Medicines Policy

The 5 key messages the reader should note about this document are:

1. This policy has been developed to maintain and enhance standards of professional practice in the safe prescribing, dispensing and administration of medicines.

2. Each practitioner is accountable for their actions and omissions and therefore must exercise their judgement and skill in any given situation.

3. All staff working who are contracted to work within the Trust who are involved with the use of medicines, must familiarise themselves with the correct procedures contained within this policy.

4. Medicines Management focuses on optimising the use of medicines

5. All staff are expected to act in accordance within this Policy and are personally accountable for doing so

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This policy has been approved. Circumstances may arise where staff become aware that changes in national policy or statutory guidance (e.g. National Institute for Clinical Excellence (NICE) guidance, Employment Law) may affect this policy. It is the duty of the staff member concerned to ensure that the policy author is made aware of this change so that the matter can be dealt with through the policy review process. NOTE: All polices remain extant until notification of an amended policy via Global e-mail and posting on the intranet.

Document details: Medicines Policy

Version: 5

Persons / committees consulted: Medicines Management Group Professional Council

Approved by: Medicines Management Group

Date approved: Dec 2011

Ratified by: Service Governance Committee

Date ratified: Jan 2012

Title of originator / author: Pharmacy Manager

Title of responsible committee / group (or Trust Board):

Medicines Management Group

Title of responsible Director: Medical Director

Date issued: Jan 2012

Review date: Jan 2014

Frequency of review: 2 years

Target audience: Trust wide

(All medical, nursing and pharmacy staff)

Responsible for dissemination: Medicines Management Group

Copies available from: Trust Intranet

Where is previous copy archived (if applicable)

Pharmacy Manager

Amendment Summary:

1. Equality Impact Assessment updated to new format

2. TNA updated to include BACHS staff transferred in April 2011

3. Remit of Medicines Management Group (section 4.4) updated

4. References updated

Amendment detail:

Amendment number

Page Subject

4 23 References updated

3 13 Remit of Medicines Management Group updated

1 25 Equality Impact Assessment update

2 30 TNA updated

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Contents

APPENDICES (THESE ARE AVAILABLE SEPARATELY ON THE TRUST INTRANET)

MEDICINES MANAGEMENT PROCEDURES, PROTOCOLS AND GUIDANCE

1 PRESCRIBING OF MEDICINES

2 MEDICINES RECONCILIATION

3 MEDICINES ADHERENCE

4 ORDERING AND RECEIPT OF MEDICINES

5 PHARMACY SERVICES (INCLUDING OUT OF HOURS)

6 PREPARATION AND ADMINISTRATION OF MEDICINES

Section Topic Page Number

1 Introduction 5

2 Purpose of Document 7

3 Definitions 8

4 Duties 12

5 Procedural Document development 17

6 Equality Impact Assessment 19

7 Training Needs Analysis 19

8 Consultation, approval and ratification process 20

8.1 Consultation process 21

8.2 Approval process 21

8.3 Ratification process 21

9 Review of the Procedural Document 21

10 Dissemination & Implementation 21

11 Process for monitoring compliance and effectiveness 22

12 References 23

13 Associated Documents

24

APPENDICES

A Equality Impact Assessment 25

B Compliance Checklist 28

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7 GUIDANCE ON THE ADMINISTRATION TO ADULTS OF OIL BASED DEPOT AND

OTHER LONG ACTING INTRAMUSCULAR ANTIPSYCHOTIC INJECTIONS

8 TRANSPORT OF MEDICINES

9 STORAGE OF MEDICINES

10 CUSTODY AND SAFE-KEEPING OF MEDICINE KEYS

11 CHECKING OF STOCK BALANCES AND DEALING WITH LOSSES OR

DISCREPANCIES

12 DISPOSAL OF MEDICINES NO LONGER REQUIRED

13 PATIENT'S OWN MEDICINES

14 SELF-ADMINISTRATION OF MEDICINES BY PATIENTS

15 COMPLIANCE AIDS

16 USE OF UNLICENSED MEDICINES

17 CLINICAL TRIALS INVOLVING PHARMACEUTICAL PRODUCTS

18 MEDICAL GASES

19 USE OF ESSENTIAL OILS AND COMPLEMENTARY MEDICINES, HOMEOPATHIC

OR HERBAL SUBSTANCES

20 MEDICINES RELATED DUTIES PERFORMED BY HEALTHCARE ASSISTANTS

21 DAY HOSPITALS AND RESPITE CARE

22 MEDICATION ERRORS

23 ADVERSE DRUG REACTIONS

24 MEDICINE DEFECT REPORTING

25 DRUG ALERTS, RECALLS AND SAFETY NOTICES

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26 ILLICIT DRUG USE / SUBSTANCE MISUSE / POSSESSION

27 CONSENT TO TREATMENT

28 COMMUNITY BASED PRACTITIONERS

29 CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH (COSHH)

30 COVERT ADMINISTRATION OF MEDICINES

31 CONTACT WITH THE PHARMACEUTICAL INDUSTRY

32 GUIDELINES FOR THE CARE AND CONTROL OF CONTROLLED DRUGS

33 OUTPATIENT OUT OF HOURS EMERGENCY TREATMENT

34 RECEIPT, CHECKING AND ADMINISTRATION OF MEDICATION IN REGISTERED

CARE HOMES

35 NON MEDICAL PRESCRIBING FRAMEWORK

36 PRESCRIPTION STORAGE AND SECURITY

37 REDUCING HARM FROM OMITTED AND DELAYED MEDICINES IN HOSPITAL

38 PRESCRIBING FOR DENTISTRY IN BRADFORD AND AIREDALE SALARIED

DENTAL SERVICE

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1 Introduction

1.1 The Department of Health requires that NHS Trusts establish, document and maintain

an effective system to ensure that medicines are handled in a safe and secure manner.

1.2 Medicines Management focuses on optimising the use of medicines and is defined in the Audit Commission’s Report ‘A Spoonful of Sugar’ as ‘ encompassing the entire way that medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to produce informed and desired outcomes of care’ 1.3 Aspects of medicines management run throughout the organisation, across all localities and service areas, and comprehensive medicines management is crucial to the achievement of the Trust strategic and operational objectives. Medicines Management involves service users, carers and all the clinical professions. It is supported, facilitated and sometimes lead by the Pharmacy Service within the Trust. 1.4 This policy has been developed to maintain and enhance standards of professional practice in the safe prescribing, dispensing and administration of medicines and is a collaborative effort between the doctor, pharmacist, practitioner and patient. This is not a mechanistic task to be performed routinely; it requires thought and the exercise of professional judgement. 1.5 Each practitioner is accountable for their actions and omissions and therefore must exercise their judgement and skill in any given situation. 1.6 All staff working who are contracted to work within the Trust who are involved with the

use of medicines, must familiarise themselves with the correct procedures contained within

this policy. Those in charge of wards, units and clinics are responsible for ensuring that

their staff, (especially new and locum staff), follow procedures in this policy, which may

differ from procedures used elsewhere. Copies of the policy will be available at all in-

patient and outpatient sites as well as being accessible on the Trust intranet.

1.7 The Medicines Management Group will review this policy 2 years after the

implementation, although it may be fully or part reviewed on any occasion prior to this

formal review in response to legislative changes or significant procedural changes in

nursing, medical or pharmacy practice The Group will however continuously monitor its

implementation and practice through an agreed programme of clinical audit.

1.8 This policy was implemented following a Trust wide programme of training and

preparation that will be for all groups of staff that will be involved in its use and practice.

New staff will be introduced to the policy via the mandatory Trust induction programme,

which all new employees have to undertake. Any training may be subject to input from the

Equality and Diversity Team when considering any implications for protected groups

1.9 For community care local protocols should be in place to compliment this policy

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1.10 It should be noted that BDCT staff based at the Airedale Centre for Mental Health and Airedale General Hospital will be expected to follow this policy 1.11 District Nurses and Ward Based Nursing staff should refer to the Royal Marsden Manual of Nursing Procedures as applicable. 2 Purpose The Bradford District Care Trust Policy is based on relevant primary legislation concerning medicines and attempts to reflect recommendations and requirements of professional bodies. This means that you are answerable for your actions and omissions regardless of advice

of directions from another professional. You must keep your knowledge and skills up to

date throughout your working life. Particularly, you should take part regularly in learning

activities that develop your competence and performance. To practice competently you

must possess the knowledge, skills and abilities required for lawful, safe and effective

practice without direct supervision. You must acknowledge the limits of your professional

competence and only undertake practice and accept responsibilities for those activities in

which you are competent. If an aspect of practice is beyond your level of competence or

outside your area of registration you must obtain help and supervision from a competent

practitioner until you and your employer consider that you have acquired the requisite

knowledge and skill.

See section 12 for references Each clinical area will have access to an update copy of the British National Formulary (BNF). An electronic version of the BNF can also be accessed through the Trust intranet website. Staff should familiarise themselves with the relevant COSHH regulations. The NMC Council expects that all practitioners will have taken steps to develop their knowledge and competence in accordance with the NMC CPD standards and that they will bring to their manager’s attention any gaps in their knowledge. 3 Definitions

3.1 Staff Definitions

Throughout this Policy, certain specialist titles describe healthcare staff who have defined responsibilities regarding the management of medicines. Only staff with contracts (or honorary contracts) of employment to work in Bradford District Care Trust (BDCT) are recognised as having any involvement with medicines. This includes agency staff.

3.1.1 Medical Staff

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With the exception of clozapine, which can only be initiated by a consultant psychiatrist,

who in turn must be registered with eCPMS, all qualified doctors may prescribe licensed

medication on in-patient charts, leave prescriptions, discharge prescriptions (TTOs) and

outpatient prescriptions.

Any unlicensed or off-licence prescribing must be consultant led and should be recorded in the patient’s case notes. 3.1.2 Independent prescribing

Prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing. Within medicines legislation the term used is ‘appropriate practitioner’.

3.1.3 Non-Medical Prescribing Supplementary Supplementary non-medical prescribers with the agreement of service users, make adjustments to medication based on agreed clinical management plans, thus facilitating a more flexible approach to care delivery and the development of new professional roles. Special consideration will be given in respect to vulnerable adults, people who may not have mental capacity, who may have physical/sensory impairments. The Department of Health (2003) defines supplementary prescribing as “A voluntary partnership between an Independent Prescriber (a Doctor or Dentist) and a Supplementary Prescriber to implement an agreed patient specific Clinical Management Plan (CMP) with the Patient’s agreement” DOH (2003). Independent Independent non-medical prescribers may prescribe any licensed medicine for any medical condition, including Controlled Drugs from a limited list as stipulated in the BNF for the relevant conditions. Prescribers must only ever prescribe within their own level of experience and competence.

Health visitors and school nurses should prescribe in line with The Well Child Pathway 3.1.4 Practitioner The general term used to describe a qualified medical practitioner, nurse, pharmacist or other authorised healthcare employee trained in specific aspects of medicines administration. 3.1.5 Appointed Practitioner in Charge The senior practitioner appointed in charge of a ward or department e.g. Ward Manager

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In situations where the person in charge is not from a professional background appropriate to take such responsibility (e.g. community team leader with a social work background) another member of the team must undertake the role of Appointed Practitioner in Charge. 3.1.6 Assigned Practitioner in Charge The senior practitioner on-duty for the ward or department, who has been rostered as the professional in charge for that shift. 3.1.7 Designated Practitioner Any registered practitioner identified by the Appointed Practitioner in Charge as competent and appropriate to perform a specific function. The designation as such has been communicated to and accepted by the Designated Practitioner. If the practitioner is based in the community the term used is Designated Community Practitioner. 3.1.8 Designated Complementary Therapist Any practitioner of a complimentary therapy who has obtained the appropriate qualification from a recognised organisation, and is approved by the Trust. 3.1.9 Authorised Pharmacy Staff Any qualified pharmacist or pharmacy technician authorised by the Pharmacy Manager as competent and appropriate to perform a specific function. 3.1.10 Authorised Employee A member of staff who has following training, been authorised by the BDCT to undertake specific duties in relation to medicines. 3.2 Patient /Service User

"Service User" is the title preferred by the Trust and service users to refer to people in receipt of Trust services. However, in the arena of medicines management the term 'patient' predominates. In order to maintain consistency with national standard usage and avoid confusion, the term 'patient' has been used throughout this document.

“Patient” refers not only to a person being cared for in a hospital or nursing home, but also a resident of a residential home; a person receiving services in his/her own home or community home; a person attending a clinic or GP’s surgery and an employee attending a workplace occupational health department.

“Patient” also refers to the person receiving a prescribed medicine

Patient Involvement Concordance refers to a consultation and negotiation process between a health care professional and a patient which has an ethos of a shared approach to decision making.

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Within this context it is the process of prescribing and medicine taking based on partnership. Patients have beliefs, attitudes and life experience which will influence their medicine taking behaviours, taking these into account and prescribing with that knowledge will have a positive effect on concordance. It is important that staff have an appropriate level of cultural competence in order to understand these issues.)

The following three essential elements define the process:

CONCORDANCE

A process of prescribing and medicine taking based on partnership

1. Patients have enough knowledge to participate as partners

2. Prescribing consultations involve patients as partners

3. Patients are supported in taking medications

Information is provided which is:

Tailored

Clear

Accurate

Accessible

Sufficiently detailed

Education empowers

patients Information is available within original packs of medication (PILs), from pharmacy, PALS and a variety of other resources such as MIND and UKPPG PILs

Patients invited to talk about medicine-taking

Professionals explain proposed treatment fully

i.e. what the medication is, what is for, how long it should be taken and what to do if stopping it

Agreement reached jointly

Understanding and ability to follow treatment checked

All opportunities used to discuss medicines

Information effectively shared between professionals

Medications reviewed regularly with patients

Practical difficulties addressed

Translating and Interpreting There is a requirement on public sector organisations such as Bradford District Care Trust to meet the specific needs of different service users and carers in relation to the quality of their care, as defined in the Care Quality Commission Standards, the Equality Act 2010, Disability Discrimination Act (2005) and the Human Rights Act (1998). This includes their ability to comprehend and understand information about their treatment and care. As a result of this, information should be given to service users and carers in the most

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appropriate format. This might mean talking through the information with interpreters or staff that speak their preferred language. It could also mean providing information that is not written but spoken via audio or visual aids. The Trust has a bank of interpreters who can be booked using NHS Professionals. To source or search for information that already exists in alternative formats to support your service users and carers, contact the Library Service. For guidance on how to best communicate with service users or carers from seldom heard groups, or to develop information in different formats contact the Involvement and Equality Team 3.3 Medicines Any substance or combination of substances presented for treating or preventing disease. Any substance or combination of substances which may be administered with a view to making a medical diagnosis or restoring, correcting or modifying physiological or psychological functions. Medicines, whether for internal or external use, will be regarded, for the purpose of this policy, as comprising the following categories: - Controlled Drugs controlled under the provisions of the Misuse of Drugs Act 1971, with stringent requirements for supply, storage and administration. All other medicines and medicinal products prepared for administration to patients and which are controlled by the Medicines Act 1968. This also includes many diagnostic agents, X-ray contrast agents and medical gases. Whilst less stringent regulations apply than in the case of Controlled Drugs, they must be treated with equal care. All complementary medicines e.g. aromatherapy, herbal or homeopathic remedies. These products are used for therapeutic purposes and require the same safeguards as other medicines. Other pharmaceutical preparations. Disinfectants, reagents and other preparations are not used directly to treat patients. However, the use of these products must still be subject to agreed and approved procedures. Full attention must also be given to the requirements of current Control of Substances Hazardous to Health (COSHH) Regulations. It is important to understand that procedures listed in this document apply to all medicines used in BDCT. These include topical lotions, applications, injectable fluids, medicated dressings, dietary products and complementary medicines. 3.4 Processes Prescribe To authorise (in writing) by full signature, the supply and administration of a medicine. Dispense To prepare a clinically appropriate medicine for a patient for self-administration or administration by another. The act of dispensing includes supply and also encompasses a number of other cognitive functions (e.g. checking the validity of the prescription, the

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appropriateness of the medicine for an individual patient, assembly of the product). These functions are performed under the supervision of a pharmacist. Supply To supply a medicine to a patient, carer or authorised representative for administration to that patient. Administer To give a medicine by either introduction into the body, (e.g. orally or by injection) or by external application (e.g. cream, ointment or application of a patch). 3.5 Miscellaneous instructions Group Protocol (Standing Order) A specific written instruction for the supply and administration of named medicines in an identified clinical situation in the absence of a written prescription. It has been drawn up within the Trust by doctors, pharmacists and other professionals and approved by the Mental Health Prescribing Committee. Patient Group Direction (PGD) A specific and detailed written direction for the administration or supply of named medicines, (including those classified as prescription-only), by named designated practitioners in a specific clinical situation. PGDs will be drawn up within the Trust by doctors, pharmacists and other healthcare professionals, and approved by the Mental Health Prescribing Committee. It applies to groups of patients or other service users who may not be individually identified before presentation for treatment (Crown Report 1998).

4 Duties

4.1 Trust Board

The Trust Board, through the Medical Director, is responsible for medicines management within the Trust. The Medical Director is supported by the Medicines Management Group

4.2 Service Governance Committee

The Service Governance Committee has responsibility for approving this policy. It receives information reports from the Medicines Management Group every six months and ensures that action is taken by the Meds Management Group or others identified where appropriate.

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Medicines Management Structure and Accountabilities

4.3 Medical Director The Medical Director is the Chair of the Medicines Management Group and has overall responsibility for ensuring that the medical staff are aware of this policy procedures and guidelines contained within it. The Medical Director reports to the Trust Board and SGC through the information provided in the six monthly Medicines Management reports prepared by the Pharmacy Manager. 4.4 The Medicines Management Group The Medicines Management Group develops and approves the policy. It is also responsible for the approval and ratification of the procedures and guidelines contained within it. The Medicines Management Group will review this policy every 2 years after its

implementation, although it may be fully or part reviewed on any occasion prior to this

formal review in response to legislative changes or significant procedural changes in

nursing, medical or pharmacy practice.

Service Governance Committee

Drugs and

Therapeutics Group

Medicines

Management Group

(Chaired by Medical

Director)

Trust Board

NICE Monitoring

Group

Clinical and Social

Care Audit

Steering Group

(CASCA)

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The Group will however continuously monitor its implementation and practice by receiving

an agreed programme of clinical audit as well as receiving the Medicines Management

Annual report prepared by the Pharmacy Manager, and Quarterly Incident reports.

Medicines Management Group remit includes:

The development of effective medicines management which ensures compliance with medicines legislation and good professional practice in prescribing, supplying, administering and monitoring of medicines.

The production, promotion and encouragement of adherence to prescribing guidelines through the Trust formulary and other documents.

The ratification and registration of all unlicensed medicinal products supplied or administered through Bradford District Care Trust.

The promotion of safe medication practices by systematic review of incidents and medication errors including benchmarking.

The ratification of all documentation associated with the prescribing and administration of medicines.

The ratification and registration of protocols which enable non-medical practitioners to supply and administer medicines.

The audit of medicine management procedures as part of the annual audit programme.

Oversee the activities of the Drugs and Therapeutics Group

Approve and ratify any procedures, protocols and guidance produced by the Drugs and Therapeutics Group

To oversee the Medicines Management Risk Register

To monitor costs, value for money, patterns of prescribing, external guidelines such as NICE Guidelines, and the introduction of new drugs for use within the Care Trust

The remit of the Drugs and Therapeutics Group includes:

Through literature review and with consideration to efficacy, safety, and cost effectiveness, make recommendations concerning the introduction of new products onto the formulary to the Medicines Management Group/Service Governance Committee.

To produce, promote and encourage adherence to prescribing guidelines through the Trust formulary and other documents

To work with PCT prescribing leads and pharmaceutical advisors to promote safe, effective and economic use of medicines across the primary/secondary care interface

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To raise organisational awareness of recommendations from NICE concerning medicines

4.5 Pharmacy

It is recognised that the Pharmacy Manager is responsible for ensuring the safe and secure handling of medicines which includes systems for organising and reporting of medicines in relation to this policy and procedures. The Pharmacy Manager will monitor the safe handling of medicines in regard to this policy and prepare reports for the Medicines Management Group, and other groups/committees as required for agreement and action as necessary. The Pharmacy Manager will liaise with the Medical Director as appropriate in regard to the implementation of this policy.

The Pharmacy department provides advice on all aspects of medicines

management included within this policy and procedure.

Pharmacy staff are responsible for the stock of medicines held in the pharmacy, their manipulation and preparation and for their supply to wards and departments. They provide advice on the safe, effective and economic use of medicines. These responsibilities include advising practitioners on the storage of medicines in clinical areas. Authorised Pharmacy Staff will inspect the stocks of medicines held on the wards or in departments at any time to ensure the medicines are in date and stored under the proper legal and environmental conditions. A record showing appointment and signature of all prescribers will be retained by the Pharmacy Manager and updated at induction and upon any change by the appropriate manager. A record showing appointment and signature of Appointed Practitioners in charge must be notified to the Pharmacy Manager and updated annually. 4.6 Medical Staff In most situations medical staff are responsible for prescribing medicines for patients. They and any other authorised prescribers must comply with legislation, in addition to the Medicines Policy, when performing these duties. It is the Prescriber’s responsibility to ensure that the prescription chart is written correctly. The Prescriber must ensure all patient details are included on the prescription chart and medication is written in accordance with the standards in the Policy. If a situation arises where medication, which has been prescribed, has not been written in accordance with the standards in the Medicine Policy, nursing staff may administer the medication provided they are satisfied the prescription is legible and safe and that any delay in administration would be detrimental to the patient. The Prescriber should be contacted immediately and informed of the deficiencies. The prescription must be rewritten correctly within 24 hours.

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All medical staff should report all ‘near misses’, clinical incidents and serious incidents through the IR-e reporting system (or PRISM) regarding the prescription, dispensing, storage and administration of medicines.

4.7 Nursing staff The Appointed Practitioner in Charge of a ward or department is ultimately accountable for the stock of all medicines held and is responsible for ensuring that this policy and procedures are followed correctly, so that the security of medicines is maintained. The Assigned Practitioner in Charge of the ward or department is responsible for the stock of medicines held in the ward or department and for ensuring that stocks of Controlled Drugs, if held, correspond with the details shown in the register. The Appointed Practitioner in Charge is responsible for ensuring that this is carried out. The administration of medicines is the responsibility of the Assigned Practitioner in Charge of the ward or department who may delegate these duties to a Designated Practitioner, but who must exercise supervision as is necessary. It is the responsibility of the Appointed Practitioner in charge to ensure that the Designated Practitioner has received the relevant training and experience before being allowed to take on responsibility for medicine procedures. Practitioners in training must be given every opportunity to become proficient in medicines related activities under appropriate supervision. The supervising Practitioner has responsibility for such medicine procedures at all times. The responsibilities for medicine procedures that may be held by various grades of practitioner are indicated in this document. Practitioners must be aware of the tasks they may or may not perform.

All practitioners will identify their training needs and make their managers aware of training deficit, maintain personal records of all competency based assessments

All practitioners will report all ‘near misses’, clinical incidents and serious incidents regarding the prescription, dispensing, storage and administration of medicines through the IR-e reporting system (or PRISM)

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5 Procedural Document development The development of this policy lies with the Medicines Management Group. The Pharmacy Manager prepared the document on behalf of the Medicines Management Group. The policy has been revised to take account of National Health Service Litigation Authority (NHSLA) minimum standards requirements and in the previous version clearly separated the policy from procedures and guidelines to make it easier for staff to follow. Completed Procedural Document Development Checklist

Title of document being reviewed: Yes/No/ Unsure

Comments

1. Title

Is the title clear and unambiguous? Yes

Is it clear whether the document is a guideline, policy, protocol or standard?

Yes

2. Rationale

Are reasons for development of the document stated?

Yes

3. Development Process

Is the method described in brief? Yes

Are people involved in the development identified?

Yes

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Yes

Is there evidence of consultation with stakeholders and users?

Yes

Have the requirements of the following been taken into account where applicable:

Mental Health Act

Mental Capacity Act

Care Programme Approach (CPA) Guidance

Yes

4. Content

Is the objective of the document clear? Yes

Is the target population clear and unambiguous?

Yes

Are the intended outcomes described? Yes

Are the statements clear and unambiguous? Yes

5. Evidence Base

Is the type of evidence to support the document identified explicitly?

Yes

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Are key references cited? Yes

Are the references cited in full? Yes

Are supporting documents referenced? Yes

6. Approval

Does the document identify which committee/group will approve it?

Yes

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

Yes

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

Yes

Does the plan include the necessary training/support to ensure compliance?

Yes

Is the Training Needs Analysis completed Yes

8. Document Control

Does the document identify where it will be held?

Yes

Have archiving arrangements for superseded documents been addressed?

Yes

9. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

Yes

Is there a plan to review or audit compliance with the document?

Yes

Does the above plan include the minimum NHSLA monitoring requirements (if applicable)

Yes

10. Review Date

Is the review date identified? Yes

Is the frequency of review identified? If so is it acceptable?

Yes

11. Overall Responsibility for the Document

Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the document?

Yes

Individual Approval

If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval.

Name Alistair Tinto Date 28th February 2011

Signature

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6 Equality Impact Assessment - see Appendix A The Trust has no intent to discriminate and endeavours to develop and implement policies that meet the diverse needs of our workforce and the people we serve, ensuring that none are placed at a disadvantage over others. Our philosophy and commitment to care goes above and beyond our legal duty to enable us to provide high-quality services. Our Equality Analysis and equality monitoring is a core service improvement tool which enables the organisation to address the needs of disadvantaged groups. The aim of Equality analysis is to remove or minimise disadvantages suffered by people because of their protected characteristics. An impact assessment has been undertaken to consider the need and assess the impact of this policy and is evidenced at Appendix A of this policy.

7 Training Needs Analysis (TNA) The Trust is committed to high quality targeted training and effective communication to support this policy. The Trust recognizes that training capacity can fluctuate and will depend on resources available. As such based on an assessment of capacity and risk, the training needs analysis will identify the high priority groups for training. The objective of the training to implement this policy is to meet training to this group over the time frequency stated. The focus of Trust monitoring will be on this group over the agreed period or lifetime of the policy. Issues relating to capacity to meet training needs for the high priority group will be escalated by the policy lead to the relevant Director for action to mitigate the risk and inclusion on the appropriate risk register. For a detailed account of training numbers, Please see the Trusts Training and Development Policy. Specific training may be identified as a result of: • Items identified as part of the annual Job Development Review process • Issues arising from analysis of PRISM reports • Changes in legislation and professional codes of conduct • National initiatives e.g. NPSA alerts

If the member of staff is unable to attend the training it is their responsibility to contact their line managers and the trainer to cancel their booking. All DNA’s are reported to the line manager and relevant General Manager

If unable to attend planned training, it is the individual’s responsibility to inform their line manager and contact the appropriate trainer at their earliest opportunity to arrange a further date within the required timescale.

Committee Approval (Medicines Management Group

If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation’s database of approved documents.

Name Dr Steve Hopker Date

Signature

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If a member of staff does not attend the training as previously arranged in accordance with the requirements of this policy, notification of non attendance will be sent to their manager.

Directors and General Managers will be sent attendance and non attendance reports for staff through an annual report.

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The safe prescribing, dispensing, storage and administration of medicines is an ongoing part of clinical practice and all professionals should continuously monitor their own performance and that of their colleagues.

Continuing Professional Development (CPD) Medical Students (F1 & F2) Assessment of competence is undertaken as part of their medical training and is co-ordinated by the clinical supervisor Qualified Medical Staff Post qualification, medical staff are deemed to be competent in the mechanics of prescription. Individuals may choose to undertake update training / specialist courses as part of their on going CPD however there is no requirement to do so. Competence is reviewed in an ongoing manner through the Pharmacy and Nursing staff who undertake informal review as part of the ongoing working relationships e.g. highlighting any issues, discrepancies or patterns of prescription Nursing Staff Nursing staff will follow the guidance on CPD specified by the NMC Pharmacists Pharmacists will follow the guidance on CPD by the GPhC

8 Consultation, Approval and Ratification Process

8.1 Consultation Process

The table below shows the details of who has been consulted and to what extent:

Stakeholder Level of involvement

Medical Staff Comment and consultation

Senior Nursing staff Comment and consultation

Pharmacy Staff Comment and consultation

Professional Council Comment and consultation

Equality and Diversity Team Comment and consultation

Medicines Management Group Development, comment, consultation, Approval and presentation to Service Governance Committee for ratification.

Service Governance Committee Comment and Ratification

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8.2 Procedural Document Approval Process This document will be approved by the Medicines Management Group Please refer to the policy version control sheet for further details. 8.3 Ratification Process This document will be ratified by the Service Governance Committee Please refer to the policy version control sheet for further details.

9 Review of the Procedural Document

The Medicines Management Group will review this policy every 2 years

although individual procedures and guidelines included in the appendices

may be fully or partly amended on any occasion prior to this formal review in

response to legislative changes, service developments or significant

procedural changes in nursing, medical or pharmacy practice.

The most up to date version of this document will always be available on the

Trust intranet and any changes will be notified to affected staff.

The Medicines Management Group will however continuously monitor its

implementation and practice through an agreed programme of audit as well

as reviewing annual reports, incident reports and minutes (See compliance

Section 11).

10 Dissemination of the Procedural Document The Medical Director is responsible for ensuring that this policy and related procedures is disseminated appropriately. This document will be distributed electronically to key managers and senior clinical staff for discussion and incorporation into local operational policies.

This Policy should be available at all the Trust’s designated locations.

It will also be published on the BDCT Intranet alongside other clinical policies

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11 Monitoring Compliance The policy will be monitored through the following

Criteria Evidence identified to

indicate compliance with the policy

Method of Monitoring

Frequency of monitoring

Lead Responsible for monitoring

How medicines are prescribed

Incident Records Medication Charts Clinical Audit results- POMH UK Training records

Review of collated reports by Medicines Management Group Chart Audit Tool CASCA Attendance Records

Annually Pharmacy Manager

How the organisation makes sure that all prescription charts are accurate

Chart Audit Tool Incident reports

Collated audit tool results Review of collated reports by Medicines Management Group

Annually Pharmacy Manager

How the side effects of prescribed medication are monitored

Ward Reviews Nursing Competency Administration Toolkit Prescribing Trigger Tool

Individual patient entries on RiO Completion as part of preceptorship process Trigger Point Analysis

Annually Pharmacy Manager

How the organisation learns from medication errors

Incident Reports Action plans Annually Pharmacy Manager

How medication is administered, including patient identification

Medication Charts Clinical Audit Results Incident records Training Records Nursing Competency Administration Toolkit

Annual report Audit

Annually Pharmacy Manager

Patient self-administration

Medication Charts Annual report Audit

Annually Pharmacy Manager

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How a patient’s medicines are managed on handover between care settings

Incident Reports Outpatient Out of Hours Emergency Treatment Forms See also handover of care and CPA policies

Action plans Completed forms

Annually Pharmacy Manager

How drugs are disposed of safely

Waste Management Audits Disposal records Drug registers

Audit report Annually Waste & Energy Efficiency Manager

12 References

The Bradford District Trust Medicines Policy is based on relevant primary legislation concerning medicines and attempts to reflect recommendations and requirements of professional bodies

Guidance has been obtained from the following: - Medicines Act, 1968. http://www.legislation.gov.uk/ukpga/1968/67/contents

Standards for Medicines Management. Nursing and Midwifery Council, April 2010. http://www.nmc-uk.org/Documents/Standards/nmcStandardsForMedicinesManagementBooklet.pdf

Control of Substances Hazardous to Health (COSHH) Regulations 1989.

Crown Report 1998 and 1999.

Department of Health ‘Building on the Best, Choice, Responsibility and Equity in the NHS, (2003)

Duthie Report – Guidelines for the Safe and Secure Handling of Medicines.

Medicines Adherence, Involving patients in decisions about prescribed medicines and

supporting adherence NICE Clinical Guideline 76 January 2009

Medicines Management, Everybody’s Business. A guide for mental health care. DoH

NIHME National Workforce Programme 2008

The Medicines, Ethics and Practice Guide. (Royal Pharmaceutical Society)

The NMC Code of Professional Conduct. Standards for Conduct,

Patient Group Directions HSC2000/026.

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Performance and Ethics, (May 2008).

The Royal Marsden Hospital, a Manual of Clinical Nursing Procedures, 8th Edition,

Wiley-Blackwell (2011)

The Misuse of Drugs Act, 1971.Home Office, 1971. http://www.legislation.gov.uk/ukpga/1971/38/section/23 Misuse of Drugs (Safe Custody) Regulations 1973. Home Office, 1973. Misuse of Drugs Regulations, 2001. Home Office, updated December 2004. http://www.homeoffice.gov.uk/about-us/home-office-circulars/circulars-2006/020-2006/ Records Management: NHS Code of Practice. Department of Health, April 2006. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4131747 The best medicine- the management of medicines in acute and specialist trusts. Healthcare Commission, January 2007. http://www.cqc.org.uk/_db/_documents/The_Best_Medicine_acute_trust_tagged.pdf 17. A guide to good practice in the management of controlled drugs in primary care (England). Second Edition. National Prescribing Centre, February 2007. http://www.npci.org.uk/cd/public/docs/controlled_drugs_third_edition.pdf 18. Safer management of controlled drugs: guidance on strengthened governance arrangements. Department of Health, March 2007. http://www.sehd.scot.nhs.uk/mels/HDL2007_12.pdf Promoting safer use of injectable medicines. NPSA, March 2007. http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59812&p=3 Guidance on the destruction of controlled drugs- a new role for accountable officers. Department of Health, August 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_078034 Safer management of controlled drugs: a guide to good practice in secondary care (England). Department of Health, October 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079618 Technical patient safety solutions for medicines reconciliation of adults on admission to hospital. NICE/ NPSA. December 2007. http://www.nice.org.uk/nicemedia/live/11897/38560/38560.pdf Oxygen safety in hospitals. NPSA, September 2009. http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=62811 Reducing harm from omitted and delayed medicines in hospital. NPSA, February 2010. http://www.nrls.npsa.nhs.uk/alerts/?entryid45=66720 Guidance about compliance: Essential standards of quality and safety. Care Quality Commission, March 2010. http://www.cqc.org.uk/_db/_documents/Essential_standards_of_quality_and_safety_FINAL_081209.pdf

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British National Formulary. British Medical Association and Royal Pharmaceutical Society of Great Britain. September 2011.

13 Associated Documentation

BDCT Incident Management Policy and procedures

BDCT Risk Management Strategy

Medicines Management Procedures, Protocols and Guidance can be found in the Appendices.

APPENDIX A Equality Impact Assessment This document has been impact assessed to identify any adverse impacts on any equality groups which would, if left unresolved, be both highly significant and illegal.

Area Response

Policy Medicines Policy

Manager Pharmacy Manager

Directorate Corporate

Date October 2011

Review date October 2013

Purpose of Policy This policy has been developed to maintain and enhance standards of professional practice in the safe prescribing, dispensing and administration of medicines and is a collaborative effort between the doctor, pharmacist, practitioner and patient.

Associated frameworks e.g. national targets NSF’s

See references. NPSA, NICE, MHRA,

Who does it affect All Medical, nursing, pharmacy and allied health professional staff

Consultation process carried out

Professionals Council; Medicines Management Group Medical Advisory Group

QA Approved by Service Governance Committee

Impact on

Discrimination

Equality of opportunity

Relations between groups

Education and learning, or skills

Positive impact expected outcome. System in place to implement policy. There is currently no information identified through the Equality Impact Assessment that would suggest that this policy has the potential to disadvantage any individual or function. Supporting policies and procedures in place to support best practice. The policy is underpinned by the key principles in Medicines Management: Everybody’s Business and the NICE Guidance on Medicines Adherence

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which offers all patients the opportunity to be involved and empowered in making decisions about their prescribed medicines.

Anybody who goes to live aboard on a permanent basis is no longer entitled to free NHS treatment unless they are in England on holiday and treatment is ‘immediately necessary’. Anybody who goes aboard for 3 months or more is expected to return their NHS medical registration card so that they can be removed from their GP’s practice list.

Some older people retire aboard, or spend extended periods in warmer climates during the winter months, may be affected by repeat prescribing, which is for a maximum of 3 months. Consideration of Muslim patients who may be undertaking Hajj/pilgrimage to Saudi Arabia. Younger people might take a gap year to travel around the world and may be affected in the same way. The solution would be to issue a private prescription, but the expectation in that they should seek medical advice in the country when they are living. Non- Medical prescribers need to consider any difficulties that the form of medication might present and consider alternatives even if they are more expensive. For example, if somebody is unable to swallow tablets the medication should be given in liquid form. The type of packaging should be considered e.g. it may be difficult to open child-proof containers.

Non-Medical Prescribers need to ensure that they work in agreement with all patients. i.e. that they understand when and how to take their medication and agree to be treated by a Non-Medical Prescriber, but special consideration may need to be given for those with learning difficulties, mental health problems and sensory or physical impairments The constituents of medication need to be considered if there is a possibility that they might conflict with religious beliefs but this should be in discussion with individual patients i.e. one should not assume that a patient will not use a product due to religious beliefs. For example informing a

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Jehovah’s Witness that immunoglobulin is derived from human blood, explaining to Jewish and Muslim patients that some insulin are derived from pork, telling Hindus that the product you are recommending contains eggs.

Impact on Lifestyle / affect

Diet & nutrition

Exercise & physical activity

Risk taking behaviour

There is currently no information identified through the Equality Impact Assessment that would suggest that this policy will have an adverse impact disadvantage any individual or function if implemented and operated in a manner that is laid out within the policy. However transgender, substance users will require consideration

Impact on / affect working environment

Social status

Employment

Stress

Positive impact expected outcome. There is currently no information identified through the Equality Impact Assessment that would suggest that this policy has the potential to disadvantage any individual or function if implemented and operated in a manner that is laid out within the policy statement. Anybody who goes to live aboard on a permanent basis is no longer entitled to free NHS treatment unless they are in England on holiday and treatment is ‘immediately necessary’. Anybody who goes aboard for 3 months or more is expected to return their NHS medical registration card so that they can be removed from their GP’s practice list. There are members of ethnic minority communities who take extended holidays in their homeland, sometimes for more than 3 months. If they require more than 3 months medication for their trip, the short-term solution would be to issue a private prescription, but no patient should also be encouraged to seek medical advice, as necessary aboard. Gypsies and travellers are often not registered with a GP but can do so on a temporary basis in order to be treated either by the GP or a Non-Medical Prescriber.

Impact on / affect physical environment

Working conditions

Living conditions

Positive impact expected outcome as policies and systems in place for best practice guides. There is currently no information identified through Equality Impact Assessment screening that would suggest

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Health safety & security

that this policy has the potential to disadvantage any individual or function if implemented and operated in a manner that is laid out within the policy statement.

Impact on affect Service Improvement

Healthcare

Social Care

Service User

Carer

Staff

Positive impact expected outcome as policies and systems in place for best practice. There is currently no information identified through the Equality Impact Assessment that would suggest that this policy has the potential to disadvantage any individual or function if implemented and operated in a manner that is laid out within the policy statement.

Appendix B Compliance Checklist . Completed Procedural Document Development Checklist

Title of document being reviewed: Yes/No/ Unsure

Comments

1. Title

Is the title clear and unambiguous? Yes

Is it clear whether the document is a guideline, policy, protocol or standard?

Yes

2. Rationale

Are reasons for development of the document stated?

Yes

3. Development Process

Is the method described in brief? Yes

Are people involved in the development identified?

Yes

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Yes

Is there evidence of consultation with stakeholders and users?

Yes

Have the requirements of the following been taken into account where applicable:

Yes

Equality Analysis SIGN – OFF

Have any adverse impacts been identified on any equality groups which are both highly significant and illegal?

No

Are you satisfied that the conclusions of the EqIA Screening are accurate?

Yes

Completed by Manager Pharmacy Manager LMH

Alistair Tinto

Q A approved E & D Team Ghazala Kazmi

Director approved Medical Director Steve Hopker

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Mental Health Act

Mental Capacity Act

Care Programme Approach (CPA) Guidance

4. Content

Is the objective of the document clear? Yes

Is the target population clear and unambiguous?

Yes

Are the intended outcomes described? Yes

Are the statements clear and unambiguous? Yes

5. Evidence Base

Is the type of evidence to support the document identified explicitly?

Yes

Are key references cited? Yes

Are the references cited in full? Yes

Are supporting documents referenced? Yes

6. Approval

Does the document identify which committee/group will approve it?

Yes

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

Yes

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

Yes

Does the plan include the necessary training/support to ensure compliance?

Yes

Is the Training Needs Analysis completed Yes

8. Document Control

Does the document identify where it will be held?

Yes

Have archiving arrangements for superseded documents been addressed?

Yes

9. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

Yes

Is there a plan to review or audit compliance with the document?

Yes

Does the above plan include the minimum NHSLA monitoring requirements (if applicable)

Yes

10. Review Date

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Is the review date identified? Yes

Is the frequency of review identified? If so is it acceptable?

Yes

11. Overall Responsibility for the Document

Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the document?

Yes

Individual Approval

If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval.

Name Alistair Tinto Date 28th February 2011

Signature

Committee Approval (Medicines Management Group

If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation’s database of approved documents.

Name Dr Steve Hopker Date

Signature

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