
7.21
Prescription of unlicensed medicines or licensed medicines for unlicensed
indications
See appendix 12 for the trust Unlicensed Medicines policy
Unlicensed medicines have no product licence or UK marketing authorisation.
Manufacturers have no liability for any harm resulting from the use of an unlicensed
medicine.
Only medical and dental practitioners can authorise the administration of unlicensed
medicines
Licensed medicines may be prescribed for indications other than those listed in the
medicines licence where there is acceptable evidence for the use of the medicine for the
intended indication.
Prescribing unlicensed medicines or medicines outside the recommendations of their
Marketing Authorisation increases the prescriber’s responsibility and potential liability.
The prescriber is responsible for the use of the medicine and any harm resulting from its
unlicensed use.
The prescriber should be able to justify and be competent in using such medicines.
7.22
Process for ensuring the accuracy of prescription charts
It is the responsibility of all staff involved in the medicines process to ensure
prescriptions are legible, legal and accurate prior to supplying or administering
medicines.
Pharmacists review prescriptions for accuracy on regular ward visits, and before
dispensing any medicines.
Where Trust approved pre-formatted prescriptions (e.g. clozapine prescription) are
available to promote accurate prescribing these must be used.
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8.
Administration of Medicines in Clinical Areas
8.1
General principles
Medicines must only be administered in line with:
A valid prescription written by a doctor or trust approved prescriber.
An approved Patient Group Direction (PGD). The person administering the medicine
must be approved to follow the PGD.
Approved homely remedies list.
Note: A pharmacist or technician (band 5 or above) may take a verbal order for a
prescription from the prescriber. The prescription must be written by the pharmacist or
technician. The prescription must be annotated with VO and signed and dated by the
pharmacist/technician. The name of the prescriber must also be noted on the
prescription. The prescription must be signed at the earliest opportunity by the
prescriber (except in the case of one-off outpatient prescriptions)
8.2
Who can administer medicines in the trust?
Medicines administration by nursing staff should be carried out in accordance with the
Guidelines for the administration of medicines as published by the Nursing and Midwifery
Council (NMC).
a) The administration of medicine by injection may only be carried out by:
a medical or dental practitioner,
a competent qualified nurse who has completed the trust competency
assessment (see appendix 5 for competency assessment documents).
support staff who have been trained to administer a specified medicine to a
specified patient.
b) Under normal circumstances, two qualified nurses should be involved in the
administration of medicines. CPNs may administer depot injections alone.
Student nurses should be given the opportunity to participate in the administration
of oral as well as intra muscular and subcutaneous medicines by a supervising
RN, who remains accountable for the student’s practice.
The student can act as the second checking person to the RN when
administering generic medications. All medicine administration carried out by a
student must be countersigned by the RN
Note
The qualified nurse who delegates this task to an unqualified colleague is responsible
for ensuring that the individual has the skills and experience to complete the
delegated tasks and that the qualified nurse delegating duties has the means to
ensure that the delegated task has been completed appropriately.
c) In some clinical areas one qualified nurse may administer medicines after being
assessed as per single nurse administration policy. The nomination of single nurse
administration must be supported by the head of nursing of that particular clinical
area.
d) Two qualified nurses must be involved in the administration of Controlled Drugs.
Medicines Policy, version 6.1 – June 2017 Page 25 of 316
e) The manager of a service must ensure that staff carrying out the administration of
medicines have received appropriate training.
f) The member of staff carrying out the administration of medicines must have been
assessed by their manager or equivalent to be competent to do so.
g) Nurses in training may only participate in the administration of medicines under the
direct supervision of a qualified nurse. (See appendix 6 for single nurse
administration).
Under no circumstances must the medicine be given to an unqualified nurse to
administer directly to the patient. If two trained nurses are jointly conducting the
medication round, each is equally responsible and accountable for the medication
administered.
8.3
Consent to treatment
Refer to the trust policy on consent to treatment
8.4
Aims of medicines administration
The aims of medicine administration are to ensure that:
The right patient receives
The right drugs and formulations
In the right dose
At the right time
By the right route
Staff involved in medicines administration must ensure that they have sufficient
knowledge of drug and patient to ensure these aims are achieved
8.5
Verbal messages
A verbal order to administer an un-prescribed medicine is not permitted other than in
exceptional circumstances for the urgent and immediate treatment of a patient.
In exceptional circumstances changes in dose of existing prescriptions may be made by
fax or e-mail message, followed by a new prescription within 24 hours of the original
message.
8.6
Administration procedure
a) The accurate administration of medicines to patients remains the responsibility of the
individual clinician administering. It is the responsibility of persons administering
medicines to be familiar with the Medicines Policy.
b) Administration of medicines on behalf of the trust may take place in trust premises, in
the patient’s home or other premises in which services are provided (schools, hostels
etc).
c) Members of staff administering medicines must always check the following items
prior to that administration.
Correct and legible completion of all details on the prescribing and recording
chart.
The identity of the patient.
The name, form and strength of the medicine to be administered against the
prescription chart.
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The allergy status of the patient. Medication should not be administered until
the allergy/drug sensitivity section of the prescription chart is completed.
The validity of the prescription (check start and stop dates).
The calculations of the correct dose to be administered.
The time and frequency of the administration.
The route of administration.
Any special guidance relating to the dose offered, e.g. dilution with water,
before or after food etc.
The expiry date of the medicine.
d) If a label on a drug container is altered, damaged or obliterated in any way the
container must be returned to the pharmacy.
e) The competent person administering or assisting with the administration of medicines
must record on the prescribing and recording chart to indicate that the patient has
either received the due medication, or if not, the reason the dose has been omitted
(e.g. refused, absent). Failure to do so may result in an administration error.
f) When making a record of administration the date line at the top of the medication
chart should correspond with all the drugs on the chart.
g) It is recommended that oral syringes be used to measure small volumes of liquids.
h) Injectable medicines must be drawn directly from their original ampoule or container
into syringes and then administered immediately. Injections must not be decanted
into open pots. Injections must not be drawn-up and left unlabelled for administration
at a later time.
8.7
Identification of the patient
Patients must be positively identified prior to administering any medicines.
Clinical staff must confirm the identity of the patient by asking the patient their name.
If the patient is unable or not willing to give their name another staff member should
confirm their identity.
Medications must not be taken out their original package until the patient’s identity
has been confirmed and the patient is ready to take the medications.
No drugs may be administered to a patient who cannot be positively identified.
8.8
Administering PRN (when necessary) medication
Medications prescribed on the ‘prn’ section of the medication chart are administered at
the discretion of clinical staff. Two registered Nurses are required for administration of
‘prn’ medication
Before administering any dose of ‘prn medication’ the RN must check that the
maximum dose has not been exceeded
After administration the RN must record on the prescription, for each ‘prn’ dose of
medication administered, the indication, and the dose and route of administration.
PRN medication must be reviewed at least once a week
Note: When calculating maximum dose allowance, a 24 hour period should be
considered a continuous time period and not the beginning and end of a calendar day.
8.9
Administration of CDs to patients on the ward/unit/clinic
Registered nurses and doctors may administer CDs to a patient. Two people must
be involved in the administration.
When a dose is administered to a patient, the patient’s name must be entered in the
CD register, together with the amount administered.
Medicines Policy, version 6.1 – June 2017 Page 27 of 316
The administered amount must be subtracted from the running balance and the new
balance recorded. A margin of up to 2.5% (under or over) of the original volume may
be allowed for liquids.
Extreme care must be taken when measuring volumes of concentrated potent liquids
(e.g. methadone 10mg/ml). Always read-off volumes from the bottom of the
meniscus at eye-level to avoid parallax errors. It is recommended that an oral
syringe with a bottle stopper (obtainable from Pharmacy or Supplies) be used to
measure small volumes (less than 5ml).
8.10
Self administration of medicines by in-patients
See appendix 8 for details
8.11
Self administration of CDs by patients
CDs for self administration by patients should be labelled with directions for use.
A record of administration must be made in a CD register.
Patients receiving CDs for self administration should sign for receipt of a specified
number of doses.
On the ward CDs for self administration must be stored in a non-portable locked
metal receptacle next to the patient’s bed or the ward CD cupboard.
8.12
Covert administration
See appendix 15 for the trust Covert Administration Policy
8.13
Other administrations
See appendix 7 for administration of medicines without a prescription (Homely
remedies).
See the relevant appendix for any local policies on administration.
8.14
Administration of medicines under a patient group direction (PGD)
See appendix 16 for the trust PGD policy
A Trust approved PGD can act as a direction to a practitioner, authorised to operate
under that PGD, to administer medicines to patients following assessment of that
patient’s need
Administration of a medicine under a patient group direction must be documented in
the patient’s medical record and/or on their inpatient drug chart
The authority to administer a medicine under a patient group direction cannot be
delegated to another health care practitioner
8.15
Recording the medicine administered or omitted
A record of all medicine administration must be made at the time of administration.
The record must include the signature of the person administering the medicine
Medication that is not given due to refusal, wastage, lack of availability or any other
reason must be recorded on the drug chart or in the patient’s notes. The reason for
omission must also be noted.
The omission must be reported to the prescriber so that alternative treatments may
be considered.
Where a second practitioner checks the administration of a medicine, the identity of
the checking practitioner should also be recorded; however the ultimate responsibility
remains with the administering nurse.
Medicines Policy, version 6.1 – June 2017 Page 28 of 316
8.16
Omission of critical medicines
Critical medicines are those which must never be unintentionally omitted or delayed.
They include anticonvulsant medications and insulins. Administration must occur within 2
hours of the prescribed time of dose, unless otherwise stated.
Below is a table of critical medicines commonly used in SLaM. The list is not
exhaustive.
Drug name or class
Systemic
antimicrobials
(including
antibiotics,
antifungals,
antivirals
and
antimalarials) within the first 48 hours of therapy
Antipsychotics
Mood stabilisers
Antidepressants
Antiretrovirals
Insulin
Oral hypoglycaemic agents
Glucose/
glucagon
Opiates prescribed regularly for the management of severe chronic pain. Includes
regular oral therapy, parenteral therapy and transdermal therapy
Naloxone
Corticosteroids
Anticoagulants
Antiepileptic agents
Anti-Parkinsonian agents
Benzodiazepines and parenteral vitamins for the management of acute alcohol
withdrawal syndromes
Oxygen
8.17
Hazardous substances
Certain medicinal substances have specific handling requirements for example, wearing
gloves. Clinical staff must check with pharmacy when handling a medicine with which
they are previously unfamiliar or unsure of handling requirements.
Pregnant staff must not handle hazardous substances.
Clinical staff must follow any specific guidance issued by the manufacturer for handling
individual drugs.
Medicines Policy, version 6.1 – June 2017 Page 29 of 316
9.
Ordering Medicines from Pharmacy
9.1
General principles
Medication is ordered from the local hospital pharmacy department or community
pharmacies. Orders must be in the form of a permanent record, and any requisition
book or order sheet must be kept in a secure place.
Medicines may not be obtained directly from companies or company representatives.
Community and outpatients should be assessed regularly for suitability of obtaining
medication from their GP.
9.2
Pharmacy opening hours and out-of-hours services
See appendix 4 for details on obtaining medicines out-of-hours.
Pharmacy opening times differ according to hospital site; contact your local
pharmacy department for details.
Outside normal working hours either the on-call or resident pharmacist may be
contacted (via the hospital switchboard) to arrange the supply of any
urgently required items or advice. See appendix 4 for further information.
The Duty Nurse (Emergency Team Leader) may be contacted for access to out-of-
hours cupboards.
9.3
Prescriptions used for ordering medicines
a) In-patient prescriptions
Medicines must be labelled with the patient’s details and medication name, form,
strength quantity, batch number and expiry.
b) Community
prescriptions/repeat
out-patient
prescriptions/Out-patient
prescriptions
Medicines must be labelled with the patient’s details, drug name, strength, form
and directions for use i.e. not ‘as directed’.
Prescriptions must be dispensed at trust hospital pharmacy departments.
SLAM Community Prescriptions are valid for up to 6 months of repeat
dispensings. Prescriptions must be reviewed and re-written every 6 months.
c) FP10HPs/FP10SS/FP10MDA
FP10HP - forms are blank green prescription forms. Prescribers must handwrite
these prescriptions.
FP10SS forms are individual blank green prescription forms intended to be used
with the PJS FP10 printing system.
FP10MDA – Addictions prescription for dispensing in instalments
Some community/outpatients may receive an FP10 prescription which they can take to a
community pharmacy for dispensing.
Prescribers must ensure that the prescriptions are stamped/pre-printed with the
appropriate unit/cost code.
Medicines must be labelled with the patient’s details, drug name, strength, form
and directions for use.
FP10 prescriptions should be used whenever appropriate.
FP10 prescriptions are not usually dispensed by the trust pharmacies.
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9.4
Ordering stock/Community clinic stock/Temporary stock items
Stock items are commonly prescribed medicines that are kept on the
ward/clinic/team whether or not they are currently in use.
Community clinic stock items will usually consist of depot antipsychotic injections and
procyclidine injection. Certain other medicines may be held as stock (preferably in
the form of pre-packs) for emergency situations. All other medication should be
dispensed for individual patients.
The list of drugs that comprise “ward/clinic/team stock” will vary from one ward to
another. This list will be agreed between the team manager and pharmacy and will
be reviewed regularly (at least every 6 months) to accommodate changes in
prescribing patterns.
Stock items are regularly replenished by pharmacy.
If an item of stock needs replacing before the next scheduled visit, it can be ordered
from the pharmacy department.
‘Blue’
Emergency boxes are supplied automatically from pharmacy when the current
box expires. If however, the box is opened in between those times it is the
responsibility of the ward to contact pharmacy for a replacement box. There must be
a box on the ward at all times.
Note: procedures on Lewisham and Guy’s and St Thomas’s sites may vary
9.5
Ordering individual patient items (non-stock) for in-patients/out-patients and
community patients
Individual patient medicines (non-stock) must be prescribed by an approved trust
prescriber on an appropriate trust prescription (e.g. out-patient/community/in-patient)
or FP10HP.
Individual patient medicines are supplied for the sole use of the patient whose name
appears on the label.
Out-patient and community prescriptions must also be labelled with the directions for
use.
A pharmacy technician will visit the ward regularly to replenish individual in-patient
items.
If any item needs replacing before the next scheduled visit or a new drug is
prescribed (which is not ward stock) it can be obtained by sending the prescription
chart to pharmacy.
Clozapine is always supplied as an individual patient item as all patients who receive
this drug must be registered with the clozapine patient monitoring service. Clozapine
must never be administered to a patient whose name is not on the label without prior
discussion with pharmacy.
For off-site locations, prescription charts may be faxed to pharmacy unless a
Pharmacy top-up service is provided. Contact local pharmacy departments to
confirm whether this arrangement is in place. The prescription must be faxed each
time a medicine is ordered.
Medicines Policy, version 6.1 – June 2017 Page 31 of 316
9.6
Ordering medicines out-of-hours
See appendix 4 for full details of the pharmacy out-of-hours service.
The ETL or DSN must be contacted to obtain access to the out-of-hours drugs
cupboard.
If the medicine is not available in the out-of-hours cupboard, the ETL or DSN must
contact the on-call pharmacist to obtain authorisation to “borrow” a medicine from
another ward. Note: this is not permitted without authorisation from the on-call
pharmacist.
ETL or DSN should contact the duty/on-call pharmacist via trust switchboard.
9.7
Ordering take-away medicines for leave or discharge (TTAs)
Leave and discharge medication must be labelled with the patient’s details and
directions for use.
All discharge medication should be prescribed on the appropriate prescription form.
9.8
Planned leave or discharge
TTAs should be ordered from pharmacy at least one day before the planned leave or
discharge.
9.9
Unplanned leave or discharge
Nursing staff must not dispense medication from ward supplies under any
circumstances.
During Pharmacy opening hours:
A prescription should be written and sent immediately to pharmacy.
The discharged patient may only deliver and collect their own prescription from the
pharmacy if prior agreement has been reached between ward staff and pharmacy.
In all cases, no special priority can be given to the dispensing of TTAs for discharged
patients. All patients sent to pharmacy must be informed that they will have to wait in
turn for their prescription to be dispensed. An estimate of the waiting time can be
obtained by contacting pharmacy first.
Outside Pharmacy opening hours:
The duty doctor can be contacted and a TTA or discharge prescription written. The
patient can present this prescription to Pharmacy when it is next open. The on-call
pharmacist should
not be contacted to dispense TTA medication.
If it is not possible or inconvenient for the patient to return to the hospital pharmacy
an FP10 (where available) for the TTA or discharge medication can be given to the
patient. This can be dispensed at a retail pharmacy at the patient’s convenience.
If the patient requires TTAs or discharge medication immediately, the duty doctor
may dispense labelled medication from the out-of-hours cupboard or ward (where
available), or pre-packs (where available) against a valid prescription. Medication
must be dispensed using boxes and labels provided in the out-of-hours cupboard.
Controlled Drugs may not be dispensed from ward stock by the Duty Doctor. The
Duty Doctor may however return to the patient any of their own Controlled Drugs
(PODs), which have been stored on the ward. PODs must only be returned to the
patient if the Duty Doctor is satisfied that the medication is consistent with medication
currently prescribed for that patient and that returning the PODs to the patient does
not present any risk to the patient or others.
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9.10
Ordering Controlled drugs (CDs) from pharmacy
Note: procedures may differ on the Guy’s and St Thomas’ and Lewisham sites:
9.11
CDs for administration to patients on the ward/unit or in community clinics
CDs should be ordered as 'stock' or 'temporary stock' not for individual patients.
CDs must be ordered in the ward CD order book supplied for the purpose. Patients’
prescription charts must also be sent to Pharmacy.
The order must state the name, strength, form and quantity of the drug required.
The order must be dated and signed (with a print of the name in block capitals) by an
authorised nurse from the ward/unit/clinic/dept. The person signing the order must
have previously supplied pharmacy with a sample signature. It is the responsibility of
the ward/unit/clinic to supply pharmacy with up- to- date signatures. Orders signed
by an “unknown” qualified nurse will not be supplied. The patient's prescription must
also be sent to pharmacy.
A pharmacist may amend the order on the request of the person ordering the CD.
The pharmacist must sign and print their name on the order page.
A duplicate of the order must be made in the order book, using the carbon paper
provided. This duplicate must be retained (and be available for inspection) by the
ward for two years.
Any member of staff may deliver a CD order book to Pharmacy.
9.12
CDs for patients in community teams/TTAs or outpatients
The prescription must be sent to pharmacy. The CD does not need to be ordered in
the CD book in this case.
9.13
Ordering medicines for Clinical trial use
All medicines for use in clinical trials must be ordered from Pharmacy. Any alternative
arrangement must be agreed with the Chief Pharmacist.
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10.
Receiving Medicines in Clinical Areas
10.1
General principles
All medicines will be delivered from pharmacy in a sealed bag or locked box.
Alternatively, an appropriate, clinical member of staff may collect medication in
person from Pharmacy.
Systems should be in place to record the receipt of all medicines on the ward/team
base.
All medicines should be checked against the requisition. Any discrepancy between
the order and the delivery should be reported to the pharmacy as soon as possible.
All medicines must be stored appropriately (see below) immediately (or as soon as is
reasonably possible) after receipt.
10.2
Receiving Controlled Drugs (CDs) (see appendix 2)
Note: procedures may differ on the Guy’s and St Thomas’ and Lewisham sites
Collection of CDs from pharmacy
If a CD is prescribed as a TTA or for a patient in a community team (i.e. the CD is
labelled with directions for use), it must be collected from pharmacy. It may be
collected by the person for whom it is prescribed. Alternatively, it may be collected by
a carer with written permission from the patient.
In all other cases, the CD must be collected from pharmacy by a qualified nurse
(permanent or agency). Appropriate photo identification must be supplied (e.g. trust
ID badge).
Before leaving pharmacy, the nurse must check the supplied CD against the CD
order or prescription.
The collecting nurse must sign in the case of stock items, the section in the ward CD
order book marked “accepted for delivery” and in the case of CDs dispensed for the
patient, the CD register in pharmacy.
Carers collecting CDs on behalf of a patient must sign the CD collection book.
The top copy of a CD order will be kept by pharmacy.
Copies of CD orders and the CD collection book must be retained (and be available
for inspection) in pharmacy for at least 2 years.
In the case of a TTA, community or out-patient prescription, a photocopy of the
prescription should be kept by pharmacy. Copies should be retained in pharmacy for
at least 2 years.
Receipt of CDs on the ward
On receipt of CDs on the ward, two qualified nurses (one permanent) must check
that the drugs received correspond to the order in the CD order book and sign the
section marked “Received by”.
In the IOT clinic, CDs may be received by either two nurses or a nurse and a
pharmacist. Two people must be involved in the receipt of a CD.
The CDs must be stored in the CD cupboard as soon as they are received on the
ward.
Details of the CD must immediately be entered into the ward CD register. Each CD
must be entered under the name, form and strength of the drug provided.
The requisition number must be recorded when entering the drug into the register.
All entries into the CD register must be witnessed and countersigned by another
registered nurse.
Each strength and form of a CD preparation must be recorded on a separate page.
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For tablets and injections: If the balance of the CD is nil, simply enter the amount
received into the balance column. However, if there is already an amount stated in
the balance column, add the new amount to the outstanding balance to give a new
overall total. The total should be expressed in numbers of tablets/capsules/
injections.
For liquids only – A new page must be started for each requisition number/receipt
(except on the Lewisham wards). The received volume must not be added to any
existing volume in the register. The total volume must be expressed in millilitres not
number of bottles. In the community drug and alcohol teams, the “overage” may be
measured and the balance in the register adjusted according to the extra liquid in the
bottle.
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11.
Storage and Security of Medicines in Clinical Areas
11.1
General principles
The overall responsibility for establishing and maintaining a system for the secure
storage of medicines in a clinical unit lies with the manager of that unit or a
designated deputy, in consultation with the senior pharmacist and appropriate
medical staff. If the manager is not a nurse the responsibility must be devolved to the
most senior nurse in the unit.
The team manager/senior nurse is responsible for control of access to medication
and medication keys and therefore has responsibility for ensuring that the system is
followed and that the security of medicines in the clinical unit is maintained.
In clinical areas without a team manager/senior nurse individual clinicians bear the
responsibility.
The pharmacist must ensure that there is a secure method of supply storage and
disposal of medication in place. The pharmacist must report any failure to comply
with the medicines management policy to the team manager/senior nurse.
11.2
Storage of medicines in clinical areas
All medicines in clinical areas must be stored in a locked medicines cupboard or
refrigerator approved for this purpose or a locked medicines trolley (or equivalent)
attached to a wall (which may be removed from its fixings during medicine rounds).
Note, fridges must be locked.
Medicines cupboards must be in a locked room with controlled access. Authorised
staff are responsible for ensuring secure storage of medicines and keys. Cupboards
must not be visible from external windows and should not display a red light or other
obvious indication as to their content.
Resuscitation drugs are the only exception to this rule. They should be stored inside
a locked clinical room but not a locked cupboard within the clinical room. This
ensures ease of access in an emergency situation.
Medicines for external use must be stored separately from internal liquids, tablets
and injections.
Medicines should be stored at temperatures below 25 degrees Celsius.
11.3 Transportation of medicines in the community, for example, between community
teams and patients’ homes
Medicines and related equipment such as needles and sharps bins must be
transported in the community in a trust approved bag for this purpose. The bag is
called DynaMed Compact Medic Bag. Bags may be ordered by following the link
below:
http://sites.intranet.slam.nhs.uk/resus/Medical%20Devices/Medical%20Devices.aspx
?PageView=Shared&DisplayMode=Design (List of Trust-approved medical devices 2016 - alphabetical orderV1 2)
The bag must be cleaned after each use using general purpose detergent wipes
followed by disinfectant wipe if the bag is contaminated with blood or body fluids. If
the bag is too contaminated to be able to be cleaned, it must be disposed of in a
clinical waste bin.
Staff must carry a copy of waste carriers licence and standard operating procedure
for “transportation of sharps waste in the community”.
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11.4
Monitoring clinic room temperatures
Clinic room temperatures should be monitored daily to ensure they are at the
required temperatures. The clinic room temperature should not exceed 25 degrees
Celsius. It is the responsibility of the unit manager to ensure that medicines are
stored at the recommended temperatures.
If the temperature is above 25 degrees Celsius, the unit manager must contact the
Estates and Facilities department to report the problem and to obtain advice on
rectifying the problem.
Pharmacy should be contacted for advice on medication storage and stability.
The unit must record the clinic room temperature on the temperature sheet (see
appendix 26)
Records must be kept for at least one year.
11.5
Monitoring fridge temperatures
Fridge temperatures should be monitored daily to ensure they are at the required
temperatures. The fridge temperature should be maintained between 2 and 8
degrees Celsius. It is the responsibility of the unit manager to ensure that medicines
are stored at the recommended temperatures.
If the fridge temperatures are found to be outside those recommended the Works
department must be contacted to report the problem. Pharmacy should be contacted
for advice on medication storage and stability.
The unit must record the clinic fridge temperature on the temperature sheet (see
appendix 26)
Records must be kept for at least one year.
11.6
Keys
The keys to the medicine trolley, medicine cupboards and bedside medicine lockers
are the responsibility of the RN in charge of the shift/unit
The keys to the individual bedside medicine lockers may be delegated to patients
where they are part of an approved self-administration scheme.
When the ward has CDs in stock the keys to the Controlled Drug cupboard must be
kept on a separate key ring from the other medicine cupboard and be held by a
second Registered Nurse. The main medication keys remain the responsibility of the
designated registered Nurse in Charge.
Health Care Assistants /Student Nurses must not hold any keys.
11.7
Borrowing and lending medicines between wards/departments
Medicines must not be routinely borrowed/lent between wards during normal
pharmacy opening hours.
If a medicine is required outside normal pharmacy opening hours the out- of-hours
pharmacist should be contacted according to local policy.
In some cases, to avoid unnecessary delay, the pharmacist may authorise
‘borrowing’ the medicine from another ward.
Pharmacy will charge/credit the borrowing/lending ward as appropriate
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11.8
Reporting the loss of medicine
The person discovering a loss shall notify immediately:
a) The appropriate ward/department manager via the Nurse in charge.
b) The Ward Pharmacist or On-call pharmacist if out of hours
After consultation together, the Nurse in Charge shall report the loss, in writing, to
Ward Manager/Team Leader, the Head of Nursing and the Chief Pharmacist. A
DATIX report should be completed.
The Head of Nursing will inform the police where necessary.
11.9
Reporting the loss of the medicines cupboard keys
If a Health Care Professional leaves the hospital with medicines keys it is their
responsibility to return the keys to the ward/department immediately.
If the key cannot be traced the nurse in charge concerned shall be informed
immediately of the loss.
After every effort has been made to find the key or have it returned the Nurse in
Charge will obtain a duplicate key by contacting the Clinical Site
Manager/Emergency Team Leader
(refer to trust site procedures)
If a duplicate is not available arrange for the cupboard to be broken open by Estates
in the presence of a Registered Nurse and for a new lock to be fitted.
A new set of duplicate keys must be given to the Clinical Site Manager for storage.
A new lock must be fitted whenever a lost key cannot be found, regardless of
whether a duplicate key is available.
If a key to a Patient’s Own Drug locker (POD locker) goes missing do not break the
locker open or replace the lock. Pharmacy will arrange for the key or lock to be
replaced. Spare POD locker keys should be kept in a locked cupboard on the ward.
The key to this cupboard should be kept on main bunch and held by Nurse in Charge
11.10 Storage of Controlled Drugs in clinical areas
See appendix 2
Controlled drugs must be stored in a separate Controlled Drugs Cabinet that
complies with the Misuse of Drugs (Safe Custody) Regulations 1973
If the ward has CD stock the keys must be kept on the possession of a registered
nurse on a separate key ring from the other medicines keys.
Controlled drug balance
A running balance of controlled drugs must be maintained in the CD record book.
The Controlled Drugs balance should be checked at least every 24 hours
The balance check must be carried out by a Registered Nurse and witnessed by
another Health Care Professional, both of whom should record the check on the
assigned page of the Controlled Drug record book
Any discrepancies in the running balance should be reported to pharmacy
11.11 Storage of clinical trials medication in clinical areas
All unlabelled stocks of medicines for use in a clinical trial must be stored in
Pharmacy.
Only medicines dispensed and labelled for individual patients may be stored in
clinical areas outside Pharmacy after approval by clinical trials pharmacist.
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All medicines in clinical areas must be stored in a locked cupboard, fridge, or
equivalent, in accordance with the trust Medicines Management Policy.
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12.
Dispensing and Supply of Medicines by Pharmacy
12.1
Definition of dispensing
Dispensing involves the supply of a medicine for administration to a patient in
accordance with the prescriber’s written instructions.
Dispensing includes such activities as checking the validity of the prescription,
checking the appropriateness of the medicine for an individual patient, assembly of
the product, labelling in accordance with legal requirements and providing
information leaflets for the patient.
12.2
Who may dispense or supply
Pharmacy is responsible for the dispensing/supply of all medicines used within the
Trust except where there is an approved procedure in place for practitioners to issue
pre-labelled medicines which have been supplied by Pharmacy for this purpose, or
medicines which have previously been supplied by a pharmacy for that patient’s use
(e.g. patients’ own drugs)
Medicines must not be repackaged or ‘dispensed’ from ward or department stock
cupboards other than by pharmacy staff as part of an approved procedure
Nurses may issue medicines which have been supplied by a pharmacist to a patient
against a signed discharge prescription which has been clinically confirmed by a
pharmacist.
The nurse issuing the medicines must ensure that the patient is supplied all items
currently prescribed for the patient, and that they are accurately labelled, or confirm
with the patient that they have correctly labelled supplies of currently prescribed
medicines at home.
For guidance on the supply of controlled drugs dispensed to patients as discharge
medication refer to the Controlled Drug Policy.
When the pharmacy is closed, duty doctors can dispense medicines using bottles,
boxes and labels supplied by pharmacy in the out-of-hours cupboard.
12.3
Dispensed medicines
Dispensed medicines are medicines that have been supplied and labelled for named
patients against an individual patient prescription or patient specific direction. See
stock medicines below.
Patients may be inpatients, outpatients, community patients or patients being
discharged from hospital.
12.4
Labelling of dispensed medicines
All dispensed items must be labelled in accordance with the requirements of the
Medicines Regulations 1994 (and amendments)
Labels must be typewritten or computer-generated
No amendments may be made to printed labels (other than completion of labels
where required on certain pre-packed medicines).
12.5
Stock medicines
Stock items are medicines supplied for use in a specific unit which are not labelled
for individual patient use.
Stock medicines are supplied to wards/ departments for use in patients being treated
in that clinical area.
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Stock medicines are usually medicines frequently used within that clinical area or
medicines which may need to be accessed in an emergency.
The list of stock medicines held in a ward/ department should be decided by the
pharmacist in consultation with medical staff and the Nurse in Charge.
The amount of stock medicines held in a ward/department will be determined
by
usage patterns and reviewed at regular intervals.
12.6
Pre-packed medicines
Pre-packed medicines are supplied as pre-labelled packs of agreed numbers of
doses, labelled with standard dosing instructions.
The patient’s name and date of issue are completed when the medicine is issued to
the patient.
All medicines issued to patients must be recorded. The records must be available
for audit purposes.
No medicines may be added to or removed from pre-packed medicine containers.
12.7
Patient information leaflets
All medicines supplied to patients for self administration in hospital or after discharge
must include a patient information leaflet.
12.8
Supply of Controlled Drugs from pharmacy (see appendix 2)
Note: procedures may differ on Lewisham sites
The CD may be dispensed by a pharmacist (or pre-registration pharmacist under
supervision) or a band 4 (and above) technician. The dispensed CD must be final
checked by two people (either a pharmacist or technician but not the same person
who dispensed it). A pharmacist must be involved in at least one stage of the
process.
When dispensing a CD, the following details must be recorded in the CD register:
- either the name of the ward (for stock) or the patient's name (for TTA)
- the CD requisition number from the order book (for stock) and the name
of the nurse ordering the CD or the prescribing doctor (for TTA)
- the CD name, form and strength
- the quantity issued
- the entry must be signed and dated
- A record of who collected the CD and whether ID was requested and
seen
When patients are admitted to an in-patient unit, pharmacy must determine the dose
and supply quantity of opiate substitutes in each individual case. Note, some
patients may be on a daily supervised administration regime. Care must be
exercised when dispensing medication on discharge. One or two week supply may
not be appropriate in many cases. If in doubt, confirm with the patient’s community
drug and alcohol team.
The stock balance must be checked and recorded in the register on each dispensing.
The two people involved in the dispensing and checking must do this. Any
discrepancy must be accounted for and clearly documented in the CD book.
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12.9
Supply of medicines under a patient group direction (PGD)
See appendix 16 for the trust PGD policy
A Trust approved PGD can act as a direction to a practitioner, authorised to operate
under that PGD, to supply medicines to patients following assessment of that
patient’s need.
Under a PGD medicines must be supplied to the patient by the practitioner who
assessed the patient for that treatment.
Supply of medicines under a PGD may not be delegated to another member of staff.
12.10 Supply of clinical trials medication from Pharmacy
See appendix 21 for clinical trials policy
All clinical trial medication must be dispensed by Pharmacy.
The medication must be labelled for use in accordance with the clinical trial protocol
and the trust Medicines Management Policy.
All relevant paperwork must be completed and kept in Pharmacy.
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13.
Disposal of Medicines in Clinical Areas
13.1
Disposal of medicines
All out-of-date medication or medication that is no longer required should be returned
to pharmacy. When patients are discharged all medication for that patient should be
returned to pharmacy. All medicines no longer needed on the wards should be
disposed of in pharmabins provided on the wards. The wards must ensure that
these bins are collected directly from them. Please refer to the trust Healthcare
Waste Policy for further guidance.
Non-pharmaceutical waste e.g. sharps, empty bottles should not be returned to
Pharmacy.
Illicit drugs are not covered by this policy.
13.2
Disposal of Controlled Drugs in clinical areas (see appendix 2)
Note: procedures may differ on the Guy’s and St Thomas’s and Lewisham sites
Teams on hospital sites
If a CD has expired or is no longer needed (e.g. patient discharged, medication
changed) the pharmacy must be contacted to arrange for the CD to be removed from
the ward.
CDs may be removed from the ward by a pharmacist or pharmacy technician Band 5
or above.
If part of a vial is wasted it may be disposed of on the ward, by placing it in the
sharps bin. If part of a tablet is wasted it should be destroyed on the ward using the
DOOP kit. A registered nurse may dispose of individual doses/vials on wards/clinical
units. The disposal must be witnessed by another nurse. Details of CD destroyed
must be recorded in the ward CD register. Both nurses should sign the CD register.
CDs must be checked by the pharmacist or pharmacy technician on the ward before
being returned to pharmacy.
The pharmacist or pharmacy technician must sign the CD out of the ward CD
register with a registered nurse acting as witness and deliver it to pharmacy. A
record must be made in the ward CD register of the date, reason for return, name,
strength, form and quantity removed.
The balance must be adjusted accordingly in the ward CD book.
CDs should not be returned to pharmacy by any ward staff or via porters.
CDs which are not fit for re-use must be destroyed in pharmacy using the DOOP kit.
Destruction must be witnessed by a pharmacist or a technician (band 5 or above).
Teams not on hospital base sites
Teams not on hospital base sites must be registered with the Environmental Agency
and trust Estates and Facilities department for authority to destroy CDs on the unit
(exemptions certificate).
CDs from units not on hospital base sites should be destroyed on the unit, not sent to
pharmacy.
Each unit will have a nominated pharmacist to witness the destruction of CDs on that
unit.
If a CD has expired or is no longer needed (e.g. patient discharged, medication
changed) the unit must contact the authorised witness (in pharmacy) to arrange a
suitable time for CDs to be destroyed.
CDs must be destroyed using the DOOP kit. Destruction must be witnessed by a
trust authorised witness.
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A record of all CDs destroyed must be kept in the back of the ward CD register
current at the time of the CD destruction. Registers must be kept for at least 7 years
after the time of record of last CD destroyed.
Any CDs to be destroyed must be signed out of the front of the register and recorded
in the back of the register. The CD stock in the cupboard must match the balance in
the register. CDs must be destroyed according to the procedure for destruction in
appendix 2
A record must be made in the ward CD register of the date, reason for destruction,
name, strength, form and quantity to be destroyed.
The balance must be adjusted accordingly in the ward CD book.
13.3
Disposal of clinical trials medication in clinical areas
Any unused medicines must be returned to pharmacy (not destroyed in clinical
areas)
13.4
Hazardous substances
Please refer to the trust Healthcare Waste Policy.
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14.
Issuing Medicines to Patients and Their Carers
See appendix 2 for Controlled Drugs.
14.1
Definition
The delivery or handing over of medicine in person to a patient or carer that is for self-
administration by the patient. The medication must have been dispensed by the
pharmacy department, as a TTA (To Take Away) or outpatient medication, and clearly
labelled with the patient’s details and instructions on how the individual patient should
take or use the medicine.
14.2
Who can issue medicines to patients and their carers?
All trust staff, employed in a clinical role, are authorised to issue medication to individual
patients. The issue of medication is part of the overall care of the patient and each
clinician has a responsibility to ensure that prescribed medication is dispensed and
issued to their patients correctly and appropriately, and that accurate records are
maintained. The CMHT/ward/team manager/senior nurse will determine local procedures
for the issue of medication.
14.3
Responsibility
The pharmacist is professionally responsible for ensuring that the medication
dispensed for an individual patient is correct and corresponds to the prescription.
Medication will be dispensed by the hospital pharmacy against a valid prescription.
The medication will be clearly labelled with the name of the patient, the name,
strength and form of the medicine, the quantity dispensed, the date of dispensing
and instructions for use.
Medication must always be issued in person to the patient/carer except in pre-
arranged exceptional circumstances.
The medication must always be issued to the patient in the original container as
supplied by the pharmacy. The label must not be altered in any way and the
medication must not be tampered with or transferred into any other container e.g.
envelopes. The only exception to this is when it is necessary to transfer medication
dispensed for an individual patient into a compliance aid, and it is not possible for the
pharmacy to fill the aid. In these circumstances a registered nurse may fill the aid
following the SLaM Policy and Guidelines for Medication Compliance Aids. See
appendix 9.
The member of staff who hands out the medication to the patient has a responsibility
to ensure that the medication corresponds with the current prescription (i.e. that
there have been no changes to the prescription since the medication was
dispensed).
The patient should have the opportunity to ask any questions about their medication.
The clinical worker may be able to answer these questions directly or may refer to
another clinician.
All clinical workers have a duty to acquaint themselves with the medicines that are
prescribed for their patients. This is possible by attending training sessions, through
discussions with colleagues and by reading current guidelines and literature e.g.
British National Formulary, Patient Information Leaflets etc.
Individual patient risk must be assessed before determining the supply quantity of
medication at any one time.
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Before issuing medication, staff should feel confident and able to do so. Where there
is any doubt staff are expected to approach their team manager/colleagues for
advice and assistance.
14.4
Documentation
A system should be in place to record the issue of medication dispensed for
individual patients. The issue of medication to the patient should be recorded on the
community prescription chart and a record made in the patient’s notes.
A system should in place for recording/indicating when the next supply of medication
is required.
Details of any advice sought or given must be recorded in the patients notes (ePJS),
including the names of the persons involved.
14.5
Issuing procedure
Special care should be taken to confirm the identity of the patient, e.g. by asking
them to state their date of birth.
The person issuing the medication should select the medication from the cupboard,
taking care to ensure that the medication dispensed for that individual patient is
selected. Take extra care when there are patients with similar names.
The person issuing the medication must check that the timing of the issue is in line
with the instructions on the prescription chart. The patient should not be given more
than one instalment at a time or at intervals different from those directed, unless
otherwise agreed by the prescriber or team leader/senior nurse.
If an interval has lapsed when medication has not been collected and the patient has
been without medication during this time then clinical advice from the prescriber
and/or pharmacy must be sought as to whether it is appropriate to issue the
medication.
The person issuing the medication must check the medication against the
prescription. They must confirm that no changes have been made to the prescription
since the medication was dispensed, and that the prescription is still valid. If there
are any discrepancies between the prescription and the medication supplied, the
member of staff must contact the pharmacy before handing out the medication.
The person issuing the medication should ensure that the patient/carer understands
the following:-
-
the name of the medicine and the dosage.
-
the purpose of the medication.
-
the route, frequency and intended duration of use
.
-
the correct use of special dosage forms and administration devices e.g.
inhalers.
-
the actions to be taken in the event of a missed dose.
-
instructions on the storage of the medicine
-
advice on possible side effects and interactions (including OTC medicines)
and what to do if they do occur.
-
how to obtain further supplies.
-
how to obtain further information.
In addition, the person issuing the medication should check that the patient/carer can
read the label and open the container and measure the dose required. If they
cannot, alternative arrangements should be made with the pharmacist, e.g. non-child
proof tops, compliance aids etc.
It is the prescriber’s responsibility to ensure that the patient/carer is informed about
their medication at the time of prescribing.
Staff have a duty to withhold the medication where there are any concerns that the
administration of the medicines may lead to harm to the patient e.g. hypersensitivity
Medicines Policy, version 6.1 – June 2017 Page 46 of 316
reaction, serious adverse reaction, pregnancy, risk of overdose. This must be
discussed with the patient’s RMO or designated doctor immediately.
The issue of medication to an individual patient must be recorded immediately on the
prescription chart and/or in the patient’s case notes.
14.6
Provision of medicines information to patients and carers
Pharmacy will supply the manufacturer’s Patient Information Leaflets (PILs) with
dispensed medication. If the amount of medication supplied is less than that in the
manufacturer’s original pack, the pharmacist will ensure that a PIL is supplied the
first time a medication is dispensed, and then at least once a month.
Patient information leaflets provide information to supplement the manufacturer’s
information. These can be obtained from pharmacy or can be printed from the trust
Intranet
It is the key worker’s responsibility to ensure that the patient has access to
information about medication.
The patient may ask to speak to a mental health pharmacist about their medication.
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15.
Ordering, Storage and Supply of Controlled Stationery (CD registers, CD
requisition books, FP10HPs and FP10MDAs
15.1
Storage of Controlled Drugs (CD) registers and requisition books
CD registers and CD requisition books for supply to wards/units/dept must be kept in
a locked cupboard in pharmacy.
CD registers and CD order books on wards/unit/dept must be kept in a locked
cupboard.
Only one CD order book must be in use per ward/unit/dept at any one time. At IoT
clinic, one CD order book per CD may be used at any one time in such clinics.
The CD order book and CD register must be retained on the ward/unit/dept (and be
available for inspection) for at least 2 years from the last entry.
15.2
Ordering CD registers and requisition books from Pharmacy
Procedures may differ on the Guy’s and St Thomas’s and Lewisham sites
CD stationery may be ordered from pharmacy by a permanent qualified nurse using
the CD order book.
The date of issue must be recorded on the front of CD stationery supplied by
pharmacy.
CD stationery may be collected from pharmacy by a permanent qualified nurse.
The following details must be recorded in the CD stationery issue book in pharmacy:
date of issue, ward/unit/dept, name of person ordering and collecting and the type
and quantity of stationery issued. The entry must be signed by the pharmacy
member issuing as well as the staff member collecting.
15.3
Unused, lost or stolen CD registers and CD requisition books
Any unused stationery must be returned to pharmacy. An entry of return must be
made in the CD stationery issue book.
All loss or theft of CD stationery must be reported immediately to the Chief
Pharmacist.
15.4
Ordering FP10HPs/ FP10MDAs/FP10SS
(See appendix 17 for FP10SS Security Policy)
The security of prescriptions and associated stationery is the joint responsibility of the
trust and the individual prescriber.
FP10HP - forms are blank green prescription forms. Prescribers must handwrite
these prescriptions
FP10SS forms are individual blank green prescription forms intended to be used with
the PJS FP10 printing system.
FP10MDA – Addictions prescription for dispensing in instalments
15.5
Ordering FP10 forms
All blank FP10 forms should be ordered from the Maudsley hospital pharmacy.
Email “FP10” in the SLaM email address book.
All FP10 forms should be ordered two weeks in advance to ensure stocks are
available – the team business manager should ensure stocks are replenished as
necessary.
Requisitions for new pads must be written on trust headed paper.
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FP10s should be collected in person by a member of team staff carrying trust ID.
On the Guy’s site, prescriptions will be sent to the teams in sealed bags or locked
boxes. The receipt form must be signed and sent back to the Pharmacy.
Prescription identifier numbers must be recorded by pharmacy (the first and last
numbers of each pad) for those being supplied. The person collecting the forms
should check the numbers are correct and sign for the forms. Pharmacy must keep
the signed record of all FP10s collected.
FP10HPs will be pre-printed with the hospital unit and identifier code.
15.6
Storage and use of FP10 forms
FP10s forms must not be taken home by prescribers.
All FP10s must be stored in a locked cupboard or drawer when not is use.
FP10SS are supplied in large boxes of 2000 prescriptions. The team stock of blank
FP10SS forms must be kept in a locked cupboard by the team leader/administrator.
The business manager should designate a member of the administration team as
responsible for the security of the team’s FP10s. Only this member of staff should
have access to the prescriptions and should issue to prescribers as necessary.
Each time FP10s are issued to a prescriber the first and last serial numbers of the
prescriptions must be recorded and signed for. The prescriber will be asked to sign
for all prescriptions issued to them, and should check the identification numbers they
are signing for. These records must be kept by the administration team.
Once issued, prescribers should keep their FP10s in a secure, locked cupboard or
drawer, and ensure they request a new batch of prescriptions before they have used
all of their blank forms.
15.7
Responsibility of the individual member of staff
Prescribers should
Record the number of the first and last prescription received.
Keep prescriptions locked in a cupboard or drawer when not in use.
Mark and cross-through as ‘void’ any incorrect/void prescriptions and destroy in
confidential waste.
Follow the above procedure for ordering and maintaining your own stock of
prescriptions.
Prescribers should only use their own issued prescriptions.
Keep FP10HP
pads with them whilst out of the office.
Consider only taking one or two FP10HP prescriptions out of the office.
Record the number of each FP10HP prescription used and the date of use.
Notify the manager if any prescriptions go missing and follow the procedure below
Return all unused forms if leaving the employment of the team.
Prescribers should not
Leave FP10s unattended
Pre-sign blank prescription forms
Use the blank FP10SS forms to handwrite prescriptions on (they will be rejected by
the pharmacy as the prescriber address and identification details are not complete)
Leave any FP10 forms unattended in an unlocked place.
Use prescription forms not authorised for them.
Leave an FP10HP prescription pad in a car.
Have more than one FP10HP prescription pad in use at any one time.
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15.8
Responsibility of the trust
To provide secure, lockable storage for prescriptions.
To ensure the provision of new prescriptions as required.
To minimise the risk of fraud by keeping clear and up to date records of the serial
numbers of prescriptions received and issued.
To retrieve unused prescription pads from clinicians leaving the trust.
To ensure the procedure for dealing with lost or stolen prescriptions is followed.
15.9
Lost, stolen or fraudulent prescriptions
The unit manager, pharmacy site lead and the trust Local Security Management
Specialist (LSMS) must be informed immediately if prescription forms are known to be
lost, stolen or used fraudulently.
The incident must be reported on a trust incident form or on DATIX
For further details and the form to be completed by the unit manager, see appendix
17
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16.
Risk Management
16.1
Recording allergies and adverse drug reactions
See appendix 19 for the trust Medicines Reconciliation policy
It is the responsibility of the prescriber to accurately determine a patient’s allergy status
before prescribing any medication for that patient.
All patients must be asked specifically for any history of drug allergies or
hypersensitivities and previous adverse drug reactions on admission. These should
be clearly documented in the medical notes and medication chart. All notations must
be signed and dated by the prescribers.
Where no allergies, hypersensitivities or adverse reactions are reported by the
patient the patient record and prescription must be annotated with NKDA or no
known drug allergies. Prescribers must sign and date all notations to this effect.
Under no circumstances must the allergy section on the prescription be left blank
On discharge all allergies must be included on any relevant discharge liaison forms.
If a patient experiences an adverse drug reaction, the prescribing doctor or
pharmacist or nurse should complete a yellow card (if appropriate) and send it to the
Medicines and Healthcare Regulatory Agency (MHRA). Yellow cards can be found at
the back of the BNF or the MHRA website www.mhra.gov.uk.
Training in adverse event reporting must be included in induction programmes for all
staff involved in medicines management.
16.2
Medicines Reconciliation
See Appendix 19 for Medicines Reconciliation Policy.
16.3
Medicines Safety Committee
The trust has a Medicines Safety Committee which meets once every three months.
The Committee is chaired by the Medical Director and the Deputy Director of Pharmacy
is the secretary. See appendix 27 for terms of reference.
Medication Safety Officer
The trust Medication Safety Officer is the Deputy Director of Pharmacy.
16.4
Error reporting
See appendix 20 for guidance on the reporting of medication errors
It is the responsibility of all clinical staff to report any medication incidents.
All medication errors relating to the administration, prescribing and supply and disposal
of medicines should be reported electronically on DATIX, as a “grade C” or above.
Any serious error (i.e. health or life threatening) or potentially serious error (near
miss) related to any aspect of medicine use must be brought to the attention of the
immediate manager(s) and the relevant practitioners at the earliest opportunity.
A DATIX incident form must be completed for all medication errors. The drug name,
dose, strength and route of administration must be included in the report. The
medical practitioner will decide upon the appropriate course of medical action (if any)
and the immediate supervisor/service manager will decide upon the appropriate
course of action in relation to the staff concerned.
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Minor errors must be reported to the immediate manager who will decide on the
relevant action.
Prescribing errors identified by other staff members should be brought to the
attention of the prescriber and department manager.
All prescribing errors (resulting in administration to the patient or not) must be
reported on DATIX incident form. The prescriber and their manager must be made
aware of the error.
A DATIX incident form should be completed for all errors leaving the pharmacy.
Errors in the supply of medicines must be reported to the pharmacy as soon as
possible, but certainly within two working days, (within three working days at
weekends and bank holidays). Out of hours - contact the on call pharmacist if
necessary.
Learning from medication errors
Medication errors reported on DATIX will be examined every 3 months.
A summary of the errors is presented to the Medicines Safety Committee
The trust Patient Safety Department report all medication errors to the National
Patient Safety Agency.
Recommendations from the Medicines Safety Committee are communicated in the
Medicines Bulletin and individually to CAG leads.
16.5
Defective pharmaceutical products
A defective pharmaceutical product is one which is unfit for use. This includes all
products supplied by the pharmacy (tablets, mixtures, injections, dressings, etc.),
whether manufactured commercially or by the hospital, and which are faulty by
reason of manufacture, storage or handling.
Defects noted
before a medicine is administered must be reported immediately to
the pharmacy (out-of-hours to the resident or on-call pharmacist contacted via the
hospital switchboard) and fresh supplies obtained.
Defects noted
after a medicine has been administered must be reported
immediately to:
- the doctor
- the pharmacist (on-call or resident pharmacist out of hours)
- the operational manager/senior nurse
If appropriate the pharmacist will initiate the notification process.
All products and
equipment associated with the defective product must be retained for investigation.
If the defective product has been administered to a patient, record the
manufacturer's name, the batch number and expiry date of the product in the
patient's notes.
Pharmacy will arrange collection of the defective product.
Do not send to
pharmacy via ward boxes.
16.6
Recall of defective pharmaceutical products
Hospitals are required to comply with notification procedures when pharmaceuticals
products are found to be defective. The pharmacist in charge will arrange for the recall
of any product that has been notified to them as being defective.
See appendix 22 for procedure.
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17.
New Drugs, Clinical Trials and Unlicensed Medicines
17.1
Introduction of new drugs in the trust
See appendix 11 for new drug request form
The trust Drug and Therapeutics Committee (DTC) will consider the place in therapy
of any relevant new products and report its decision to the relevant PCT forum and to
the trust board for ratification. The secretary of the DTC will disseminate information
to relevant parties.
The pharmacy will not purchase any new product until its place in therapy has been
assessed by the Drugs and Therapeutics Committee.
Medical representatives are not permitted to promote in the trust the use of any
product that has not been approved by the DTC. See appendix 10 for the Medical
Representatives policy.
17.2
Drugs and Therapeutics Committee
The SLaM Drug and Therapeutics Committee meets every three months and is
accountable to Quality Sub Committee (QSC) of the board. The committee has a
chair and the secretary is the Chief Pharmacist. The terms of reference are as
follows:
See appendix 11 for the Committee’s Terms of reference.
The DTC minutes and associated documents are available on the trust intranet.
17.3
Clinical Trials
All trials must have the approval of the Research Ethics Committee R&D approval
and regulatory (MHRA) approval
All clinical trials must have a protocol outlining medicines use.
17.4
Unlicensed medicines and off label uses of licensed medicines
See appendix 12 for the Unlicensed Medicines policy
A list of trust approved unlicensed medicines and unlicensed uses of licensed
medicines is contained in the unlicensed medicines policy.
Medicines may be added to this list by application to the Drugs and Therapeutics
Committee.
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18.
Local Policies
Local procedures may be developed which adhere to the principles of this policy but take
into account differences in service provision/needs in local areas. Policies for local
services not covered by this policy must be prepared in accordance with SLAM
guidelines for clinical policies and be approved by the Drug and Therapeutics
Committees.
19.
Monitoring Compliance
This is an update of previous policy and will replace the existing policy on the trust
intranet once ratified. Implementation of the policy will be monitored through the Drug
and Therapeutics Committee.
Training
All clinical staff on induction will be informed of the policy and how to access it. It is the
responsibility of the individual and their line manager to ensure that they are familiar with
the policy and competent to work within the framework of the policy.
Responsibility of clinical staff
All trust employees involved in any aspect of the use of medicines in the trust are
responsible for ensuring that they comply with this policy.
What will be monitored i.e. measurable policy objective
Group(s)/committee(s)
monitoring is reported
to, inc responsibility for
action plans and
changes in practice as
a result
The policy will be monitored as per Medicines Optimisation The Medicines Policy is
programme. The programme is updated annually.
overseen by the trust
Drug and Therapeutics
The trust participates in the POMH-UK audit programme
Committee.
The trust undertakes an audit of the storage and record keeping of Medicines Incidents are
Controlled Drugs every three months
reviewed by the
Medicines Safety
The trust audits the safe and secure handling of medicines once a Committee.
year.
The Medicines
In addition, as and when necessary, the trust will survey prescribing Optimisation Report is
and medicines management practices
presented to the trust
board annually.
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20.
Associated Documentation
Medicines Annual Report and Medicines Optimisation Programme
Medicines Bulletins
Drugs and Therapeutics Committee minutes
Medicines Safety Committee minutes
Medicines Reconciliation
http://www.nice.org.uk/nicemedia/pdf/PSG001Guidance.pdf
Medicines Adherence
http://www.nice.org.uk/nicemedia/pdf/CG76FullGuideline.pdf
Clinical Waste Policy
Consent to Care and Treatment Policy
CPA Policy
Discharge and Transfer Policy
Mandatory Training Policy
21.
References
The NMC ‘Standards for medicines management’ (2007)
The NMC ‘The Code - Professional standards of practice and behaviour for nurses and
midwives Code of Professional Conduct’ (2015)
The NMC Standards for competence for registered nurses (2014)
The Medicines Act (1968)
The ‘Duthie Report’ (2005)
Misuse of Drugs Act (1971)
CQC Regulations for Service Providers and Managers (2015)
Building a safer NHS for patients: improving medication safety (2004)
Healthcare Commission: Talking about Medicines (2007)
The Hackett Report. Homecare Medicines: Towards a Vision for the Future (2011)
The Carter Review (2016)
22.
Freedom of Information Act 2000
All Trust policies are public documents. They will be listed on the Trusts FOI document
schedule and may be requested by any member of the public under the Freedom of
Information Act (2000).
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