UHM-PGN 01

Use and Handling of Medicines Practice Guidance Note

Safe and Secure Medicines Handling and Supply – V04

Date Issued Issue 1- Jul 2020 Issue 2 – Mar 2021 Issue 3 – May 2021 Issue 4 – Aug 2021

Planned review Jul 2023

UHM-PGN 01 Part of CNTW(C)17 Medicine Optimisation Policy

Author/Designation Matthew Haggerty - Lead Clinical Pharmacist

Responsible Officer / Designation

Tim Donaldson – Trust Chief Pharmacist

This Practice Guidance Note (PGN) is one of a series of five guidelines, developed by a working group of the Medicines Optimisation Committee, which underpin Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/CNTW) Medicines Optimisation Policy CNTW(C)17, and provides step by step guidance to assist and support the following staff in the delivery of aspects of medicines optimisation relevant to their role This guidance should be read in conjunction with other related medicines optimisation policies and procedures as referenced:

This Practice Guidance is relevant to the following groups of Trust staff:

Doctors

Nurses including Nursing Associates

Non-registered nurses

Student healthcare practitioners (including Trainee Nurse Associates)

Allied Health Professionals

Pharmacists, Pharmacy technicians and Dispensing Assistants/Store keepers

Porters and Drivers (Sections 3.1.4, 3.1.5, 3.2.8, 5.3.1 and 5.5)

Reception/ administration staff (Sections 3.1, 3.1.5, 3.1.6)

Medical Secretaries (3.1)

Hospital switchboard operators (4.4.3)

Estates staff (Section 6.4 and Appendix 12 - Orders - Medical Gas Pipeline System (MGPS)

Community Based Teams

Social workers (Section 6.6)

Click here statement of changes to this Version 4

http://nww1.ntw.nhs.uk/spider/services/files/1372181005UHM-PGN-01-App15-Medical%20Gas%20Pipeline%20System-V01-May13.doc

http://nww1.ntw.nhs.uk/spider/services/files/1372181005UHM-PGN-01-App15-Medical%20Gas%20Pipeline%20System-V01-May13.doc

UHM-PGN-01

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust UHM-PGN 01–Safe, Secure Medicines Handling and Supply-V04-Iss4-Aug 2021 Part of CNTW(C)17 - Medicines Optimisation Policy

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Safe and Secure Medicines Handling and Supply Index

Section Contents Page No.

1 Introduction 4

2 Procurement of Medicines

2.1 General Principles

2.2 Responsibilities

2.3 Purchasing Strategies

2.4 Purchasing Advice

2.5 Bribery Act 2010

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3 Ordering Medicines

3.1 Controlled Stationery

3.2 Ordering medicines

3.2.1 Stock Medicines

3.2.2 Non-stock medicines

3.2.3 Individual Patient Dispensed (IPD) medicines

3.2.4 Medicines for Short Term Leave or Discharge

3.2.5 Ordering Controlled Drugs

3.2.6 Scanning/emailing Orders/Prescriptions to Pharmacy

3.2.7 Turnaround Times for Orders/Prescription

3.2.8 Ordering Medical Gas Cylinders (Oxygen and Medical Air)

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4 Dispensing and Supply of Medicines


4.2 Dispensing unlicensed medicines

4.3 Dispensing medicines in compliance aids

4.4 Access to medicines when the Pharmacy is closed

4.5 Over-labelled medicines use

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5 Transfer, Collection and Posting Medicines


5.3 Transfer/transportation of medicines within the Trust

5.4 Delivery/collection of medicines for Leave/Discharge

patients

5.5 Delivery/transportation of medicines by Community Staff

5.6 Transportation of oxygen gas cylinders

5.7 Loss or theft of medicines in transit

5.8 Posting medicines and prescriptions

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Section Contents Page No.

6 Receipt, Storage/Safe Custody of Medicines including Key Security

6.1 Receipt of medicines

6.2 Storage of medicines in wards/Units

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6.3 Storage of Flammable Liquids and Aerosols

6.4 Storage of medical gas cylinders

6.5 Stock Checks and review

6.6 Key Security

6.7 Temporary closure of a Ward/Unit

7 Use of Patient’s Own Drugs 44

8 Supply of Medicines under a Patient Group Direction 46

9 Supply of medicines for Patients on Community Treatment Orders

46

10 Supply of Pre-dispensed Medication for Clozapine Patients

48

11 Handling Medicines of abuse/ illicit substances 49

12 Handling of Investigational Medicines (Clinical Trials) 50

13 Reporting and Managing Medication Incidents - Side Effects, Errors and Defective Medicines

51

14 Medical Gas Pipeline System (MGPS) 54

15 Disposal and/or Return of Unwanted and Waste Medicines

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16 Patient Information Leaflets 57

The following appendices are listed separate to this practice guidance note

Appendix 1 Recommendations for the retention of pharmacy records, before being destroyed

Appendix 2 Request to create authorised pharmacy signatory

Appendix 3 Request for allocation of FP10 code and script pad

Appendix 4 FP10 Prescription Log

Appendix 5 NHS England – FP10 lost-stolen prescription notification form

Appendix 6 Pharmacy process for ordering medicines/Turnaround times

Appendix 7 Medication supply to North Cumbria Locality

Appendix 8 Temperature Monitoring Sheet

Appendix 9 Patients Own Drugs Assessment for Suitability

Appendix 10 Patient Assess Form – Self Administration

Appendix 11 Suspected Defective Medicinal Product Report Form

Appendix 12 Medical Gas Pipeline System - Walkergate Park

Appendix 13 Developing, authorising and monitoring PGDs

Appendix 14 Risk Assessment Storage of Medicines outside clinical room

Appendix 15 Supply of Medication Out of Hours flowchart for Crisis Resolution and Home Treatment (CRHT) teams.

Appendix 16 Medicines Supply for Patients on Community Treatment Orders

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Appendix 17 Acknowledgment of receipt for FP10 Prescriptions

Appendix 18 FP10 Prescriber Changes

Appendix 19 CRHT Return of Medications Form to Community Pharmacies

1 Introduction

1.1 This Practice Guidance Note (PGN) has been developed to support Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (the Trust) staff (including community based teams) in the procurement, ordering, dispensing, supply, transfer, storage and security of medicines on Trust premises. It defines those standards, legislation and principles for these functions. Staff involved in any of these functions must be aware of the contents of this PGN. Support and advice will be available from the Trust Pharmacy staff to those requiring assistance.

1.2 The term ‘medicines’ and ‘drugs’ are used interchangeably in the document

to reflect everyday usage. By using the word ‘patient’ in this document this refers to both ‘service user’ and patient therefore this PGN will refer to patient throughout.

1.3 Social care settings, e.g. care homes, are not specifically covered by this

guidance. Further information on managing medicines in care homes can be found in the NICE social care guidelines

1.4 Medicines that are obtained and stored by patients in their own homes, are

not directly within the scope of this guidance. However, some of the

principles are likely to apply and be of value to healthcare professionals who

work or advise on the safe use and storage of medicines in peoples’ homes.

2 Procurement of Medicines 2.1 General Principles

The Trust Pharmacy Department has sole responsibility for procuring medicines for the Central, North and South Localities. Lloyds pharmacy is responsible for procuring medicines for the North Cumbria Locality

Medicines constitute a significant proportion of Trust expenditure and make a large contribution to patient care. It is therefore important that high quality, safe and effective medicines are purchased by the Trust

2.2 Responsibilities

Procurement of medicines will not work against overall advantage to the NHS. The Trust will achieve this through membership of the North East Pharmacy Purchasing Group (NEPPG) and active

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participation in national, regional and consortia purchasing arrangements

Purchasing outside of the above arrangements will only occur where specific clinical reasons are indicated. e.g. purchasing ‘off contract’ to obtain a supply for a patient in an emergency

2.3 Purchasing Strategies

Medication error reduction strategies (sometimes referred to as ‘Purchasing for Safety’) will be incorporated into all procurement decisions. These will take account of current policies and advice from the NHS England (accessed 14.05.2021) and the NHS Pharmaceutical Quality Assurance Service and applied as necessary

2.4 Purchasing Advice

The NHS Pharmaceutical Quality Assurance Service undertakes medication error potential assessments (MEPA) and serves to alert users of products accepted for the National Contract and which have been assessed as having high or medium MEPA scores. The Pharmacy department will take appropriate action to ensure all staff are made aware of any assessments made and take reasonable precautions to reduce the risk of a medication errors occurring

Advice on the suitability of a new supplier will be obtained from the Regional Specialist in Pharmaceutical Quality Control before any orders are placed

Unlicensed medicines will be purchased in accordance with PGN, UHM-PGN-02 - Prescribing of Medicines, Section 9

2.5 Bribery Act 2010 2.5.1 This Act makes it a criminal offence to give, promise or offer a bribe and to

request, agree to receive or accept a bribe. In the context of procuring medicines this includes offers, promises or giving financial or other advantages to another person, and where it is known that acceptance of the advantage constitutes improper performance. Staff must comply with the requirements of this Act.

CNTW(O)23 – Fraud, Bribery and Corruption Policy Also see UHM-PGN-05 - Code of Practice for Pharmaceuticals

Representatives and Staff with whom they Interact

http://www.england.nhs.uk/

http://www.legislation.gov.uk/ukpga/2010/23/pdfs/ukpga_20100023_en.pdf

https://www.cntw.nhs.uk/about/policies/fraud-bribery-corruption-policy-response-plan/

http://nww1.ntw.nhs.uk/services/?id=5682&p=5539&sp=5544

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3 Ordering of Medicines 3.1 Controlled Stationery

All prescription stationery (excluding inpatient treatment charts) and medicines order books must be treated as controlled stationery. Controlled stationery is defined for these purposes as stationery which in the wrong hands, could be used to fraudulently obtain medicines. These include:

o Prescription forms of any description (Discharge/Leave, Hospital Outpatient, Outpatient Prescription for Clozapine, FP10(HNC), FP10MDA

o Individual Patient Dispensing/Temporary Stock Order Book

o Controlled Drug Order Book and Record Book

o Repeat Leave Medication Order Form

o Returns notes

o Depot Injection Medication Prescription and Administration Sheet (for depot clinics and CMHTs)

All completed drug related stationery must be held for the requisite time period, see Appendix 1 - Recommendations for the Retention of Pharmacy Records, before being destroyed

All lost or stolen controlled stationery must be thoroughly investigated and reported via the web-based reporting system– see Trust policy CNTW(O)05– Incidents, PGN IP-PGN-07 - Medication Incidents.

Prescription pads are the property of the Trust. These pads are uniquely numbered and need to be fully accounted for. It is the responsibility of the Registrant in Charge of the ward/department to ensure safe and secure handling of controlled stationery.

All controlled stationery must be securely locked away when not in use

3.1.1 FP10 Pads

Prescription forms are uniquely numbered and need to be fully accounted for. It is the responsibility of a designated member of staff within a department to ensure safe and secure handling of FP10 pads

http://nww1.ntw.nhs.uk/services/?id=6017&p=6016

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FP10HNC pads and FP10 MDA pads must only be used for CNTW NHS FT patients. Use of these prescriptions for treating private patients is considered fraudulent

Consultants/Teams are allocated specific codes

All prescribers must complete an authorised signatory form (see Appendix 2 – FP10 Authorisation Signatory Form and send this electronically to [email protected]

FP10HNC prescription pads and FP10MDA prescription forms must be ordered from [email protected] , (see order form Appendix 3 – FP10 Request to order an FP10 pad, by the consultant or authorised administration staff

The pharmacy will issue the pads in tamper-proof security numbered bags via the internal courier, porter or recorded delivery route. If a bag is suspected to have been tampered with, contact the pharmacy, St. Nicholas Hospital

An ‘Acknowledgment of Receipt’ (see Appendix 17) stating the serial numbers of the pads/forms will be enclosed. This receipt must be signed as soon as the delivery is accepted and returned electronically to [email protected]. A copy of this acknowledgement must be retained by the team for their records. The person responsible for distributing prescription forms will check the prescriber is on the FP10 spreadsheet and that an authorised signature form has been received.

Prescribers are responsible for the security of FP10 controlled stationery once received and must keep a record (preferably electronic) of the following for audit purposes:

FP10 receipt into the team

Date of FP10 delivery

Name of person accepting delivery

Quantity received and serial numbers

Where it is being stored

FP10 issue to a prescriber in the team

When it was issued

Who issued the forms

Serial numbers issued

Details of the prescriber

Securely store pads / forms when not in use. It is also good practice to record the number of the first remaining prescription form in an in-use pad at the end of the working day. This will help to identify any prescriptions lost or stolen overnight

Do not, under any circumstances, pre-sign blank prescription pads/forms before use. The prescription form should only be produced when needed and never left unattended

mailto:[email protected]



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If a prescriber moves to another service within CNTW or leaves the Trust, an FP10 Prescriber Changes Form (Appendix 18) must be completed and returned electronically to [email protected]. Any unused prescriptions/pads must be returned to the medical/team secretary, who must then contact the pharmacy admin office, St. Nicholas Hospital for advice on the appropriate action to take.

Home Visits:

o Record the serial numbers of any prescription forms/pads being carried on home visits before leaving the practice/clinic premises. Only a small number of prescription forms should be taken – ideally between 6 and 10 to minimise potential loss. The same precautions should be taken by prescribers visiting care homes.

o Take suitable precautions to prevent the loss or theft of the form such as ensuring prescription pads are carried in an unidentifiable locking carrying case or are not left on view in a vehicle, ideally locked in the car boot

Crisis Teams (Out of Hours) / 136 Suites: Where FP10s are used by on call doctors the following must be followed: o The FP10 must be stored in a secure lockable cupboard or

drawer on site

o A record sheet detailing all of the individual prescription serial numbers must be retained with the FP10 pad (see Appendix 4 - FP10 Prescription Log )

o When issued, prescribers must complete the record sheet

Spoiled prescriptions

If the prescription is spoilt in anyway i.e. an error is made on an FP10 prescription, the prescriber must do one of the following:

If there is enough space on the prescription to still clearly write the item and the prescription is still in good overall condition -cross through the error, initial and date the error and then write the correct information or

Destroy the form by shredding or adding to confidential waste and write a new prescription. Make a record of the person and a witness who destroyed the form and the serial number of the prescription. Records should be kept for at least 18 months (see Appendix 1 - Recommendations for the Retention of Pharmacy Records, before being destroyed).

Missing or stolen FP10 prescription pad


https://www.cntw.nhs.uk/about/policies/safe-and-secure-medicines-handling-and-supply-uhm-pgn-01-appendices/

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o Report the loss or theft of any controlled stationery immediately to the pharmacy admin office, St. Nicholas Hospital who will inform the Chief Pharmacist and CD Accountable Officer (CDAO)

o Prescribers or their medical/team secretary must log the incident online via the web-based incident reporting system. They must also complete an NHS England Notification of Fraudulent/Lost/Stolen Prescription form (see Appendix 5) scan and send this immediately by email to [email protected] .

o The pharmacy will liaise with the patient safety team and appropriate authorities (Local Security Management Specialists [LSMSs] and Local Counter Fraud Specialists [LCFSs]). If the theft occurs on a weekend or ‘out of hours’ then the LSMSs and LCFSs will be informed on the next normal working day

o The lost/stolen prescription information will be reported to Contractor Services who will inform all community/hospital pharmacies in the area

o The prescriber must write a replacement single script in red ink. If a full pad is missing, all prescriptions must be written in red ink for a period of 1 month

3.1.2 Forged/Fraudulent Prescriptions

If a forged/fraudulent prescription is suspected or reported the prescriber should be contacted to check the authenticity of the prescription

A web-based incident report form must be completed whenever a forged/fraudulent prescription is identified or suspected and the Trust Chief Pharmacist/CDAO and/or Local Counter Fraud Specialist (LCFS) will be informed following receipt of this incident form within pharmacy

Following investigation if the prescription is deemed to be fraudulent the prescriber/clinician should be informed to review using their clinical judgement which of the below actions are appropriate in given circumstances; (NB. The review and decision as above and rationale for this must be documented on the patient’s electronic care record by the clinician)

Inform the police and obtain a crime reference number

Inform NHS England in order to send out an alert to community pharmacies in the local area if the incident is likely to recur

Staff may also report any concerns about fraud to the confidential NHS Fraud and Corruption Reporting Line on 0800 028 4060.

3.1.3 Pharmacy Records for Leave/discharge, outpatient, FP10HNC Prescriptions

The following details must be recorded:


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o The type of prescription received and the serial numbers

o Name of person who issued the forms and date issued

o Name of person whom the forms were issued to, and the serial numbers

o Serial numbers of any unused prescription forms that have been returned

o Details of prescription forms that have been destroyed

3.1.4 Delivery and Distribution of Prescription Forms

Deliveries must be made in appropriate secure transport, ensuring as far as possible the shortest distance possible between distribution points to minimise the risk of theft and prevent attacks or assaults on staff

Prescription forms must be transported in a tamper-proof security numbered bag to prevent access to the forms whilst in transit

Items waiting to be collected must be stored and not left in a place or area where there is unsupervised access

When distributing prescription forms within the hospital, the driver or porter should sign for their consignment

Prescribers or authorised medical secretaries must sign for the forms received from the porter or other delivery staff. The receipt of acknowledgement for indicating the serial numbers must be returned to the pharmacy

Prescriptions must always be stored securely whilst in transit

3.1.5 Issuing Signed Prescriptions to Pharmacy

Completed prescription forms intended for the pharmacy for dispensing must be contained in a sealed vessel to prevent access to the form(s) whilst in transit

3.1.6 Receipt and Storage of Stock of Prescription forms

Stocks of prescription stationery must be kept in a secure room with limited access to those who are responsible for prescription forms

Keys for access rights for any secure area must be strictly controlled and a record made of keys issued or an authorisation procedure

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implemented regarding access. This should allow a full audit trail in the event of a security incident

3.2 Ordering of medicines for the ward/unit or community team base(Central, North and South Localities only – for North Cumbria see appendix 7)

The registered nurse in charge of the ward/unit or community team base or a member of the Pharmacy staff is responsible for ordering medicines from the Pharmacy

3.2.1 Stock Medicines:

To obtain stock medicines:

Submit a written requisition from the official order book or order sheet (obtained from the Pharmacy). This must be signed by a registered nurse or a member of the pharmacy team

A scanned copy of the written requisition (see Section 3.2.6) can be emailed to the SNH dispensary ([email protected]) Scanned and emailed documents for schedule controlled drugs is not permitted, please refer to PGN, UHM-PGN-04 - Controlled Drugs. However, an order or prescription for a controlled drug may be scanned and emailed to allow pharmacy to prepare the medicines in advance of the arrival of the original order to facilitate supplies via scheduled transport. The original order must however be received by the Pharmacy (via normal routes or by a member of Pharmacy staff) prior to the medicines leaving the Pharmacy department

3.2.2 Non-stock medicines

To obtain non-stock medicines for the ward/unit or community team base:

Submit a signed Temporary Stock Order and the patient’s inpatient prescription chart, or

Submit a scanned copy of the order and chart as above in Section 3.2.1 to [email protected] or

Use the patient’s own medicines if available but firstly obtain consent from the patient or obtain permission/ agreement from the patient’s carer (as appropriate) and record this in the patient’s notes. The medicines must comply with the standards set out in Section 7 - Use of Patient’s Own Drugs



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3.2.3 Individual Patient Dispensed medicines (IPD)

Individual Patient Dispensed medicines are arranged through agreement with the Pharmacy. These medicines will either be topped up by visiting pharmacy staff or ward clinical pharmacy team or ordered from the Pharmacy by a registered nurse. A maximum supply quantity of each IPD medicine is 28 days or the nearest original pack size

3.2.4 Medicines for Leave or Discharge

To obtain medicines for leave or discharge use one of the following methods:

o Submit a leave or discharge prescription together with the in-patient

treatment chart or a copy of the chart to the Pharmacy. Scanned copies of the chart may be sent to [email protected] Scanned prescriptions for controlled drugs are not permitted However, an order or prescription for a controlled drug may be scanned and emailed to allow pharmacy to prepare the medicines in advance of the original order to facilitate supplies via scheduled transport. The original order must however be received by the Pharmacy (via normal routes or by a member of Pharmacy staff) prior to the medicines leaving the Pharmacy department (please refer to PGN - UHM-PGN-04 - Controlled Drugs)

o If located at Hopewood Park (HWP), or St Georges Park (SGP) complete a prescription and contact your ward pharmacy team who will attend your ward to dispense the leave/discharge prescription

o Utilise Individual Patient Dispensed (IPD) supplies where IPD has

been introduced, provided the following conditions are met:

There are sufficient supplies of medication

The patient has been deemed suitable to receive IPD supplies following assessment by the nurse (See Appendix 10 – Patient Assessment Form – Self Administration) and a member of the pharmacy team

The decision has been recorded on the patient record along with a copy of the assessment

The medicines stored in their individual drawer within the ward medicine trolley correspond to those prescribed on the discharge or leave prescription

The medicines have a label including the name of the medicine, directions for use, name of the patient that correspond to those on the prescription, and date of dispensing

The first level registered nurse checking these medicines has been deemed competent to assess medicines for self-administration



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Where the short-term leave or discharge prescription differs from the medicines in the patient’s drawer, or when there are insufficient supplies of medicines, contact the Pharmacy department to make arrangements for the required discharged medicines to be dispensed

The patient’s suitability or unsuitability must be reviewed if the patient’s condition or circumstances change

Issue patient medicine information leaflets if possible and where deemed clinically appropriate (see Section 16.2)

3.2.5 Ordering Controlled Drugs

Please refer to PGN, UHM-PGN-04-Controlled Drugs

3.2.6 Scanned and emailed Orders/Prescriptions to Pharmacy

The transmission of orders/prescriptions by scanning and emailing carries both clinical and information governance risks. Staff must follow the following guidelines for items required urgently outside of the scheduled delivery system

Contact pharmacy by telephone to confirm if it is appropriate to scan and send the order / prescription. Then scan the exact order/prescription requirements and email to the following Pharmacy mailbox – [email protected] (Scanned orders/prescriptions of Controlled drug are not permitted. However, an order or prescription for a controlled drug may be scanned and emailed to allow pharmacy to prepare the medicines in advance of the original order to facilitate supplies via scheduled transport. The original order must however be received by the Pharmacy (via normal routes or by a member of Pharmacy staff) prior to the medicines leaving the Pharmacy department)

All prescriptions must be accompanied by a scanned copy of the patient’s in-patient treatment chart

Endorse on the original order/prescription with the word ‘EMAILED’ and the date to record that the order has already been dispensed. This avoids the risk of the item(s) being inadvertently re-dispensed when the original order/prescription is received by pharmacy. Place the original order/prescription in the pharmacy bag for transport to pharmacy via the next scheduled delivery

Where the original order/prescription contains a Schedule 2 or 3 controlled drug ensure that it will be received by the pharmacy before you would expect the medicines to leave the pharmacy, as they cannot be released before the original order is received.

3.2.7 Turnaround Times for Orders/Prescriptions


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For details on turnaround times for the various types of orders for medicines sent to the Pharmacy please refer to Appendix 6 – Pharmacy process for ordering medicines/Turnaround times

3.2.8 Ordering Medical Gas Cylinders (Oxygen and Medical Air)

Contact the NTW Solutions porters when an oxygen or medical air cylinder is required. Porters will arrange this supply for the ward/department (see Section 5.5, Transportation)

Any request for medical gases (other than oxygen or medical air) must be discussed with the pharmacy department (including the emergency duty pharmacists in out of hours period). Requests for Entonox may only be made by Tissue Viability Nurses in accordance with TV-PGN-05 Entonox – Clinical use during wound management by the Tissue Viability Nurses

If high volumes or long-term oxygen is required, wards/departments should ensure continuity of supply is upheld. It is the responsibility of the Registrant in Charge of the ward to ensure adequate stock levels of oxygen cylinders on the ward/department to meet the current need

The supply and management of Medical gas supplies is managed by NTW Solutions. NTW Solutions portering staff must record any issue, return or transfer of medical gases using the electronic management system. This will ensure correct charging

If a cylinder is required out of hours for NTW Solutions and the gas store is empty, contact other areas of the Trust by contacting the ward or site manager to source an appropriate cylinder. Transport should be arranged via the porters. If a cylinder cannot be sourced from other locations within the Trust, the ward or site manager should contact BOC and arrange for an emergency supply to be delivered. To do this:

o Pharmacy (via Emergency Duty Pharmacist in out of hour period) must be contacted prior to ordering any unusual sized medical gas cylinders.

o Telephone BOC on 0800 111 333

o Give operator the postcode of the hospital site, ward name and number and details of what is required

o NTW Solutions to record the issue, return or transfer of medical gases using the electronic management system.

4. Dispensing and Supply of Medicines – Central, North and South Localities only. For Cumbria, see Appendix 7


The Pharmacy is the sole provider of dispensed medicines to inpatients of the Trust. A pharmacist will evaluate each prescription for clinical accuracy before being dispensed





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The maximum quantity of dispensed medicines for leave, discharge, and outpatient prescriptions is 28 days. If quantities greater than 28 days supply are required contact the Pharmacy for advice

A usual minimum supply of 14 days will be made, except in cases where this is not felt to be clinically appropriate for an individual patient

All dispensed discharge/leave supplies sent to wards/units must be checked against the inpatient treatment chart by a registered nurse or member of pharmacy staff prior to issue to patients

Patients (or their carers) should be given sufficient information about their medication to ensure a good understanding of purpose, side effects, cautions (or other dosing advice), frequency of dosage and duration of treatment. Patient Information Leaflets will normally be provided by the hospital Pharmacy at some point during the patient stay. Patients should be advised how to obtain further supplies of medicines where appropriate (see Section 16 for details)

Where patients receive regular medicines via CNTW on an outpatient basis, clinical teams should ensure that concordance is routinely assessed and documented to ensure that patients are compliant with medication and to avoid unnecessary accumulation of medicines at home. Where clinical teams uncover excessive medication (including Monitored Dosage Systems), this should be removed and returned to the originating pharmacy for destruction (see section 5.5.3 Patient’s Own Medicines for further guidance)

If medicines need to be returned to the Pharmacy to be corrected due to e.g. a dispensing error, the medicines must be returned via hospital transport in a Pharmacy bag (seals are available from Supplies department) together with the ‘Returns’ form (available from the Pharmacy). Unsealed bags will not be accepted by porters/couriers

Any dispensing errors identified by ward or team staff should report this to a member of the Pharmacy team and report it using a web-based incident report form.

For the return of Controlled Drugs - see PGN, UHM-PGN-04 - Controlled Drugs - Section 13.

4.2 Dispensing unlicensed medicines

Before a new unlicensed medicine is introduced into use Pharmacy staff must refer to the department’s SOP for Dispensing Unlicensed Medicines (SOP PD13)

4.3 Dispensing medicines in Monitored Dosage Systems (MDS)


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The decision to supply MDS to a patient must be made by the multidisciplinary team in consultation with the patient’s GP and local/regular community pharmacy

A clinical assessment of medicines suitable for dispensing inside a MDS (based on stability information of medicines outwith their original packaging interpreted in the context of the individual patient situation) will be made by the validating pharmacist

4.3.1 Patient Assessment

Medicine compliance aids are not suitable for every situation or patient. Alternative methods of improving compliance may be more appropriate e.g. large print labels, reminder charts. Where initiation of a new MDS is considered this should be discussed with the ward pharmacy team as part of the discharge planning process

4.3.2 Dispensing and supply

(a) Initiation of new MDS:

The decision to initiate a new MDS has implications for primary care providers and the individual caregivers. The assigned nurse in charge should discuss and agree this in advance of discharge with the patient’s GP and local/regular community pharmacy as part of the discharge planning process. To order a patient’s medicines submit a prescription to the pharmacy

Note: Controlled Drugs (CDs) - it is possible to place controlled drugs into compliance aids, so long as appropriate enquiries have been made as to the stability of the product in such a container. Where a CD requires safe custody, the compliance aid must be stored in the CD cupboard. Where an entry in the CD Record Book is required, this should be made at the time of supply.

(b) Existing MDS:

To order a patient’s medicines submit one of the following to the Pharmacy:

o Individual Patient Dispensing form, or

o Temporary Stock Order form, or

o Prescription (a prescription required for controlled drugs – see above)

(c) Community Teams

The responsibility for filling compliance aids lies with the dispensing pharmacist, patient or carer. Community team staff must not routinely fill compliance aids. Where it is not possible to get a compliance aid filled by a community pharmacist consult the hospital pharmacist for advice.

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If a registered nurse undertakes this activity they must ensure they are able to account for its use (further guidance available from Royal Pharmaceutical Society/ (RPS) Professional guidance on the safe and secure handling of medicines) accessed 17.05.2021. If the choice is made to repackage dispensed medicines into compliance aids, the staff member should be aware that this carries a risk of error. The properties of the medicines might change when repackaged and so may not be covered by the product license. The appropriateness of repacking dispensed medicines should be checked with a pharmacist

4.4 Access to medicines for inpatients (excluding controlled drugs) when

the Pharmacy is closed

Pharmacy’s working hours are Monday to Friday 8.30 to 5pm. The Pharmacy is closed at weekends and on Bank Holidays

If medicines are not available on the ward/unit, they can be obtained out of pharmacy opening hours in one of three ways:

o From the emergency medicine cupboard, or

o Borrowing from another ward, or

o Contacting the Emergency Duty Pharmacist to arrange a supply of the medicine(s)

Please also refer to the algorithm at the end of this section

4.4.1 Out of Hours Emergency Drug Cupboards

Emergency Drug Cupboards are located at various sites across the Trust. They can be accessed by the nurse with site responsibility or assigned nurse in charge of the ward on which the cupboard is located

The emergency drug cupboards must only be accessed when pharmacy is closed and the ward/unit does not have the required medicine in stock. Ward staff should firstly check the availability of the required medicine within the Emergency Drug Cupboards (stock lists available for these on the intranet Pharmacy and Prescribing section – Emergency Duty Pharmacy – Stock lists) or where available using Omni-explorer on an Automated Drug Cabinet (ADC).

Contact the Nurse with Site responsibility for advice on whether or not the required medicine is available in the locally held Emergency Drug Cupboard.

Before taking a medicine from a medicines refrigerator check the temperature of refrigerator. Do not remove an item if the temperature is out of normal range (see Section 6.2.2) and contact the Emergency Duty Pharmacist for advice

4.4.2 Borrowing between Wards:

https://www.rpharms.com/recognition/setting-professional-standards/safe-and-secure-handling-of-medicines/professional-guidance-on-the-safe-and-secure-handling-of-medicines




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Borrowing of stock medicines between wards is not allowed except when pharmacy is closed or in an emergency

During the out of hours period the assigned nurse in charge must ensure the availability of medicines for all scheduled doses

If a medicine is not available, the assigned nurse in charge may identify a ward that has the required medicine(s) and a full container requested from ward stock of the supplying ward

Controlled drugs cannot be supplied from one ward to another under any circumstances for the purposes of ward stock. A single dose may be supplied to a patient following the procedure outlined in PGN, UHM-PGN-04 - Controlled Drugs

The person collecting the medication does not have to be a registered nurse but must produce a valid inpatient prescription chart and provide personal identification e.g. ID Badge to facilitate supply

The assigned nurse in charge of the ‘supplying’ ward will check the prescription chart is valid, check the ‘collecting person’s identity, make the appropriate supply, ensuring the person collecting the medication signs for receipt.

Where a full container cannot be supplied and the medicine is available as blister strips (i.e. for tablets and capsules) then a split pack can be supplied to the other ward, otherwise a suitable quantity of the medicine may be supplied in a labelled container. In both cases the container must bear the name of medicine, formulation, strength, quantity supplied, patient’s name, and date of supply. Care must be taken to ensure that the original batch number and expiry date remain visible

Medication intended and labelled for an individual named patient (IPD supply) should not be transferred between wards. However, in exceptional cases when medication is needed urgently for a patient during out of hours and an IPD supply is the only source of the medication a named patient supply medicine may be used for another patient. This must have been supplied by the Trust’s own Hospital Pharmacy and not have left the hospital at any point

Patient’s own drugs which have been supplied by an external pharmacy must only be used for that named patient

Medicines must be transported in a sealed pharmacy bag or other suitable container

The transfer of medicines between wards may require transportation by Trust appointed courier or taxi service. These medicines must be placed in a secure transport bag. Disposable transport bags are available in the emergency drug cupboards

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The ID badge of the driver collecting the item should be seen before handing over the bag. The driver must sign a transport sheet to record the transaction. Transport sheets are located in the emergency drug cupboard. A copy must be retained on the ward and another copy sent to pharmacy the next working day. The ward requiring the supply of medication will be responsible for the cost of transportation except when the pharmacy is at fault for not supplying medicines during normal working hours. Where wards are not prepared to book taxi’s out of hours their account will be charged the next working day by the Transport manager if appropriate to do so

4.4.3 Medication supply to Crisis Resolution and Home Treatment (CRHT) Teams Out Of Hours (OOH)

There is the provision to provide CRHT teams access to medication OOH which is documented on the flowchart in Appendix 16 – Medication Supply for Patients on Community Treatment Orders

4.4.4 Emergency Duty Pharmacist (EDP)

The EDP is available outside of pharmacy hours for advice, medicines information and/or the supply of medicines that are not available by any of the above methods

The EDP operates this service from home and covers the whole Trust. This is not a routine supply service and any supply of inpatient medicines is only made in an emergency situation. This service does not include the dispensing of leave or discharge supplies (see Section 4.5) or non-urgent medicines

Only the hospital switchboard on the instruction of the nurse with Site responsibility/ Night Coordinator or a doctor responsible for the patient, can contact the EDP. The telephone number of the EDP must not be given to wards and the caller should be connected through the hospital switchboard

The EDP will use their professional judgement to recommend an alternative formulation where possible (syrup, tablets, liquid product) or advise that non-urgent dose may be delayed or omitted until the pharmacy reopens (the registered nurse should record this recommendation in the notes section of the inpatient treatment chart and patient record)

When the medicine is deemed to be clinically necessary, the EDP will identify a ward that stocks the medicine and will recommend borrowing a supply from that ward, or will personally supply the medicine

Patients or members of the public must not be connected to the EDP and instead be directed to an appropriate out of hour’s service or the duty doctor for their area

4.4.4 Return of Telephone Calls by the Emergency Duty Pharmacist

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Following receipt of a page message or telephone call the EDP must return the call within one hour of receiving it. When telephoning a home or mobile telephone for the EDP the switchboard operator must attempt to call the number again if this is not answered within this period

If a call is not returned the switchboard operator must try to establish contact with the EDP using the original or an alternative contact number provided on the on-call rota sheet, and inform the senior nurse with site responsibility if contact cannot be made

Callers (switchboard operators) must refrain from leaving messages on call minder services as this may result in significant delay if the pharmacist is away from home or out of signal. In this situation the pharmacist should be contacted using the pager or mobile telephone

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OUT OF HOURS MEDICATION SUPPLY ALGORITHM (Not Schedule 2

Controlled drugs )

No medication on ward

Ward staff to check Emergency Drug Cupboard (EDC) List or Omni-Explorer on ADC (see Section 4.4.1)

If no access to a computer contact the Nurse with Site

responsibility

Drug in EDC or ADC

Ward staff contact nurse with site responsibility to arrange supply of drug from cupboard, or if cupboard located on a ward i.e. Castleside ward at CAV, staff can contact ward directly.

Drug not in EDC or ADC

Try wards within near locality and borrow from them if possible. Contact nurse with site responsibility if you cannot locate the drug as they hold ward stock lists for their local area

Drug still not located

Call Emergency Duty Pharmacist (EDP) only when all above options have failed to locate the drug. The EDP will try to locate the drug from another location or attend their local hospital to supply the drug if they feel it will be detrimental to the patient to miss the dose. The pharmacist will not automatically supply every out of stock drug and each case will be assessed individually. In the event where the Pharmacist advises for the patient to miss a dose of drug, this should be recorded in the notes section of the inpatient treatment chart and on Rio. Any staff member wishing to raise particular concerns with emergency access to medicines should refer these to a pharmacist

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4.4.5 GP Visits Out of Hours

On call doctors visiting from GP practices may prescribe medicines out of hours restricted to the local formulary. If the doctor prescribes a medicine that is not available on the ward/unit the assigned nurse in charge should refer the GP to the emergency drug cupboard ‘list’ to show available medicines. Where medicines are prescribed which are not located in the drug cupboard and which are required clinically steps 4.4.2 – 4.4.3 above should be followed.

Non-urgent medicines will be supplied when the pharmacy reopens the next working day

4.4.6 Obtaining ward discharge and leave medicines out of hours – For

Central, North and South Localities only. For Cumbria, see Appendix 7

Discharge and leave prescriptions will not be dispensed by the pharmacy outside of the Pharmacy’s working hours

Medicines may be dispensed for in-patients by ward nursing staff using ward stock medicines and the ‘out of hours dispensing box’ and must be in accordance with a registered prescriber’s written instructions and the following procedure. These boxes hold containers and labels and can be found on designated wards; (see Out of Hours Dispensing Boxes (accessed 14.05.2021) section on the intranet – pharmacy and prescribing section – Emergency duty) the medicines must be supplied in these containers - use of other containers is against Trust policy. Medicines must never be provided in envelopes to patients. o Check that the leave medication has not already been ordered and

dispensed, check transit bags and the medicines cupboard. Also consider whether the patient could leave after, or return to the ward before the next dose of medication is due

o The assigned nurse in charge of the ward/ unit should contact the duty doctor to discuss the appropriate course of action

o The duty doctor may authorise the supply of medication for leave by telephone with the exception of schedule 2 and 3 controlled drugs (see details in, UHM-PGN-02 - Prescribing of Medicines - Section 6)

o Schedule 2 and 3 controlled drugs must not be supplied from ward stock for leave and discharge under any circumstances

o Where a prescription is not written and the leave is authorised by telephone the names of the medicines, strengths and quantities supplied must be documented on form PH2 (available from Pharmacy) and scanned into the patient notes. This form may also be used as a prescription when a doctor is available and is located in the out of hours dispensing boxes


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o Supply sufficient medication until the hospital pharmacy opens and is able to supply a further supply

o Patients whose medicines are labelled using the in-patient dispensing system may be given their IPD supply where the risk of harm is low

o Labels must be prepared before the tablets/medicines are removed from original packaging. The labels must be affixed to the dispensed medication as each medicine is removed from the original container.

The following information must be detailed on the label using indelible ink to satisfy legal requirements:-

o Name, formulation and strength of the drug

o Quantity supplied

o Dose and frequency

o Patient’s name

o Date of dispensing

o Items for external use must be labelled ‘for external use only’.

o Ear drops and suppositories must be labelled ‘Not to be taken’.

o Medicines containing paracetamol must be labelled with ‘contains paracetamol’ using the cautionary and advisory labels provided in the dispensing box (e.g. co-codamol)

o Cautionary and advisory labels are provided for use as indicated under the individual drug monographs of the BNF. The BNF must be consulted prior to dispensing to ensure that all warning labels are included on the label as this is a legal requirement

o The dispensing must be carried out by a first level registered nurse or doctor using stock medicines from the ward or the emergency drug cupboard

o All dispensing must be checked by a second person preferably a doctor or in exceptional circumstances by another registered nurse who has not been involved in the dispensing process. The initials of both the person dispensing the medication and the person checking the dispensed medication must appear on each container label

o Where the risk of supplying large quantities of medication is too high or unknown the medication must be supplied in smaller quantities

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o The quantity supplied must be recorded on form PH2 which must also be signed by the dispenser and checker and then placed in the dispensing box

o A copy of the form must be scanned into electronic patient care record (RiO)

o The used out of hours dispensing box will be topped up by the Pharmacy Assistant on their next visit to the ward

4.5 Over-labelled medicines use

Over-labelled pre-packed medicines are provided by Pharmacy for supplying to patients in approved locations in the Trust

A first level registered nurse must supply patients with over-labelled medicines against a prescription (e.g. inpatient treatment chart or outpatient prescription) written by an authorised prescriber, or against a Patient Group Direction (see Section 8). The prescription must be scanned and filed in the patient’s record. Please also refer to PGN, UHM-PGN-03 - Administration of Medicines

Over-labelled medicines typically contain all dosing instructions. If they do not, a space is provided in which the dosing instructions must be written. If the instructions on the label do not exactly meet the prescribed requirements, then over-labelled drugs must not be used

At the time of removing the over-labelled medicine from the medicine cupboard, the patient’s name and the date (and any dosing instructions) must be entered in ink. This may be undertaken by a first level registered nurse, doctor, pharmacist or pharmacy technician. A second healthcare professional must check the accuracy of the supply

Local SOPs must be developed to ensure the safe supply of over-labelled medicines. Pharmacy can advise on this process

5. Transfer, Collection and Posting Medicines 5.1 This section deals with the physical supply aspects of NHS Resolutions,

former NHSLA Risk Management Standard Medicines Management 6.10 (g): ‘how a patient’s medicines are managed on handover between care settings’; these standards remain best practice guidance for staff.

5.2 General Principles:

Medicines must be transported in individual tamper-evident secure containers designed solely for that purpose and labelled with the final destination (for transportation of controlled drugs see PGN, UHM-PGN-04 - Controlled Drugs)

Containers must be kept under surveillance whilst awaiting collection from or on receipt at the designated areas

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Medicines must only be transported within hospitals by members of staff or by authorised/contracted transport and not delegated to patients or carers

Voluntary drivers, relatives or representatives can collect leave/discharge medicines for inpatients following proof of their identity

5.3 Transfer/transportation of medicines within the Trust

5.3.1 Medicines must only be transported within hospitals by members of staff or between sites (including third party service providers) by authorised or contracted transport (e.g. taxi service).

5.3.2 Transfer using hospital transport

The responsibility for the security of transported medicines rests with the driver until the delivery is completed and the necessary signatures obtained

All medicines must be transported in locked boxes or sealed pharmacy bags

Controlled drugs must be transported in sealed bags or tamper evident containers with uniquely numbered tamper evident seals with the number recorded in the CD requisition book and the top copy kept in the pharmacy

Issue the driver with a ‘transport sheet’ stating the destination, the number of containers for each destination, and where controlled drugs are being transported, a record of the unique seal number is required. Signatures of the person issuing the medicine, transporting the medicine and receiving the medicine must be made. The records must be kept in the Pharmacy for a minimum of 2 years (for audit purposes)

Containers must be kept securely or under surveillance whilst awaiting collection or on receipt at the designated areas

On arrival at the ward/unit, the driver must handover the containers to the assigned nurse in charge of the ward/unit who must sign the transport sheet and then secure the containers in the designated area – see Section 6.1. Once delivered, the responsibility for the security and storage of the medicines rests with the assigned practitioner in charge. Controlled drugs must be checked and received into registers or Omnicell cabinets immediately on receipt (see PGN, UHM-PGN-04 - Controlled Drugs)

Where the medicines are delivered to a central distribution point, local audit trails must be established. The containers must be securely stored while waiting to be distributed to the ward/department

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


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5.3.3 Transfer using a Taxi

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

Containers holding controlled drugs must not indicate controlled drugs or controlled drugs in transport

The Pharmacy must provide the taxi driver with three copies of the transport sheet. A copy must be retained in the pharmacy department

When controlled drugs are being transported by taxi the tamper evident seal number of the container must be recorded on the transport sheet

Items must be collected from the pharmacy or an agreed designated manned area, and delivered to the named destination e.g. ward reception. If items are not delivered direct to the named area the responsibility for security rests with the person receiving the container until delivery is completed and documentation countersigned

On arrival the driver must obtain a signature from the assigned nurse in charge. The driver must retain one copy of the transport sheet and the ward/department must retain their copy secured in a locked drawer for 2 years

5.3.4 Transfer of medicines accompanying the patient

Medicines accompanying a patient and being transferred from one hospital to another may be transported with the patient in an ambulance or by authorised hospital transport, or taxi. The medicines must be packaged securely and labelled with the final destination

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

If a relative is accompanying the patient between units, unless there are concerns about security, medicines and documents can be transported by them in a sealed package clearly marked with the addressee’s name and address.

5.4 Delivery/collection of medicines for Leave/Discharge patients

Patients who have left hospital before all their medicines have been dispensed should be encouraged to return to the hospital later to collect their medicines. A Community Team member may assist in the delivery of these medicines to a patient’s home.

In exceptional circumstances, the medicines may be delivered to a GP practice or health care clinic by authorised hospital transport, taxi or post (see Section 5.7), for later collection by the patient. Arrangements must be

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agreed with the receiving premises and the assigned practitioner in charge. It is important that medicines are packaged securely and are labelled with the final destination

5.4.1 Delivery/collection by Voluntary drivers, Relatives or Representatives

of the Patient

Voluntary drivers, relatives or representatives of the patient may collect discharge/outpatient medicines from a hospital pharmacy on behalf of a patient provided the appropriate pharmacy has received prior notification of their impending arrival by the ward/department/clinic

Voluntary drivers who receive medicines on behalf of a patient must deliver the medicines to the patient and not pass the medicines to another voluntary driver

Voluntary drivers must carry identification of their role. Patients and Patient representatives must be able to provide identification to prove identity

5.5 Delivery/transportation of medicines to patients by Community Staff 5.5.1 Delivery to Patients unable to obtain prescriptions or unable to

collect dispensed medicines

When a patient or their carer is unable to make their own arrangements for obtaining prescriptions and/or collecting medication, Community Based Staff may deliver the medicines to a patient in their own home. The plan to deliver medicines to a patient in this way must be documented in an agreed care plan and the delivery documented in the clients progress notes. The following circumstances are acceptable. This should be reviewed every four weeks:

o The patient or carer is unable to attend the unit or pharmacy and

arrangements for supplies have not yet been finalised

o The patient is on a rehabilitation programme (post discharge) as an interim measure, whilst local arrangements for the supply are being developed

o Where clinical need dictates i.e. a patient would clearly benefit from receiving medication at home and this is detailed in the Care Programme Approach (CPA) plan

o Only in exceptional circumstances will a member of staff deliver medicines to a patient if this need is not identified on the CPA plan

Medicines should be delivered by a registered nurse of the patient’s multidisciplinary team, although this may be delegated to a nursing assistant, support worker, social worker or an Occupational Therapist or assistant (see note on training below*)

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The staff member will sign the prescription log when they take the medicines and will carry an authorised staff identification card

Medicines must be transported in a discreet bag, out of sight in a locked car. If his container is lost or stolen then it must be reported immediately to the line manager. Care must be taken to ensure the stability of the medicine is not compromised by high temperatures in the vehicle.

Any medicines that require refrigeration should be transported in a cool bag/box

Medicines must be handed directly to the patient (or, if this is not possible, to the carer so long as they are known to the team). Under no circumstances can medicines be posted through the door or left with another person

If medicines cannot be delivered they must be returned to the Community Team Base on the same day, recorded as returned, and stored securely in the Community Team Base medicine cupboard

If the patient requires advice on their medication this must be referred back to a doctor, registered nurse or pharmacist or pharmacy technician as appropriate

If there is any doubt about the safety of leaving the medicines with the patient the prescriber must be contacted for advice. This may include concerns about non-concordance or accumulation of excessive supplies.

Training Note : Where non-registered nurses/non-nursing staff are to be used for delivering medicines they will receive training from a registered nurse who is familiar with the patient. Training will be provided on general and specific medication issues relating to the patient they will be visiting. Non-qualified staff must have previously met the patient. Following each visit non-qualified staff must report back to the nurse in charge of the team / unit

5.5.2 Transportation of medicines by Community Psychiatric Nurses (CPNs/Nursing Associates) for administration to patients in their home

The transportation of medication by CPN/Nursing Associates is not encouraged, but they may carry medicines from a community base, GP Surgery or pharmacy to a patient’s home for the purposes of administration to the patient. In such an instance, the Community Team Member is acting as the patient’s agent in transporting the medicines

When medicines are issued to a CPN/Nursing Associates, these medicines become their responsibility. Medicines should ideally only be transported to a named patient on the day of administration, unless it is in the form of a compliance aid or blister pack

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Medicines must be transported to and from the patient’s home in a discreet bag, out of sight in a locked car. Each medicine must be accompanied by the relevant prescription chart, and the dose administered recorded on the chart

When delivering a single ampoule of an IM injection, the CPN/Nursing Associates will check the patient’s name, prescribed medicine, strength, route and dosage and sign for the injection on collection and transport the ampoule within a suitable container (a small cardboard box packed with cotton wool within a box or case supplied by the Trust). The necessary consumables and the IM injection prescription sheet must also be taken. Individual teams will decide the size and style of box they require. The CPN/Nursing Associate will determine the amount of consumables required taking into account the individual needs of patients. The box/case must be transported in a discreet bag, out of sight in a locked car. Any medicines requiring refrigeration should be transported in a cool bag/box. Care must be taken to ensure the stability of the medicines is not compromised by high temperature in the vehicle.

5.5.3 Patient’s Own Medicines

Wherever possible, medicines should be left in a patient’s home. Storage at the Community Team Base must only be done in exceptional cases

If the patient is assessed to be at risk from medicines left in the home, a team member may remove the medicines following verbal agreement from the patient, documenting this in the patient’s notes including full details of all medicines removed

If agreement is not obtained, advice must be sought from the prescriber

These medicines are the property of the patient and should not be destroyed or otherwise disposed of without the agreement of the patient or carer. If overdose is considered likely, there is a duty to remove medicines (if safe to do so) with or without patient’s permission. Permission (or refusal) must be clearly documented in the patient’s progress notes, dated and timed, and signed by the team member and patient. If medication is removed without permission, the reasons for this must be clearly documented and explained, along with the date, time and signature of the team member taking responsibility for its removal.

Medicines for disposal must be returned to the supplying pharmacy (see Section 15.2) or another community pharmacy

Patient’s own medicines being administered or stored by the team should only be used when they can be positively identified and deemed suitable for use – see Section 7 for details. Where medicines are not suitable for use, the patient should be advised accordingly

Patient’s own medicines at the team base must be securely and separately stored from base medicine stock. A log for recording the storage will be

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maintained, and the Community Team Member will sign and document this, having their signature countersigned by a colleague at the point of delivery and removal of medicines

5.6 Transportation of Oxygen Gas Cylinders

Cylinders must be safely secured in vehicles when being distributed within the Trust sites

Transportation of medical gases must comply with The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 (CDG Regs) and the European agreement (“Accord européen relatif au transport international des marchandises dangereuses par route”, known as ADR) which together regulate the carriage of dangerous goods by road

For insurance and health and safety reasons, taxi drivers will not be able to transport oxygen cylinders. Only vehicles fitted with the appropriate equipment will be used to transport cylinders

5.7 Loss or theft of medicines in transit

5.7.1 Loss or Theft in Transit of Medicines Dispensed by the Hospital Pharmacy

Inform all of the following people and complete a web-based incident report form:

o Controlled Drugs Accountable Officer / Chief Pharmacist where the medicine is a controlled drug

o Line Manager

o Hospital Pharmacy

o Hospital doctor

o Patient/Carer for community based patients

5.7.2 Loss or theft in transit of medicines dispensed by a Community

Pharmacy

Inform all of the following people and complete a web-based incident report form:

o Patient/Carer

o Line Manager

o GP or other qualified prescriber who issued the FP10

o Dispensing Pharmacist

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If theft is suspected, or if the lost medicines may create a risk to the general public, the Line Manager should inform the police at an early stage and obtain a Crime Reference Number

Special arrangements may need to be made for the replacement of stolen items – contact the Chief Pharmacist

5.7.3 Misplaced or Lost Prescriptions and Dispensed Medicines by Service Users or their Representatives

A web-based incident report must be completed whenever a lost/misplaced prescription or medication is reported by a member of staff or service user

Ensure that the staff member or service user has undertaken a thorough search in an attempt to locate the missing prescription or medication

Inform the prescriber at the earliest opportunity and determine whether it is clinically appropriate and safe to re-issue the prescription

If prescription is re-issued ensure the rationale for this is documented on Rio and review future prescribing/collection/delivery arrangements if appropriate

If the incident involves a controlled drug or substance liable to abuse and it still remains unaccounted for then this should be reported to the Police and a Crime Reference Number obtained

If a controlled drug is involved, the pharmacy team will ensure the Controlled Drug Accountable Officer (CDAO)/Chief Pharmacist has been informed following receipt of an incident report

Any incident involving controlled drugs must be handled in accordance with UHM-PGN-04-ControlledDrugs-V02

When an incident report is received the pharmacy team will send the reporter the ‘Notification of Fraudulent/Lost/Stolen Prescription Form’ (see Appendix 5) to complete and return to the pharmacy admin team who will report the loss to NHS England.

If fraudulent activity is suspected it should also be reported via the NHS

Counter Fraud Authority Freephone number or the NHSCFA website.

5.8 Posting Medicines and Prescription Forms

5.8.1 Posting Medicines from the Hospital Pharmacy – Central, North and South Localities only

All medicines should be collected from the hospital whenever possible. Medicines may only be posted or delivered to the patient whenever such collection is not possible but there are several considerations when deciding on this course of action:

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o Patient confidentiality during the posting process. The patient’s address must be confirmed and checked by a second person. It is good practice to confirm the address with both the patient and the medical record.

o Posting is subject to prior written approval by the Royal Mail (which may be subject to conditions, including the type of medicines that may be sent, how, when, by whom and to whom), and subject to such items being sent in suitable tamper-proof packaging and only being sent by Royal Mail's Special Delivery services. The following restrictions for posting medicines apply which must therefore be strictly observed by Pharmacy staff:

The only type of Controlled Drugs permitted are those classified as Schedule 4 e.g. benzodiazepines. All other types of CDs are prohibited. Guidance may be sought from the Home Office 0207 035 4848 or visit www.homeoffice.gov.uk accessed 14.05.2021

Any medicine that uses an aerosol where the volume exceeds 50mls is prohibited from carriage by Royal Mail and will not be accepted.

Any aerosols that use flammable or toxic gases as propellants are also prohibited

Liquids, tins and bottled must be sealed with tape, wrapped in polythene and sealed again. This must be surrounded in absorbent material to soak up any leakages

Cytotoxic medicines – if there are any doubts about suitability of posting all of this medication, seek Royal Mail advice

5.8.2 Posting Prescription Forms (Outpatient, FP10)

Wherever possible prescription forms should be collected by the patient or their representative, as described above. When this is not possible, prescriptions for medicines (other than schedule 2 controlled drugs) may be posted to the patient via Royal Mail Special Delivery, following confirmation of the patients home address

All prescription forms for schedule 2 controlled drugs must be posted to a community pharmacy nominated by the patient using recorded delivery; prescriptions must not be sent directly to the patient’s home address. The Drug Treatment Centres are exempt from the recorded delivery requirement

6. Receipt/Storage/ Safe Custody of Medicines including Key Security

6.1 Receipt of Medicines

6.1.1 Wards

Medicines shall be received on the ward/unit by a registered nurse/nursing associates who will:

http://www.homeoffice.gov.uk/

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o Ensure that all bags received are dealt with promptly

o Acknowledge receipt of the outer container by signing the delivery log

o Check the items against the requisition for identity and quantity

o Immediately securely store medicines in the designated storage facility rotating stock to ensure the oldest stock is used first.

o Check receipts against the itemised delivery note and sign the note/pink copy to indicate correct delivery. Follow up any discrepancies with pharmacy immediately. If the delivery is received after the Pharmacy closes for the day it may be necessary to contact the Emergency Duty Pharmacist (see Section 4.4.3)

o Retain the signed delivery not on the ward (see Appendix 1 – Recommendations for the Retention of Pharmacy Records, before being destroyed.

o Where the ward/unit utilises an ADC, the medicines may be received by a member of Pharmacy staff

6.1.2 Community Team Bases

On receipt of medicines it is the responsibility of the nurse/nursing associates to:

o Check that medication ordered has been received for the correct

patients

o Report any discrepancies to the dispensing pharmacy immediately and complete a web incident reporting form as appropriate. If the delivery is received after the Pharmacy closes for the day it may be necessary to contact the Emergency Duty Pharmacist (see Section 4.4.3)

o Log all prescriptions received by patient name

o Ensure prescriptions are stored securely until collected by the patient

o Patients must sign for receipt of their medicines on the prescription log when they collect

Medication supplies must not be split /repacked by the community team. Either the whole package of medication (as originally dispensed) should be taken to the patient so they remove a single dose for immediate use, or separate packs should be ordered



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6.2 Storage of medicines in wards/units

The Chief Pharmacist is responsible for establishing systems for the safe and secure storage of medicines, and for approving the design and location of all ward/unit medicines storage cupboards including the security of the room and its windows. Authorised Pharmacy staff will regularly monitor storage arrangements

It is the responsibility of the Registrant in Charge of a ward, Unit or Community Team Base to maintain a safe and secure system for medicines handling and storage

All medicines must be kept in their original container or that supplied by the hospital Pharmacy. Medicines must not be transferred from one container to another.

Medicines must be stored in rotation following receipt from Pharmacy, and expiry dates checked regularly to avoid wastage and risk to patients

All medicines, including those that are to be returned to the Pharmacy, must be stored safely and securely in a locked drug cupboard, ADC, individual drug locker, controlled drugs cupboard, medicine refrigerator or medicines trolley, as appropriate. The receptacle must be designed and used for the purpose of medicines storage only.

There should be separate lockable ward cupboards as follows:

o Controlled Drugs Cabinet

o Medicines Cupboard for Internal Medicines

o Medicines Cupboard for External Medicines

o Refrigerator/freezer for medicines

o Patients individual drug locker/box

o Medicines trolley

o Omnicell automated drugs cabinet (ADC)

Separate secure storage should also be provided for:

o Cupboard for diagnostic reagents, including urine testing

o Area for sterile topical fluids

o Area for flammable fluids

o Secure area for medical gases (see Section 6.4.2)

o Area for enteral feeds

o Intravenous fluids for subcutaneous use – these must be stored in a medicine cupboard or locked room

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Vials of diluents such as saline or water for injection are prescription only medicines and as with all injections must be stored in a secure locked medicines cupboard

Insulin: Particular care must be taken with the safe and secure handling of insulin injections. Insulin should be stored in such a way that it is readily accessible when required, but locked in a medicines refrigerator or locked in the patient individual locker when issued for use

Medicines that require a reduced expiry once opened (e.g. liquids, creams, ointments, eye/ear drops) must always be marked with the date they were first opened before placing back into storage

6.2.1 Medicine Cupboards

Medicines cupboards, including ADCs, must comply with British Standard BS2881 (1989 – NHS Estates Building Note No29) or controlled drugs cupboard which complies with the Misuse of Drugs (Safe Custody) Regulations 1973), as appropriate

Wards - All ward medicine cupboards must be fixed to a wall, or be immovable and situated in a lockable room purpose designed for storing medicines e.g. Treatment room.

Community Team Bases or other Trust facilities - medicine cupboards must be located in a suitably secure area of the building. Where a patient’s own medicines are intended to be administered in a Community Team Base these may be kept at the base for administration over a series of visits. The medicines must be kept in a lockable cupboard, segregated from any stock medicines, and used for that patient only. The patient must give verbal agreement to this procedure

Consult the Pharmacy whenever a new or replacement medicines/ controlled drugs cabinet is required so that the correct specification can be provided for ordering purposes

Ensure adequate space within the treatment room to allow staff to perform all medication related tasks whilst still enabling adequate surveillance to afford maximum security against unauthorised entry

Nursing staff should monitor the ambient temperature in ALL rooms in which medicines are stored as follows:

o Ambient temperature monitoring of the clinic room must be undertaken and recorded daily on Appendix 8 – Temperature Monitoring Sheet

o Where more than 30 days-worth of medication is stored in a patient's room, the temperature in that room must also be monitored and recorded daily


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o The thermometer should not be sited near any obvious heat source (e.g. radiator or in direct sunlight)

o It is good practice for temperature monitoring to be done at the same time each day, and where possible this should be in the afternoon

o Consideration must be given to environmental conditions, and for example in the event of a heat wave monitoring may need to be increased

o In wards or departments which are not open 7 days/week, the temperature need only be recorded on the days the ward or department is staffed

o If a ward or department is closed for longer than 4 days, see Section 6.7.2

o If the temperature exceeds 250C, contact the Estates Department for advice on room cooling measures. Any implemented room cooling measures must be recorded on Daily room temperature recording form (Appendix 8 – Temperature Monitoring Sheet). Contact Pharmacy for advice on stability of medicines exposed to temperatures higher than 250C. Record any advice received from Estates/Pharmacy on the form

6.2.2 Medicines Refrigerators

Medicines refrigerators must not be used to store any other products including food, nutritional supplements (e.g. Fortisip/Ensure etc.) and any pathological sample. Medicines refrigerators must:

o Be kept locked when not in use

o Have the plug socket protected to prevent any power loss to the refrigerator and show a current PAT Test label

o Have a min/max thermometer approved by Pharmacy

o Be monitored once daily by nursing staff, recording the temperatures on the record of medicines refrigerator temperature checks chart (see Appendix 8 – Temperature Monitoring Sheet)

o Must not be sited in an area where extremes of temperature may

affect their performance

If the medicines refrigerator is used to store large quantities (or large values) of medicinal products, obtain a refrigerator that is capable of continuous monitoring of temperature, fitted with an alarm

Refrigerators and freezers must not be overloaded to allow air circulation and medicines are not stored in contact with the sides or bottom of the unit




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The minimum and maximum temperatures must be recorded every day by the assigned nurse in charge/assigned member of staff on the Medicines Refrigerator Temperature Chart kept by the medicines refrigerator, using the Min/Max thermometer. This person must re-set the Min/Max thermometer after each reading

Where a ward/unit is not open or staffed daily, it may not be possible to check the refrigerator temperatures daily. In this case, the max/min and current temperature should be recorded on the first day the unit reopens prior to administering any of the medicines contained therein. The max/min should then be reset using the Min/Max thermometer

If the temperature is outside the range of 2-8 0C the assigned nurse in charge must contact the Estates Department to report the fault. If medicines storage advice is required contact Pharmacy

In the event of a refrigerator breakdown or an accidental temporary disconnection of the electricity supply:

o Immediately re-connect the power supply if the refrigerator is still within the correct temperature range (2 – 8 0C) and it is possible to re-connect the power supply. No further action is required

o Re-connect the power supply if the refrigerator is outside the correct temperature range (2 – 8 0C). Make a note of the time at which the supply was re-connected and monitor the temperature hourly until the refrigerator is back to full working order. Contact Pharmacy for advice prior to administering the medicines

o Transfer the items to another drugs refrigerator on another ward/unit if it is not possible to re-connect the power supply or there is another mechanical fault. Keep the items separate from other contents and contact Pharmacy for advice. Keep the door of the malfunctioning refrigerator closed. Establish how long the stock may have been outside the required temperature. Check for any evidence of previous exposure to breaks in the cold chain, and establish the amount of stock when asking for advice about use and/or disposal of the stock

6.2.3 Drug trolleys and patients individual lockers/boxes

On some wards patients may have a medicines storage receptacle which is not readily portable. This can be a cabinet attached to the patient’s bedside locker, a wall adjacent to the bed, or a specialised trolley. These cabinets must be kept locked and the keys held by the assigned nurse in charge or where level 3 self-administration is occurring, by the individual patient

All medicine trolleys and trolleys of patient’s individual boxes must be kept locked and immobilised by attaching to the wall in the clinic room when not in use

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6.3 Storage of Flammable Liquids and Aerosols

Flammable liquids should be stored in a cupboard away from potential sources of ignition separate from the medicines cupboard. Bulk flammable liquids should ideally be stored in a metal cabinet

Aerosols must be stored separately in a cupboard fixed to the wall

6.4 Storage of Medical Gas Cylinders 6.4.1 Delivery and storage of cylinders to the hospital site

All deliveries of cylinders must go directly to the approved gas cylinder storage area for that site

Only appropriately trained personnel should handle medical gases

Storage facilities must: o Be well ventilated

o Have good access for delivery vehicles and be well lit,

o Have appropriate firefighting equipment

o A facility to segregate full/empty cylinders of each gas type. Signage must be clear

o Have a facility to safely store large cylinders (e.g. HX, J) upright using chains and smaller cylinders horizontally so as not to damage the paintwork on the cylinder

Signage is sited and designed in accordance with the Health and Safety (Signs and Signals) Regulations 1996 BS5378 Part 1, 1980, Part 3 1982 Safety Signs and Colours BS5499, Part 1 1984 “Fire Safety Signs Notices and Graphics Symbols” and the Health and Safety at Work Act 1974

The assigned staff member will receive the cylinders and check the quantity and type of cylinder against the delivery note. All orders, returns and transfers of medical gas must be recorded using the electronic management system.

The porters will ensure that:

o Only medical gas cylinders and cylinder trolleys are stored in the medical gas store

o The store is kept clean and tidy and free from any flammable or combustible material

o A stock system is in place that allows for regular expiry checks and for using the cylinders on a first in, first out basis. Any cylinder with an expiry date of 3 months or less at the time of the check must be returned to the supplier and a replacement ordered if necessary

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o Empty cylinders are only stored for the minimum amount of time to reduce clutter and rental costs

o Contact NTW Solutions porters when any cylinders are required to be ordered

Whenever cylinders are ordered, returned or transferred this transaction must be recorded by NTW Solutions portering staff using the electronic management system.

An up to date cylinder identification chart must be displayed in the gas store along with appropriate emergency notifications

o The Head of Facilities must keep a training record for all porters involved in medical gases to assure the Trust that they are fully trained and competent. The training must be recorded and must cover:

Manual Handling

The potential hazards and dangers of Medical Gas Cylinders

Safe handling of Gas Cylinders

Emergency procedures and the use of firefighting appliances

The safety and security of medical gases stored within external gas stores is overseen by facilities and covered by NTW Solutions portering procedures and security assignment number 026637.

6.4.2 Delivery and storage of cylinders to wards/departments

All wards must hold 2 portable ‘CD’ size oxygen cylinders (not including the one contained within the emergency grab bag)

‘HX’ size oxygen cylinders are for patients who require oxygen for longer periods (unless piped oxygen is available)

No other size oxygen cylinders should be ordered or kept on wards unless agreed in advance by pharmacy.

‘CD’ cylinders are stored securely in designated areas only, when not in use. They should be chained and held securely to prevent damage. CD cylinders can be stored either horizontally or vertically in clinical areas

‘HX’ cylinders (if being stored) are held vertically and secured by chains. Storage on an appropriate sized trolley is permissible

All medical gas must be checked weekly by ward staff and record this in an appropriate and auditable manner to ensure the cylinder:

o Is within its expiry date

o Has sufficient gas for any anticipated use

o Has masks/delivery equipment available

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Medical emergency CD-sized oxygen cylinders must be replaced immediately if used in a resuscitation event, regardless of the amount of oxygen remaining. This is to ensure that the CD-sized oxygen cylinders located in the grab-bag and in designated clinical areas, can deliver oxygen for the full specified duration in any subsequent resuscitation and medical emergency response. Part-used cylinders should remain on the ward/clinical area until replenished by a full cylinder.

All rooms used to store medical gas cylinders must have a notice clearly displayed on entry to notify persons as to the storage of the medical gas

o An example of suitable sign is

6.5 Stock checks and Reviews

Pharmacy staff will undertake medicine stock reviews regularly:

o Check the range and amounts of individual medicines against the ward’s stock list to reconcile stock levels

o Adjust the list in agreement with the nurse in charge of the ward/unit every quarter or more frequently as required

Nursing staff on all wards/units without ADCs must check ward stock cupboards weekly

Community teams that hold medicines stock or store medicines temporarily e.g. influenza vaccines, must check ward stock cupboards and medicines refrigerators monthly to:

o Check stock levels of medicines used regularly and expiry dates of stored medicines

o Check storage conditions are appropriate

o Arrange for excess/expired/damaged stock to be removed and replaced – see Section 15

Upon immediate completion of the stock check the nursing staff will access the Environmental Assurance’ database (accessible via the Trust intranet homepage - Homepage > Applications > More > Environmental Assurance) and record their findings

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Discovery of any apparent discrepancy in stock of any medicine must be reported promptly to a line manager and to the Pharmacy. If deemed appropriate by the ward manager a web-based incident report form must also be completed for the Medication Incident Coordinator, based in the hospital Pharmacy. The person reporting the discrepancy will receive appropriate feedback from Pharmacy

Where wards are equipped with Omnicell cabinets, expiry date checks will be performed monthly by pharmacy staff. Nursing staff however retain overall responsibility for storage conditions.

This pharmacy check of ADCs will consist of:

- Checking stock levels and expiry dates of stock medicines

- Checking storage conditions are appropriate

- Arranging for excess/ expired/damaged stock to be removed and replaced – see Section 15

6.6 Key Security

Staff authorised to be in possession of keys are:

6.6.1 Wards without ADCs: for wards – registered nurses, doctors, pharmacy staff

The Registrant in Charge of a ward will have overall responsibility for safe custody of all medicine cupboard/trolley keys when on duty. This responsibility can be delegated to an assigned nurse in charge of a ward/unit

The keys for the external medicine cupboard, internal medicine cupboard, medicine trolley, medicine refrigerator and pharmacy transport box must be kept together on one key ring reserved solely for these keys. The keys must be clearly identified. Keys for the Controlled Drug Cupboard must be kept on a separate ‘red tag’ key fob – please refer to PGN, UHM-PGN-04 - Controlled Drugs for further details. The key to the reagent cupboard may be kept separately and in a place designated by the Registrant in Charge

The Registrant in Charge must not relinquish keys to an unauthorised person. If he/she is in any doubt about handing over keys to another person then this must be reported to a more senior member of staff

Keys must be immediately returned to the assigned nurse in charge after use by another registered member of staff

The Registrant in Charge must take simple precautions to ensure that staff do not leave the ward/unit with any medicine keys, and maintain staff contact details to cover situations where they do leave with the keys

It is the responsibility of the nurse in charge of each shift to ensure transfer of the keys at shift change over. The handover of keys should be recorded by signature on ward documentation


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6.6.2 Wards with ADCs:

Access to ADCs is by fingerprint, or username and password

Keys are available for emergency situations where the cabinet cannot be accessed by usual means (such as in the event of a power cut and failure of backup generator)

Controlled access to these keys is managed by the ward ‘Key Tracker’ systems

In the event these keys are required to be used, a web-based incident report form must be completed and the service manager informed.

6.6.3 Community Teams – registered nurses/nursing associates, doctors, pharmacy staff, and designated team members in accordance with local procedures

The Registrant in Charge/Team Leader of a community team will have responsibility for safe custody of all medicine cupboard/trolley keys when on duty. This responsibility can be delegated to another team member but legal responsibility remains with the Registrant in Charge; a record of all those having access to keys must be maintained

Refer to PGN, UHM-PGN-04 - Controlled Drugs, Section 10, for details on possession of controlled drug keys

Where a number of registered nurses may require access to the medicine cupboards at different times a secure system must be agreed between the Registrant in Charge and the Chief Pharmacist. This system must be documented locally

Keys must be immediately returned to the Registrant in Charge/Team Leader after use by another member of staff

Duplicate keys to the medicine storage areas are not permitted to be kept on a ward/department/community base. A duplicate set of keys will be held in an appropriate location (the identity of which is recorded on the ward/unit/community base) under approved safeguards for emergency occasions, and when used recorded in a formal register. In those wards/units/teams that are remote and have no neighbouring Trust premises to hold duplicate keys then an exception to this requirement is allowed, although secure storage of the keys must be upheld

When a clinical area is closed e.g. overnight or at weekends, the keys to the medicines cupboards must be securely locked in an appropriate key safe, under the control of a Senior Nurse Manager

6.6.4 Emergency Drug Cupboards

These cupboards may only be accessed by the nurse with site responsibility or assigned nurse in charge of the ward on which the cupboard is located. The keys to the above cupboards must be kept in the designated locked

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drawer/cupboard or held by the senior nurse with site responsibility/assigned nurse in charge

For North Cumbria, the process for accessing medicines out of hours is available to staff on the intranet prescribing and medicines optimisation page, including contents and locations of emergency drug cupboards and other sources of supply of medicines out of hours

6.6.5 Loss of a Key (non-ADC)

Every effort must be made to find the key or retrieve it from duty staff

Should access to the medicine cupboard be required before the keys are retrieved the Registrant in Charge must be informed and a duplicate set of keys may be obtained

If the cupboard keys are not found or if there is not a duplicate key, the nurse in charge will arrange for the cupboard to be broken open and a new lock fitted

In the event of a key being broken within the lock please contact estates to obtain entry, a new lock and key immediately. Where the lock remains open, all drugs should be relocated to an appropriate lockable cupboard in the interim.

The line manager must be notified and a web-based incident report form completed; loss of a Controlled Drug cupboard key must be notified to the Trust Controlled Drugs Accountable Officer

6.6.6 Loss of a key (ADC)

Loss of keys for access to an automated drug storage cabinets must follow the process outlined for missing Controlled Drugs keys in UHM-PGN-04

6.7 Temporary closure of a Ward/Unit

If a ward/unit is due to temporarily close the assigned nurse in charge must contact the Pharmacy for advice on storage and security of the medicines

6.7.1 Short Term Closure

For closure of less than 4 days e.g. over weekends, overnight, bank holidays and for temporary closure of a ward:

o Medicines Other Than Controlled Drugs

Medicine trolleys – must be locked and attached securely to the wall

Medicines – must remain in a locked medicine cupboard, trolley or fridge (any items remaining in a refrigerator will require a nurse

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to access the ward/unit daily to undertake temperature monitoring of the fridge – see Section 6.2.2)

Medicine cupboards (for both internal and external products) and trolleys must be checked to ensure that they are locked

o Controlled Drugs

For short-term closure of a department - refer to PGN – UHM-PGN-04 - Controlled Drugs, Section 18

6.7.2 Longer Term Closure

The Ward or Department Manager must contact pharmacy to indicate the likely period of time the ward will be closed

o Medicines other than Controlled Drugs

If the period of closure is for more than four days the medicines may be retained on the ward/department until it reopens providing (a) transferring the medicines to another ward or returning them to the Pharmacy would be less secure than retaining them on the ward and (b) the security of the medicines can be guaranteed by undertaking the measures outlined at 5.7.1. If, however, the security cannot be guaranteed during the whole closure period then the medicines must be returned to pharmacy via sealed pharmacy boxes until the ward reopens

o Controlled Drugs

For longer-term of closure of a ward - see PGN, UHM-PGN-04 - Controlled Drugs, Section 18

7. Use of Patient’s Own Drugs (PODs) when admitted as an inpatient 7.1 Patients Own Drugs - other than Controlled Drugs

Prescribed medicines or those purchased by the patient which the patient brings into hospital are classed as a ‘patients own drugs (POD)’

Patients should be encouraged to bring in their own medicines from home prior to admission if possible. Family/carers may also bring medicines in at a later date

A patient’s own drugs can be administered to a patient during an inpatient stay according to their inpatient treatment chart after an assessment of the drugs suitability. It is the responsibility of the registered nurse caring for a patient to ensure that these medicines have been assessed and are suitable for use before administration using the approved assessment tool Appendix 10 – Patient’s Own Drugs (POD) Assessment for Suitability. The assessment may be carried out by a pharmacist, pharmacy technician, registered nurse or doctor.





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A record of the medicines brought in and their suitability for reuse must be made in the patient’s notes by the person who has completed the assessment. If the nurse is in any doubt as to the quality or suitability of a patient’s own drugs, they must not use them without first seeking advice from a pharmacist or pharmacy technician before the medicine is administered

PODs are for the sole use of the patient who they were originally issued to; they must not be entered into ward stock or administered to any other patient

Any unsuitable PODs should be destroyed. Verbal consent from the patient or their carer must be sought if destruction of their medicines is required following an explanation. It is the responsibility of the nurse to ensure that a record is made in the patient’s notes that this has been obtained including a description of the medicines. The nurse must record the nature and quantity sent to pharmacy

If a patient/carer refuses to consent to the destruction or use their medicines during their stay, the nurse must record this in the nursing notes and the drugs must be retained securely on the ward or returned to the patient/carer to take home. PODs remain the legal property of the patient and can be returned to them on discharge. However, if there are any safety concerns this should be discussed with senior medical staff; any decision not to return the medicines to the patient should be recorded in the patient’s notes with a clear rationale for this decision. This should also be explained to the patient. This should only be done when there is a significant risk associated with returning the medicines to the patient

Where a patient prior to admission is taking a blacklisted medicine (i.e. one which is not allowable on an NHS prescription as outlined in Schedule 1 to the NHS (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004), assessment should be made by the medical staff as to whether this is appropriate to continue during the inpatient stay, particularly in conjunction with other prescribed medication. If it is deemed appropriate, it may be prescribed on the inpatient treatment chart but must be supplied by the patient/relative, as it will not be obtainable from pharmacy

Patients own Drugs may be held by the patient if the medication may be required for urgent use. Glyceryl trinitrate (GTN) sprays and reliever inhalers may be held by the patient; the patient should be advised to store these out of sight of other patients and to inform the nurse whenever they have used the medication or if the medication is lost. The medicine must be assessed as suitable for use, in date and clearly labelled by a pharmacy (trust pharmacy or community pharmacy if POD) with the dose instruction. Pharmacy must be consulted for advice if the ward propose to enable self-administration of any other medications.

Medicines such as vitamins, herbal preparations, over the counter (OTC) medicines which may not be available in the hospital should be assessed for use, and if suitable for use and necessary for the patient’s treatment, should be prescribed on the prescription chart, annotated ‘Patients Own’.

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These products are unlikely to have dispensing labels attached. A label with the patients name and date should be applied, by the nurse or pharmacy staff, so that it is clear who the medication belongs to, and the medication stored in the medicines trolley. These medicines cannot be ordered from the usual pharmacy suppliers for wards; patient will need to obtain their own further supplies if necessary. These medicines may be returned to patients at discharge if safe to do so.

7.2 Patients Own Controlled Drugs

Please refer to PGN, UHM-PGN-04 - Controlled Drugs - Section 17

8. Supply of Medicines under a Patient Group Direction (PGD)

8.1 A PGD is a written direction authorising named practitioners to supply and/or administer named medicine(s) including prescription only medicines (POM), in an identified clinical situation to persons generally (subject to specified exclusions), without the need for a prescription. For full details on writing, approval and reviewing PGDs (see Appendix 13) – Developing, Authorising and Monitoring Patient Group Directions). The PGD must be appropriately approved before use.

Where a PGD is used to supply medicines to a patient a pack labelled with instructions for use must be issued. The directions on the pack must be as indicated on the PGD

The staff member supplying the medicine must ensure the patient’s name is on the label, complete any instructions on the label, provide a manufacturer’s patient information leaflet and any counselling required

9. Supply of medicines for Patients on Community Treatment Orders

The National Health Service (Charges for Drugs and Appliances) Amendment Regulations 2008) (accessed 14.05.2021) The above is superseded by (Charges for Drugs and Appliances) Regulations 2015, accessed here: https://www.legislation.gov.uk/uksi/2015/570/contents/made (accessed 14.05.2021) provide that Community Treatment Order (CTO) patients must not be charged for medication they need for mental disorder (as defined in the Mental Health Act), provided that the medication is supplied via direct supply by the Clinical Commissioning Group (CCG) or Trust or by a health professional through a Patient Group Direction (PGD). If the patient is prescribed medication through the community pharmacy route, by means of a prescription on form FP10, the exemption will not apply. Any CTO patient entitled to exemption from charging on other grounds will of course remain entitled on that basis

Arrangements should be made at local level to ensure that CTO patients on SCT can receive their medication via the routes described above, so that charges do not apply. It is expected that this will in most cases be consistent


http://www.opsi.gov.uk/si/si2008/uksi_20082593_en_1

http://www.opsi.gov.uk/si/si2008/uksi_20082593_en_1

https://www.legislation.gov.uk/uksi/2015/570/contents/made

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with systems already in place to deliver medication to patients on Section 17 discharge from hospital under the Mental Health Act

The responsible clinician (RC) ‘takes responsibility for the patient’s treatment in the community. See Trust policy, CNTW(C)47 - Community Treatment Order Policy or request other professionals to provide areas of treatment which are not within their own professional competence’. If a patient on CTO requires treatment in the community, the RC should ensure that the patient receives this from an appropriate person, who may either be a member of the CMHT or the patients GP. In practice, this should only affect those clients on CTO who are in employment/ not in receipt of benefits. In addition, the free entitlement applies only to medication prescribed for mental health problems (although the exact drugs are not required to be specified in the CTO)

To arrange the supply of medicines via a Trust Pharmacy department the RC should contact a Pharmacist directly, to discuss a planned CTO. This discussion should confirm that:

o The patient does not already quality for free NHS prescriptions on other grounds (medical, income/benefits, age)

o The patient does not already have a pre-payment card (or requires a sufficient number of physical medications to make purchasing a pre-payment card a worthwhile option)

o Only medication for mental health problems is provided by the Trust. The CTO exemption does not cover medication for physical problems

The RC will complete the form ‘Medication Supply for Patients on Community Treatment Orders’ (see (Appendix 16) - Medication Supply for Patients on CTOs) clearly stating the amount and frequency of supply, and submit this to the Trust Pharmacy department together with an initial/ repeat prescription from the consultant psychiatrist who will be responsible for ongoing treatment in the community

The RC is responsible for ensuring that future prescriptions arrive in a timely manner and for ensuring appropriate and secure method of transporting medicines to the patient

The RC should inform the Pharmacy of any changes to the method of supplying the medication or the patients legal circumstances (e.g. rescinding of the CTO)

Any changes to the medication should be made via a prescription presented at the Pharmacy

The Pharmacy will hold the CTO forms and prescriptions, for reference


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10. Supply of Pre-dispensed clozapine

Yumizen near patient clozapine monitoring machines are installed throughout the Trust, so where this facility is available blood samples can

be analysed within 2 minutes and a green/amber/red result obtained

whilst the patient is present in clinic

Pre-dispensed supplies of clozapine are prepared by Pharmacy for the Clozapine Clinic to streamline the supply and remove the need for the patient to make two visits to provide a blood sample and return to collect medication. This will apply only for the patients who attend the Clozapine clinic. The remainder of patients on clozapine will obtain their clozapine as per current arrangements

As pre-dispensing of clozapine is done before a full blood count is carried out, pharmacy staff are unable to perform the usual blood validity check required by Denzapine Monitoring Service (DMS) and Clozaril Patient Monitoring System (CPMS). It therefore becomes the responsibility of the clinic staff to ensure that patients only receive clozapine following a

green/amber result. The supply will be made as follows:

o Pre-dispensed medication, will be issued via the usual transport,

at a pre-agreed time either before the start of the clinic or where storage facilities exist, before the clinic.

o The patients will attend the clinic to have their blood analysed, and obtain an immediate response as to whether clozapine can be dispensed

o The result will be recorded on the Clozapine clinic record and a RIO progress note

o The result must be checked by a member of staff who is qualified and deemed competent in the use of the Yumizen machine and DMS/CPMS website. On receipt of a green result the medication will be checked and issued to the patient by a qualified member of staff (first level nurse, pharmacy technician, pharmacist). It is the responsibility of the clinic staff to ensure that the clozapine is only given to patients who have a green or amber result

o Patients with an amber result must be recalled for a further blood

test as advised by DMS/CPMS

o Patients with a red result must not be given any clozapine.

DMS/CPMS must be contacted for advice on further testing.

o The Clozapine Clinic staff must check the name and date of birth of the patient against the name written on the bag of medication supplied by pharmacy to ensure that the clozapine is handed over to the correct patient

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o Dispensary staff are responsible for ensuring the accuracy of dispensing the medication against the prescription. Any queries or discrepancies with the dispensed medication must be directed to the relevant dispensary

o Under no circumstances will pre-dispensing or secondary dispensing into compliance aids be carried out by nursing staff

o When the clozapine has been given to the patient this must be recorded on the Clozapine clinic record (dose and quantity)

o If any patient does not attend the clinic they must be followed up in the usual manner

o Any medication not given out must be stored in the locked cupboard. If there is insufficient space to store appropriately then returned to the relevant pharmacy, after agreeing this with pharmacy staff

o If the clinic has any medication no longer required (e.g. patient has discontinued clozapine), contact pharmacy to let them know why it is no longer needed and then return to pharmacy at the next available opportunity (see Section 15.2 for details)

o Pharmacy staff will continue to obtain repeat prescriptions from consultant psychiatrists and automatically supply medications to clinics using ‘Pre-dispensed Clozapine Lists’ (supplied by the Pharmacy) which are updated by pharmacy staff in liaison with clinic staff

11. Handling Medicines of abuse/ illicit substances 11.1 Misuse of Medicines in Wards/Departments

For controlled drug stock checks please refer to PGN, UHM-PGN-04 - Controlled Drugs, Section 11

If there is suspicion of abuse or misuse arising from the weekly stock check (see Section 6.5) this must be reported to the Service Manager and to the Trust Controlled Drugs Accountable Officer and a web-based incident report form completed. In such cases a stock balance must be recorded and regular checking may be introduced

11.2 Illegal Substances on Trust Premises - Primary Responsibilities of the Trust

Illegal substances in the context of this guideline means – ‘controlled drugs’ as defined by the Misuse of Drugs Act 1971. The Act defines classifications of drugs in the context of penalties for drug possession, supply (dealing) and production depending on what type or ‘class’ the drug is. For practical purposes these are commonly:

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Class A – Crack cocaine, cocaine, ecstasy (MDMA), heroin, diamorphine, LSD, magic mushrooms, methadone, methamphetamine (crystal meth) and pethidine Class B - amphetamines, barbiturates, cannabis, codeine, ketamine, methylphenidate (Ritalin), synthetic cannabinoids, synthetic cathinones (eg mephedrone, methoxetamine) Class C – Anabolic steroids, benzodiazepines (diazepam), gamma hydroxybutyrate (GHB) gamma-butyrolactone (GBL), piperazines (BZP), khat

The Trust has a duty to act within the law and has a duty to ensure criminal offences do not occur on the premises

The Trust has a responsibility for the safety of all staff

The Trust can refuse to treat a patient or discharge them early if they are not co-operative as a result of illegal drug misuse. However, any uncooperative behaviour must be balanced against underlying mental cause

If the nature of the substance taken by the patient needs to be identified, this can be done through blood and urine tests. The substance in the patient’s possession may not be the substance they have taken

11.3 Disposal of unidentified or illicit substances

11.3.1 Please refer to the Trust’s policy, CNTW(O)12 -Misuse of Alcohol and/or Illicit substances within inpatient services, for details including full guidance on the handling of unidentifiable/illicit substances and illegal items

12. Handling of Investigational Medicines (Clinical Trials)

Investigational medicinal products often are generally unfamiliar to staff handling them at ward level. Many trials are blinded which means they are labelled in a way to prevent ready identification of the active medication by the investigator and/or the patient and therefore extra precautions are necessary to ensure safety and security in their use

If a patient is admitted to an inpatient ward and is currently enrolled in a clinical trial, ward staff should:

- Securely store trial medication in a medicines cupboard/ fridge as per storage instructions on the trial label

- Only store medication in the original container

- Only use the medication for the intended recipient

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- Contact the Principal Investigator of the trial to let them know the patient is in hospital and confirm the patient should stay on the trial medication

- Ensure medication is prescribed as per Section 11, UHM-PGN 02 Prescribing Medicines

- Any unwanted trial medication and empty bottles should not be disposed of at ward level but given back to the patient on discharge or to the trials team/pharmacy involved in the trial as clinically appropriate

The Pharmacy must be made aware of and hold a copy of all Clinical Trials of Investigational Medicinal Products (CTIMP) protocols for studies being undertaken within the Trust

The ordering, storage and dispensing of all medicines or constituent ingredients must be undertaken by the hospital pharmacy only and must adhere to any stipulations with the trial protocol. Separate stocks of trial medicines must not be maintained on wards, clinics, or in private offices without a risk assessment carried out by CNTW pharmacy and approval by a trial sponsor

In trials that do not have a placebo arm, NHS Prescription charges should be collected if outpatients are to receive active medication and if they normally pay this charge.

Investigators / official sponsor must liaise with pharmacy about supply / dispensing arrangements and fees (including prescription charges)

Risk management measures should follow the Trust’s policy, CNTW(O)33 - Risk Management Policy

Risk assessments should be carried out in connection with the drug products and procedures (including the use of delivery devices) to determine potential risks to patients and staff, and risk management procedures put in place to minimize the risks from trial medicines or procedures to patients and staff

13. Reporting and Managing Medication Incidents and Defective Medicines

13.1 The Trust defines a medication incident or error as a medication related incident or event which actually resulted in or had the potential for detrimental result to a patient. Such events may be related to professional practice, health care products, procedures and systems including: Prescribing, Order communication, Product labelling, Packaging, Nomenclature, Compounding, Dispensing, Distribution, Administration, Education, Monitoring and use.

13.2 Medication Errors

Any member of staff who becomes aware of any such event must take any necessary remedial action to prevent further harm to the patient, manage

https://www.ntw.nhs.uk/about/policies/risk-management-policy/

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the event appropriately and report it promptly using a web-based incident report form in line with the Trusts policy, CNTW(O)05 - Incident Policy and PGN, IP-PGN-07 - Medication Incidents. Further information is available from the pharmacy patient safety team or the clinical pharmacy team.

Lessons learnt from medication errors must be shared across the Trust - see the monitoring framework Appendix C in Trust policies, CNTW(C)17 - Medicines Optimisation; CNTW(O)05 - Incident Policy and PGN, IP-PGN-07 - Medication Incidents

This is achieved as follows:

o The Medicines Optimisation Committee (MOC) oversees the medicine incident reporting process and ensures lessons learnt from serious incidents are embedded into medicines policies to raise awareness of policy change and staff training, and the Safer Care Group disseminates internal CAS alerts to staff, all managers and to ward managers

o Locality Care Group Q&P Committees review reports of all medication incidents within their locality, identify themes and trends and share any relevant learning within the group

o Learning from errors and near misses reported within pharmacy dispensing processes, is achieved through the Pharmacy Operational meeting

o Governance meetings are used widely by wards, departments and Group Directorates alike, and are reported via their respective Safety and Safeguarding Groups and/or Quality and Performance Committees

o A specific report on Controlled Drugs incidents is received by the Trust Quality and Performance Committee from the Trust Controlled Drugs Accountable Officer. Learning from CD incidents is shared via the local CD LIN and health providers

o Other professional and Governance sub-groups review and share learning from incidents as part of their on-going education and professional development

If a medication incident is suspected to have arisen as a result of poor practice, neglect or intention to cause harm to a vulnerable patient then any staff member who has a concern must refer to the following Trust policies, for the appropriate action; CNTW(C)04 - Safeguarding Children Policy , and CNTW(C)24 - Safeguarding Vulnerable Adults

Counterfeit medicines causing harm or potential harm must be reported to the NHS Counter Fraud Service - http://www.nhsbsa.nhs.uk/fraud accessed 14.05.2021

http://www.nhsbsa.nhs.uk/fraud

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13.3 Reporting and Managing Defective Medicines

Medicinal products can on occasion present with a defect (e.g. broken tablets in blister packs, hairline cracks in ampoules, different odour than normal, colour change/ appearance, or anything which is different from normal)

The organisation has a policy for dealing with safety alerts and product recalls ensuring that affected products are quarantined as necessary (eg Drug Alerts issued by the Medicines Healthcare products Regulatory Agency)

On suspecting a defect in a medicinal product:

o Inform the Pharmacy department immediately and a member of staff will advise on all reporting, recording and investigating of the defect. Record the details of the defect on the Medicines Defect Reporting Form (see Appendix 11 - Medicines Defects Reporting Form PH9) and send the completed form to the Pharmacy as confirmation

o Retain any remaining product and any associated products or equipment and securely store these in case they are needed for evidence

o If the product has been administered to the patient inform the doctor responsible for the patient and record the defects in the patient’s notes. A web-based incident report form must be submitted

o Report the incident to the assigned nurse in charge of the ward/ department and if appropriate via the web-based incidents reporting system as described above in Section 13

o When the Pharmacy is closed inform the Senior Nurse on Duty who may decide to contact the emergency duty pharmacist

If tampering cannot be ruled out as the cause for the defect (e.g. pin prick found in bag of saline) then this must be reported immediately to Pharmacy (including out of hours to the Emergency Duty Pharmacist). The pharmacist, ward manager or assigned nurse in charge and the doctor responsible for the patients must jointly decide if there is cause for concern. For an agreed period there must be additional monitoring of patients (determined by the doctor) in the clinical area(s) where the defect has been discovered. If there is a reasonable suspicion that deliberate tampering with sinister intent has occurred (as opposed to simple manufacturing defect or other cause for the problem) then an Executive Director must be informed immediately who will inform the Police. In this case, affected products including medicines of the same batch must be quarantined at the earliest opportunity. These must be kept securely stored in Pharmacy for possible analysis, See Section 6.2 for storage requirements for medicines


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14. Medical Gas Pipeline System (MGPS)

14.1 Walkergate Park

Please refer to Appendix 12 (accessed 14.05.2021) Medical Gas Pipeline System (MGPS), which outlines the Trust responsibilities with regards to the MGPS. Robertson Facilities Management (Project Co.) has working policies and procedures for the use of the MGPS at Walkergate Park (In relation to staff training)

14.2 Centre for Ageing and Vitality (CAV) site

The MGPS system at the CAV site is maintained by Newcastle upon Tyne Trust Hospitals (NuTH) in accordance with their own policies. NuTH Estates department facilitate alarm/fire procedure safety training

A record of all training should be recorded and the CAV site should have a local Standard Operating Procedure in place that describes the necessary actions for staff to undertake in the event of an alarm/fire

15. Disposal and/or Return of Unwanted and Waste Medicines NHS

Resolutions (former NHSLA Risk Management Standard Medicines Management 6.10 (h) – how drugs are disposed of safely)


For Controlled Drugs please refer PGN, UHM-PGN-04 - Controlled Drugs, Sections 13 and 14

Medicines must be returned to a Pharmacy (the supplying Pharmacy if possible) in a sealed disposable Pharmacy Returns bag

For full details, see Trust policy, CNTW(O)24 - Waste Management on the handling of waste including disposal of waste contaminated by blood or clinical waste

15.2 Disposal/Return of unwanted medicines – For Central, North and South

Localities only (Cumbria staff to destroy medicinal waste on wards) 15.2.1 Wards/departments

Place unwanted medicines in the designated ‘returns’ location on the ward

Do not recover unwanted medicines from these locations. New supplies must be ordered from pharmacy

In many wards, the subsequent management of unwanted medicines is undertaken by a Pharmacy Assistant. On wards where this service is not available, the following process must be followed:


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o Return the medicines in a sealed disposable Pharmacy Returns bag together with the ‘Returns’ form that includes a distinct serial number; annotate the front of the Pharmacy Returns Bag with the serial number(s) of ‘Returns note(s)’ contained within. Unsealed bags will not be accepted by porters/couriers.

o A record must be retained by the ward

o Controlled Drugs must never be returned to Pharmacy via this route – see PGN, UHM-PGN-04-Controlled Drugs, Section 13

15.2.2 Community Teams

All unwanted medicines should be returned to the supplying pharmacy. Where possible, patients should be encouraged to return surplus medicines to any community pharmacy. Where this is not possible, the surplus medicines may be removed by a community team member from a patient’s home, with the patient’s or carer’s verbal permission, and returned to the supplying pharmacy utilising sealed disposable Pharmacy Returns bags. This should also be documented in the patient records and the GP/Consultant Psychiatrist informed, for purposes of further prescription orders etc. For medicines being returned to a CNTW pharmacy, please follow the process outlined in 15.2.1 by completing a ‘Returns note(s)’ and using a sealed disposable Pharmacy Returns Bag. Completed ‘Returns Notes’ should be uploaded onto the patient RiO View Documents.

For Crisis Teams, the CRHT Return of Medications Form (Appendix 19) should be utilised for documentation and audit purposes. Completed forms should be uploaded onto the patient RIO View Documents, with an accompanying note on progress notes to reflect completion. If using sealed disposable Pharmacy Returns bags, the patient’s RIO number should be annotated on the front of the bag in place of a serial number.

15.2.3 Disposal of waste medicines in inpatient wards/departments (out of

date, expired, not fit for reuse, or individual doses prepared but not administered):

Clearly identify, segregate and then place the waste inside the appropriate pharmaceutical waste container according to the following table. All hazardous pharmaceutical waste must be placed within purple-lidded containers to permit safe destruction by incineration

All cytotoxic and cytostatic medication (hazardous waste)

Yellow waste containers with PURPLE lid

Non-cytotoxic/cytostatic sharps Yellow sharps waste containers

Controlled Drugs (Schedule 2,3 and 4 Part 1)

Denature following UHM-PGN-O4 (Section 14) followed by disposal into blue pharmaceutical waste containers

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All other pharmaceutical waste Blue pharmaceutical waste containers

o Individual doses in liquid form which have been prepared for administration but have not been used immediately or remnants of liquids in bottles must not be disposed of by flushing into the main sewer. Both must be disposed of by placing into the appropriate pharmaceutical waste container

o Small quantities of medicines in ampoule form must be placed in a pharmaceutical waste sharps bin

o Sterile solutions (fluids) of non-active pharmaceuticals for

injection/infusion (examples include sodium chloride 0.9% and dextrose solutions) in either bottles or bags which are partially used must not be sent to the Pharmacy for disposal. The contents of partially used containers which present no other hazard (e.g. contamination with body fluids or the addition of a pharmaceutically active substance) may be:

o Flushed to the main sewer via a sluice/toilet. The empty container must be disposed of in accordance with Trust policy, CNTW(O)24 - Waste Management

o Where the partially used container/sterile fluid contains a pharmaceutically active drug, then it must be disposed of as pharmaceutical waste, as described above

o Ward staff must not return any items which are contaminated by blood or other clinical waste to pharmacy. Such items are to be disposed of in the same way as other hazardous clinical waste, in accordance with the Trust policy, CNTW(O)24 – Waste Management

The assigned nurse in charge of the ward/unit should inform the clinical pharmacy team when specific stock items are no longer required to allow for adjustments to the stock list

15.3 Disposal of Patients Own Medication Brought into Hospital

For full details on Patients Own Drugs please refer to Section 7 (accessed 14.05.2021)

15.4 Disposal of Medicines Following the Death of a Patient 15.4.1 In the event of a service user’s death, all their prescribed medication should

be retained intact for a minimum of 7 days in case of a coroner’s inquest or until advised otherwise, and then returned to the supplying pharmacy. For

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further guidance on removing controlled drugs for destruction see section 5.9 and UHM-PGN-04 Controlled Drugs, section 14.9.2

15.4.2 Medication that is required for examination or consideration by the coroner

must be stored securely within the inpatient or community team base for 7 days unless already taken by the coroner’s team.

15.4.3 Any medicines no longer required, prescribed or expired stock must be

returned to the supplying pharmacy. A record of all returns must be made in a returns book, detailing quantity, and also major losses, e.g. through spillages (see UHM-PGN-01 - Safe and Secure Medicine Handling and Supply, Section 15, Return and disposal of medicines).

15.4.4 The returns book should be a duplicate, bound with numbered pages. A

copy should accompany the drugs returned to pharmacy and a copy should be retained in the service. The returned items should be checked and the returns form signed by two members of staff. Both the carer returning the drugs and the pharmacy representative collecting them are required to sign this book.

16. Patient Information Leaflets

The Trust has reviewed the type of patient information that should be provided for medicines and the dissemination process:

16.1 Types of Approved Patient Information:

The Trust has a dedicated Choice & Medications website (www.choiceandmedications.org/CNTW) (accessed 14.05.2021) that contains an approved list of patient information leaflets. The website also provides a range of easy-read, foreign language and large-text information leaflets.

Additional information leaflets relating to specific psychiatric conditions may be obtained from the Patient Information Centre

16.2 Process of Dissemination:

Manufacturer approved patient information leaflets (PILs) must be supplied where possible and deemed clinically appropriate, this includes discharge patients, outpatients, patients who are self-administering medicines, and should be supplied to the patient or carer on their request. Patients should be made aware of the availability of printed information when medication is discussed and asked if they need a leaflet

The information needs of children, young people and carers should receive particular attention

PILs are available in the following locations:

https://www.choiceandmedication.org/cntw

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o The Pharmacy during opening hours

o The internet via the Electronic Medicines Compendium www.medicines.org.uk accessed 14.05.2021

o The original manufacturer drug packets during out of hours – available emergency drug cupboard for certain medicines

Where manufacturer PILs are not deemed clinically appropriate, then ChoiceandMedications leaflets should be supplied to the patient or carer from the website https://www.choiceandmedication.org/cntw accessed 14.05.2021

Date Approved by MOC

Version Issue Date Review Date Policy Author/Contact Details

12/05/2021 4.3 Matt Haggerty, [email protected]

http://www.medicines.org.uk/

https://www.choiceandmedication.org/cntw

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Statement of changes made in this version – V04

Version Date Page/section/

paragraph

Amendment

V4.2 23.03.21 6.4.2 • Medical emergency CD-sized oxygen cylinders must be replaced immediately if used in a resuscitation event, regardless of the amount of oxygen remaining. This is to ensure that the CD-sized oxygen cylinders located in the grab-bag and in designated clinical areas, can deliver oxygen for the full specified duration in any subsequent resuscitation and medical emergency response. Part-used cylinders should remain on the ward/clinical area until replenished by a full cylinder

V4.3 14/05/2021 15.3.1 15.3.1 Wards/departments

Place unwanted medicines in the designated ‘returns’ location on the ward

Do not recover unwanted medicines from these locations. New supplies must be ordered from pharmacy

In many wards, the subsequent management of unwanted medicines is undertaken by a Pharmacy Assistant. On wards where this service is not available, the following process must be followed:

o Return the medicines in a sealed disposable Pharmacy Returns bag together with the ‘Returns’ form that includes a distinct serial number; annotate the front of the Pharmacy Returns Bag with the serial number(s) of ‘Returns note(s)’ contained within. Unsealed bags will not be accepted by porters/couriers.

o A record must be retained by the ward

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Controlled Drugs must never be returned to Pharmacy via this route – see PGN, UHM-PGN-04-Controlled Drugs, Section 13

V04.3 17/05/2021 4.3.2 (c) If a registered nurse undertakes this activity they must ensure they are able to account for its use (further guidance available from Royal Pharmaceutical Society/ (RPS) Professional guidance on the safe and secure handling of medicines) accessed 17.05.2021.

V04.4 27/07/21 15.2.2 Community Teams –

• All unwanted medicines should be returned to the supplying pharmacy. Where possible, patients should be encouraged to return surplus medicines to any community pharmacy. Where this is not possible, the surplus medicines may be removed by a community team member from a patient’s home, with the patient’s or carer’s verbal permission, and returned to the supplying pharmacy utilising sealed disposable Pharmacy Returns bags. This should also be documented in the patient records and the GP/Consultant Psychiatrist informed, for purposes of further prescription orders etc. For medicines being returned to a CNTW pharmacy, please follow the process outlined in 15.2.1 by completing a ‘Returns note(s)’ and using a sealed disposable Pharmacy Returns Bag. Completed ‘Returns Notes’ should be uploaded onto the patient RiO View Documents.

• For Crisis Teams, the CRHT Return of Medications Form (Appendix 19) should be utilised for documentation and audit purposes. Completed forms should be uploaded onto the patient RIO View Documents, with an accompanying note on progress notes to reflect completion. If using sealed disposable Pharmacy Returns bags, the patient’s RIO number should be annotated on the front of the bag in place of a serial number. Addition of Appendix 19 CRHT Return of Medications Form to Community Pharmacies Appendix 7 updated

