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The Medicines Code For

Maple Ward

Holme Valley Memorial Hospital

Policy Number MM11005

Title of Policy The Medicines Code for Maple Ward at Holme Valley Memorial Hospital

Author Updated by Linda Fox Community Services Pharmacy Manager

Approved at Locala Policy Group

Responsible Director: Director of Clinical and Operational Services

Date Ratified: 7th September 2011

Ratified By: Executive Management Group (EMG)

Review Date: November 2013 – individual sections may be updated prior to this date if procedures change

This Medicines Code is an update of the Holme Valley Memorial Hospital Medicines Code, August 2010 created by Judith Jones, Community Services Pharmacist,

Calderdale & Huddersfield Foundation NHS Trust

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CONTENTS

Useful Contact Numbers Pg 6

Introduction Pg 7

SECTION 1- PRESCRIBING MEDICINES Pg 8-18

1.1 Prescription Documents 8-9 1.2 Initiation of Treatment 9 1.3 Range of Medicines Available for Prescribing 10 1.4 Safe Prescribing 10-11 1.5 Routes of Administration 11-12 1.6 Times of Administration 12-13 1.7 Signature of Prescriber 13 1.8 Cancellation of Treatment 13 1.9 Amendment of Therapy 13 1.10 Length of Treatment 13 1.11 Medical Allergies and Adverse Drug Effects 14 1.12 Once Only Doses 14 1.13 “As Required” Prescriptions 15 1.14 Take as Directed 15 1.15 Re-written Prescriptions 15-16 1.16 Transfer of Patient Care 16 1.17 Discharge Prescriptions 16 1.18 Supply of Discharge Medication to Patients with a History of Self-Harm 16 1.19 Verbal Orders 17-18 1.20 Prescribing by Dieticians 18

SECTION 2 - ORDERING MEDICINES Pg 19

2.1 Stock Drugs

2.2 Non-Stock Drugs

SECTION 3 - TRANSPORT AND RECEIPT OF MEDICINES Pg 20

3.1 Security and Transportation

3.2 Receipt of Medicines

3.3 Returns to HRI Pharmacy

SECTION 4 –

NEWLY ADMITTED PATIENTS AND PATIENT’S OWN MEDICINES Pg 21-23

4.1 On Admission 21

4.2 Medicines Reconciliation 22

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4.3 Non Formulary Medicines 22

4.4 Storage of Patient‟s Own Medicines 22

4.5 Discharge Procedure for Patient‟s Own Medicines 23

SECTION 5 - STORAGE AND SAFEKEEPING OF MEDICINES Pg 24-26

5.1 Control of Substances Hazardous to Health (COSHH) 24

5.2 Position of Cupboards and Trolleys 24

5.3 Storage Accommodation 25

5.4 Refrigerated Storage 25-26

5.5 Flammable Liquids 26

5.6 Medical Gases 26

SECTION 5a - CUSTODY AND SAFEKEEPING OF MEDICINE KEYS Pg 27

SECTION 5b - LOSSES OR DISCREPANCIES OF MEDICINES Pg 28

SECTION 6 - CONTROLLED DRUGS Pg 29-39

6.1 Discharge Prescriptions for Controlled Drugs 31

6.2 Ordering Stock Controlled Drugs 32-33

6.3 Stock List of Controlled Drugs 33

6.4 Collection and Transport of Stock Controlled Drugs 33

6.5 Receipt of Stock Controlled Drugs 34

6.6 Unwanted Stock Controlled Drugs 35

6.7 Receipt and Storage of Patient‟s Own Controlled Drugs 35

6.8 Storage of Controlled Drugs 35

6.9 Safe Custody of Controlled Drug Keys 35

6.10 Loss of Controlled Drugs Keys 35

6.11 Stock Balances of Controlled Drugs 36

6.12 Pharmacy Stock Checks 36

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6.13 Administration of Controlled Drugs 36-37

6.14 Discrepancies with Controlled Drugs 37-38

6.15 Disposal of Controlled Drugs 38

6.16 Transferring Patient‟s Own Controlled Drugs between HRI/CRH and HVMH 39

6.17 Student Nurses 39

SECTION 7 – PREPARATION AND ADMINISTRATION OF MEDICINES Pg 40-47

7.1 Preparation of Medicines 40-41

7.2 Checking the Preparation and Administration of Medicines 41

7.3 Administration of Medicines 41-43

7.4 Administration Checklist 43

7.5 Documentation and Administration 44

7.6 Administration Devices 45

7.7 Administering Medicines via Enteral Tubes 45

7.8 Crushing Tablets 45

7.9 Covert Administration 46

7.10 Disguising and Mixing of Medicines Prior to Administration 46

7.11 Unlicensed Medicines 46

7.12 Nil by Mouth 47

7.13 Staff Requiring Treatment for Minor Ailments 47

SECTION 8 – MEDICINES AT DISCHARGE, LEAVE OR ON TRANSFERRING PATIENTS

8.1 Transfers from/to HRI/CRH 48

8.2 Transfers to Other Trusts 48

8.3 Leave 48

8.4 Processing Discharge Medication 49-50

SECTION 9 – CONSENT Pg 51

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SECTION 10 – MONITORED DOSAGE SYSTEMS (MDS) Pg 52

SECTION 11 – DISPOSAL OF MEDICINES NO LONGER REQUIRED Pg 53

SECTION 12 – PATIENT GROUP DIRECTIONS Pg 54

SECTION 13 – MEDICATION ERRORS Pg 55

13.1 Reporting Mechanism

13.2 Medical Review of the Patient

13.3 Locala Community Partnerships Serious Untoward Incident Procedure

SECTION 14 – SECURITY AND SAFE HANDLING OF MEDICINES RELATED Pg 56-57 STATIONERY

14.1 Controlled Stationery 56

14.2 Responsibilities 56

14.3 Ordering Stationery 56-57

14.4 Storage of Controlled Stationery 57

14.5 Transport of Stationery 57

14.6 Loss of Theft of Controlled Stationery 57

14.7 Return of High Risk Controlled Stationery 57

SECTION 15 – PARENTERAL THERAPY Pg 58-59

15.1 Intravenous Therapy 58

15.2 Syringe Drivers 59

15.3 Single Use Containers 59

15.4 Multidose Containers 59

SECTION 16 – OUT OF HOURS MEDICINES Pg 60

SECTION 17 – DRUG FORMULARY Pg 61

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USEFUL CONTACT NUMBERS

Pharmacy Department (HRI) – 01484 347123 or 01484 342422 (Ring 7123 or 2422 if internal) Medicines Information (CHFT) – 01422 224252 or 01422 224356 Locala Community Partnerships (LCP) Controlled Drugs Accountable Officer (Lucianne Ricketts) – 01924 351525 Medicines Management Team (LCP) – 01924 351525 Intermediate Care Services Manager – 01924 351565 or 07903 755665 Fax number for temperature record sheets – 01924 475212

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INTRODUCTION

The pharmacy service to Holme Valley Memorial Hospital is provided by Calderdale and Huddersfield NHS Foundation Trust in agreement with Locala Community Partnerships Medicines for use at HVMH are supplied from the pharmacy department at Huddersfield Royal Infirmary Pharmacy staff from Calderdale and Huddersfield NHS Foundation Trust visit the hospital as part of the service provision. Pharmacists or pharmacy technicians from Locala Community Partnerships (LCP) may also visit as appropriate. The following abbreviation codes are used through out this Appendix. HVMH – Holme Valley Memorial Hospital CHFT – Calderdale & Huddersfield NHS Foundation Trust HRI – Huddersfield Royal Infirmary CRH – Calderdale Royal Hospital LCP – Locala Community Partnerships The policies of Calderdale and Huddersfield NHS Foundation Trust and those of Locala Community Partnerships which are referred to in this appendix are available on the following respective web sites. Please see: http://www.kirklees.nhs.uk/public-information/policies-and-procedures/ http://www.kirklees.nhs.uk/your-health/medicines-management/locala-policiesguidelines/ http://nww.cht.nhs.uk/publications/policies/

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SECTION 1 – PRESCRIBING MEDICINES

Medicines can be prescribed for adults on the wards at HVMH by:

Registered medical practitioners

Registered dental practitioners

Registered supplementary and Independent prescribers

Dieticians (see section 1.21)

An accurate medication history is essential for safe prescribing. Patients may already be taking drugs that interact with, or duplicate new treatments. Often they do not take all the drugs that are prescribed for them. They may self medicate with over the counter medicines, herbal or complementary remedies. Additionally they may be taking medicines from a previous course of treatment that is no longer appropriate. Establishing an accurate medication history is particularly important when patients are transferred between primary and secondary care.

Prescribers should write prescriptions for medicines and treatments, including repeat medication only when they have adequate knowledge of the patient‟s health and medical needs. The treatment plan, including how the response to drug therapy is to be monitored, must be clearly documented in the patient‟s clinical notes. Prescriber should be aware of all patient characteristics that may affect the choice of drug or dosage regimen and adjust the treatment plan accordingly. They should review relevant drug-related information prior to prescribing. Aims and side effects in drug treatment should be discussed with the patient or their representative where possible.

1.1 Prescription Documents

Medicines must be prescribed on official Calderdale & Huddersfield Trust stationery, which has been approved by the Medicines Management Committee.

The purpose of a prescription is to provide:

A permanent record of the patient‟s medication

To facilitate the provision of the correct medicines from the pharmacy department

To direct and record the supply or administration of medicines

The prescriber is responsible for ensuring the above details are included on the prescription.

The following details must be included on each prescription:

Patient's full name (including aliases).

Date of birth.

Hospital and ward name.

Patient's NHS number and address

Known sensitivities to medicines or the statement “None known”

Weight and height as appropriate.

Weight must be recorded on all prescriptions where the dosage of medication is based on weight.

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1.1.1 Prescription Chart and Administration Record

The correctly completed prescription is the nurses‟ authority for the administration of medicines.

All inpatients must have a CHFT Prescription Chart & Administration Record. Ideally only one current Prescription Chart & Administration Record must exist at any one time for any patient. Where more than fourteen medicines are prescribed regularly, a second Prescription Chart & Administration Record will be needed. When more than one Prescription Chart & Administration Record is in use for one patient, each should be clearly marked 1 of 2 or 1 of 3 etc.

Each Prescription Chart & Administration Record must make reference to separate special charts on which drugs have been prescribed (see 1.14).

At HVMH Prescription Chart & Administration Records are kept on top of the medicines trolley in a ring binder. There is one ring binder for the „A‟ side and one ring binder for the „B‟ side.

Multiple Prescription Chart & Administration Records and any supplementary charts must be together in the folder. Records for one patient must be separated from those for the next patient by a coloured card.

When a patient is re-admitted, a new Prescription Chart and Administration Record must be written. The Prescription Chart & Administration Record of patients transferred from Calderdale and Huddersfield NHS Foundation Trust site to HVMH does not require to be rewritten but the details related to the hospital and ward must be changed.

When patients are transferred from other Trusts, a Calderdale and Huddersfield NHS Foundation Trust Prescription and Administration Record must be written.

1.1.2 Additional Prescription Sheets

The following CHFT charts should be used in addition to the Prescription Chart and Administration Record when applicable:

Infusion Fluids/Additives Prescription Sheet

Adult Subcutaneous Insulin Prescription and Administration Record (blue)

Warfarin Prescription Sheet (pink)

Syringe Driver Prescription Sheet

Prescribers must fully complete the Warfarin or Insulin Prescription Sheets when in use. There must also be an entry on the Prescription Chart and Administration Record which indicates that warfarin or insulin has been prescribed. The times of the doses should be marked and „see warfarin chart‟ or „see insulin chart‟ annotated in the dose box.

1.2 Initiation of Treatment

Prescribers may write inpatient prescriptions only for persons who are inpatients at HVMH.

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1.3 Range of Medicines Available for Prescribing

Initiation of new treatment must be in accordance with the formulary agreed by Calderdale and Huddersfield NHS Foundation Trust, NHS Kirklees and Locala Community Partnerships. Previously, prescribed therapy which is non-formulary may be continued in hospital, if appropriate, and if supplies are available.

1.4 Safe Prescribing

The British National Formulary (BNF) provides guidance on prescription writing.

Refer to guidelines for completion of Prescription Chart and Administration Records.

The completed prescription must be reread to ensure that it is correct.

The Prescriber

Prescribers must clearly identify the patient (specify full name, date of birth and NHS number) on the prescription chart.

Prescribers must write clearly, in indelible black pen, in BLOCK CAPITALS. The prescription must always be clear, unambiguous and leave no doubt as to the prescriber‟s intentions. Illegible prescriptions will need to be re-written before the drug can be dispensed or administered and may result in a delay to patients receiving medication.

Prescriptions must always carry patient directions and never be issued with the instructions „as directed‟

Prescribers must prescribe using the BNF recommended generic name. The exceptions when TRADE names should be used are:

o Drugs with a narrow therapeutic margin e.g. Lithium, Theophylline and Ciclosporin.

o If there is potential for confusion e.g. Valproate preparations.

o Drugs where there is no generic name e.g. Peptac

o Drugs with specific delivery sites e.g. Pentasa, Asacol

o Oral opiates –prescribe by brand name with generic name in brackets

Prescribers must not use chemical formulae e.g. FeSO4 or abbreviations, e.g. ISMN, with the exception of GTN.

Prescribers must specify the dose:

o Using mg, micrograms and avoid the use of decimal points where possible. A leading „0‟ must always precede a decimal expression of less than 1. A terminal or trailing „0‟ must never be used after a decimal point.

o The words micrograms and nanograms must be written in full.

o The word unit must be written in full.

o Doses of medicines must be prescribed by weight of active drug e.g. Levothyroxine 75 micrograms.

o The dose of liquids must be prescribed by milligrams except where there is no specific strength e.g. lactulose.

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o Care must be taken when prescribing the dose of drugs where the dose of the salt and the base are different (e.g. sodium fusidate, phenytoin, clomethiazole)

Prescribers must state the form of medication to be given: liquids for patients with difficulty swallowing, or feeding tubes, or slow release for medicines available in multiple formulations e.g. nifedipine.

Prescriptions for intravenous infusions should describe the drug, concentration, dose/kg/time, actual dose/time, route and rate per unit time so that the prescription can be thoroughly checked. Awareness of maximum safe dose is essential.

The route of administration must be clearly stated. When prescribing for an unusual route care must be taken to ensure that the correct formulation of the drug is specified.

Prescribers may specify multiple routes indicated for the same drug only where the dose is the same for each route.

Opioids must not be prescribed by multiple routes. (e.g. IM/IV/O)

Prescribers must always tell the patient and the nurse when making a change to the Prescription Chart & Administration Record, document the change in the patients clinical notes and re-write that medicine; not amend the prescription. (Refer to Calderdale and Huddersfield NHS Foundation Trust Self Administration and Re-use of Patients Own Medicines Policy).

Prescribers must prescribe any Controlled Drugs required by patients to take home in accordance with the legal requirements and LCP Controlled Drugs Policy. Supplies of the controlled drug prescription form used by Calderdale and Huddersfield NHS Foundation Trust are available on the ward.

Where a prescription is to be started at a future date the „start date‟ must be documented on the prescription and the appropriate administration times cancelled with a cross until the actual start date.

1.5 Routes of Administration

Accepted abbreviations:

IV Intravenous SC Subcutaneous

PO/O Oral Neb Nebulised SL Sublingual

NG By nasogastric tube PR Rectal TOP Topical

IM Intramuscular PV Vaginal PEG Via gastrostomy

INH Inhalation BUC Buccal JEJ By jejunostomy

All other routes of administration must be written out in full, e.g. intrathecal, epidural, both eyes, left ear.

Intravenous Medication

Prescribe intravenous fluids or preparations to be given via continuous infusion, (e.g. PCAS, epidurals), on the CHFT Infusion Fluids/Additives Prescription Sheet. State the name, strength and volume of fluid, any additives required and the route and rate of administration.

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Medicines to be administered by direct bolus injection or intermittent infusions (e.g. erythromycin) must be prescribed on the regular section of the Prescription Chart and Administration Record, and where appropriate, the rate of administration indicated under special instructions.

Nebuliser Therapy

The medical gas to be used with the nebuliser medicine and the flow rate of the gas must be stated on the prescription under “specific instructions”.

Topical Administration

Prescribers must specify the strength and form and precise location or area to be covered for topical drugs. For dressings the type and size and frequency of use must be included

Administration via an Enteral Tube

The prescriber must state the type of feeding tube being used and refer to the Calderdale and Huddersfield NHS Foundation Trust Medication and Enteral Feeding guidelines for advice on drug administration.

When a patient first has a feeding tube inserted, prescribers must review existing medicines prescribed and update the clinical record and the Prescription Chart and Administration Record.

1.6 Times of Administration

The prescriber must circle the times of administration in the appropriate column on inpatient prescription charts and ensure that such times are appropriate for the prescribed medicines.

Abbreviations such as 'bd' 'tds' are only to be used for as required (PRN) medicines and on take home/outpatient prescription charts. The following abbreviations are standard means of indicating a dose regimen:

OM Each morning Mane Each morning

ON Each night Nocte At night

OD Once a day Protocol As per protocol

BD Twice daily PRN As required (with indication and interval stated).

TDS Three times daily Stat Immediately

QDS Four times daily PC After food

AC Before food

All other dose regimens must be written out in full, e.g. hourly, teatime.

For 24 hour infusions bracket all relevant medicines and times and state “to be administered over 24 hours.”

If the medicine is to be administered at a non-standard time, delete the nearest stated time and enter the new time in the space available.

When doses are to be omitted the prescriber must put an „x‟ in the appropriate administration box(s). Where alternate day dosing is indicated the complete or remaining administration record must be amended accordingly.

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Depot injections should be prescribed on the once only section of the treatment sheet with the time interval expressed using the term "every" e.g. every 3 weeks rather than 3 weekly which can be misinterpreted. This must not be abbreviated as every 3/52.

Weekly doses

For medicines taken once weekly specify the day to be taken and delete the administration section of the Prescription Chart and Administration Record appropriately, e.g. methotrexate once weekly dose should be prescribed as methotrexate „dose‟ milligrams once weekly on „day of the week‟.

1.7 Signature of Prescriber

The prescriber must validate each prescription item per chart by their full signature and date all prescriptions. The signature must be recognisable to other healthcare professionals. The name of the prescriber, should be printed on the last entry of each prescribing episode. A list of authorised prescribers and sample signatures should be available on the ward.

1.8 Cancellation of Treatment

When the 'stop date' box is used in anticipation of the treatment cancellation date, this indicates that at midnight on the date specified the prescription must be discontinued and no further doses are to be administered. This must be used in conjunction with the cancellation of areas of the Prescription Chart and Administration Record to indicate when the medicine should be administered and when it should be discontinued.

When cancelling a prescription the prescriber must put a large single „x‟ through the medicine details and one through the remaining administration boxes. The cancellation must be dated and signed in full and the reason for cancellation stated in the medical notes e.g. completion of a course, adverse drug reactions.

1.9 Amendment of Therapy

When changing the dose, preparation or route of a drug or time of administration the existing prescription should be cancelled and then rewritten. This ensures there is an accurate record of any changes in drug administration and who has authorised them. It also avoids confusion when administering medication.

Prescription Chart and Administration Records become unclear after multiple deletions and revisions, with a strong risk that some doses may not be administered. In such cases the responsible prescriber or pharmacist will be required to rewrite the Prescription Chart and Administration Record.

1.10 Length of Treatment

Inpatient prescriptions are valid for a maximum of 14 days. If the prescription becomes ambiguous or unclear at any time, the practitioner responsible for the administration of the medicine must request the prescriber or pharmacist to rewrite it. If the chart has been rewritten by the ward pharmacist the prescriber must review all prescriptions when signing the chart and cancel any which are no longer required.

For antibiotics, the length of course (or review date) and the indication must be clearly stated. Guidance about the appropriate use of antibiotics, including intravenous doses is contained in the Calderdale and Huddersfield NHS Foundation Trust Formulary and antibiotic guidelines.

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1.11 Medical Allergies and Adverse Drug Effects

It is the prescriber‟s responsibility to ascertain if the patient has any known medical allergies and/or has experienced an adverse drug effect. They must document this information in the appropriate section of the Prescription Chart and Administration Record and sign and date the chart. It must also be documented in the clinical notes (in current admission record and on the alert sheet at the front of the notes). This information must be transferred to any subsequent and additional charts. Where there are no known medicine sensitivities, "None Known" must be entered. If it is not possible to ascertain the allergy status, for example an unconscious patient, then the prescriber must sign and date „allergy status unconfirmed‟. Action must then be taken to confirm the allergy status of the patient by the end of the following day. The allergy status record of the patient must be referred to each time the patient is reviewed by a member of the clinical team. This procedure must be followed even when the patient has no known allergies.

In order to distinguish between serious allergy and less harmful drug intolerance, a description of any reported allergy and/or adverse drug effect must be documented. If a patient develops an allergy and/or adverse drug effect during their hospital stay the clinical notes must be updated to reflect the current allergy status. Health care professionals must be vigilant when prescribing, supplying and administering medicines since the product name may not clearly identify an association with the documented allergy. For example Magnapen, which contains Flucloxacillin and Amoxicillin, is not appropriate for a patient with an anaphylactic reaction to Penicillins.

All staff must be aware of their responsibilities in allergy/adverse side effect documentation including updating the allergy record if a new allergy is identified. Where another health care professional is made aware that a patient has a medical allergy or sensitivity it is their responsibility to document this and inform medical, nursing and pharmacy staff as appropriate. If another health care worker is made aware that a patient has a medical allergy or sensitivity it is their responsibility to inform the nurse in charge.

Medicines must not be issued from pharmacy or administered by nursing staff if this section of the prescription chart is incomplete. If the prescriber has signed the ‘allergy status unconfirmed’ medicines can only be administered to the patient until the end of the following day.

Patients must wear a red drug sensitivity wristband that indicates all allergies and/adverse drug effects. This band must be applied immediately when a medical allergy or adverse drug effect is confirmed. The person that applies the red drug sensitivity wristband must document this action in the clinical notes.

1.12 Once Only Doses

Medicines that are to be given once only must be prescribed in the 'once only' section of the Prescription Chart and Administration Record. This includes pre-medication.

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1.13 "As Required" Prescriptions (PRN)

The 'as required' section of the Prescription Chart and Administration Record must only be used for those medicines to be given at the practitioner's discretion according to the needs of the patient e.g. antacids, analgesics, and sedatives.

The minimum interval between doses and indication for administration must be clearly specified by the prescriber. It is essential to stipulate the maximum dose to be given in a 24-hour period.

The 'as required' prescriptions must be reviewed when the Prescription Chart and Administration Record is rewritten to determine its clinical need. Prescriptions that are no longer required must be cancelled. If the chart has been rewritten by the ward pharmacist the prescriber must review „as required‟ prescriptions when signing the chart and cancel any which are no longer required.

Medicines originally prescribed 'as required', but which are needed regularly as indicated by the administration record, must be reviewed. The prn prescription must be cancelled and rewritten in the regular prescription section.

Hypnotics initiated in hospital should not normally be prescribed at discharge.

Care must be taken not to duplicate medicines being taken regularly and thus overdose the patient. Combination analgesics frequently contain paracetamol, which may already be prescribed in the regular section of the Prescription Chart and Administration Record.

Rapid dose escalation using combinations of PRN and/or regularly prescribed antipsychotic drugs is one of the most commons causes of sudden death and neuroleptic malignant syndrome and therefore should be avoided.

Prescribers must specify the indication, frequency and/or maximum dose in 24 hours for „prn‟ medication. This ensures appropriate administration.

1.14 Take as directed

Prescribers must avoid vague instructions such as take as directed or use as needed as the sole directions for use. Specific directions to the patient are useful to help reinforce proper medicine use, particularly if therapy is to be used intermittently. Clear directions are necessary for pharmacists to check the proper dose is being prescribed for the patient and to enable active patient counselling.

1.15 Re-written Prescriptions

Re-writing the prescription sheet must be used as an opportunity to review and update the patient‟s medication. Care must be taken to avoid transcription errors. The date of the prescription review must be stated as the start date. The original prescription chart must be cancelled by drawing two lines across all sides of the prescription and stating “cancelled” with the date and prescriber‟s signature. The cancelled prescription must immediately be filed in the medical notes. The pharmacist must check the re-written Prescription Chart and Administration Record at the next visit.

If a prescriber is required to re-write a Prescription Chart and Administration Record in advance:

Where possible a chart should only be re-written a maximum of two days in advance.

The re-written Prescription Chart and Administration Record must be securely stored away from the current chart. This storage area should be agreed (in advance) with medical, nursing and pharmacy staff. The prescriber must

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document in the clinical notes that the Prescription Chart and Administration Record has been re-written and the nurse in charge must be informed. The nurse in charge must then document this in the nursing record.

If the ward pharmacist has re-written the Drug Prescription and Administration Record, the doctor must check and sign it on their next visit to the ward. The rewritten Drug Prescription and Administration Record is kept behind the current chart in the folder until it is brought into use. If the doctor amends a prescription for the patient they must amend it on the rewritten chart as well as the current one.

1.16 Transfer of Patients Care

When a patient is being transferred from one location to another, in particular between hospital sites, the current Prescription Chart and Administration Record must be reviewed. Short courses, for example antibiotics and steroids, must have stop dates. Prophylactic medication must be reviewed and there must be a clear management plan documented in the clinical notes.

1.17. Discharge Prescriptions

All sections of the Medication and Discharge Summary must be completed in full.

Prescribers must write in full all current medicines and dosages on the discharge prescription. All discharge medication should be shown on the discharge prescription and not just newly prescribed medicines. It is not acceptable to write “unchanged” or similar.

Controlled Drugs must be prescribed on the Medication and Discharge Summary in addition to the Calderdale and Huddersfield NHS Foundation Trust Controlled Drug Prescription.

For courses, the duration of treatment must be clearly stated on the prescription.

A minimum of 14 days supply will be provided as part of the one-stop dispensing system unless a shorter course of treatment is indicated.

New and discontinued medicines must be listed with an explanation.

1.18 Supply of Discharge Medication to Patients with a History of Self-Harm

The guidance issued by the Confidentiality Enquiry into Suicide and Homicide (CISH) stated that patients with a history of self-harm in the last three months must receive no more than fourteen days of medication on discharge.

The prescriber is responsible for informing the ward pharmacist and documenting on the discharge prescription that a patient is at risk of self-harm. A maximum of fourteen days discharge medication only must be supplied. If another healthcare professional is aware that a patient has a history of self-harm and is concerned about medication on discharge it is their responsibility to document this in the clinical notes and discuss with the prescriber.

Nursing staff must also be informed if a restricted supply of medication is to be made on discharge. The discharge prescription may not require a check by a pharmacist. The nurse will be responsible for ensuring that no more than fourteen days of medication is supplied as prescribed.

Pharmacy is responsible for ensuring that the GP is informed of any reason for a restricted supply on the discharge prescription.

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1.19 Verbal Orders (Only in Exceptional Circumstances)

A verbal order is a spoken instruction by a prescriber to another health care professional. The Nursing and Midwifery Council state that “instruction by telephone to administer a previously unprescribed substance is unacceptable.”

Prescribing without seeing the patient denies the prescriber the opportunity to obtain a full clinical picture or reassess the case and check whether the patient‟s condition has changed. Where possible the prescriber must be encouraged to make required amendments to prescriptions in person. In areas where there are no resident prescribers the need for verbal messages can be avoided by the use of faxed or electronically transferred instructions.

The administration of medicines on a verbal order is only permissible in exceptional circumstances and in the case of an intravenous medicine, in an extreme emergency only.

The practitioner retains the right to refuse to take a verbal message to administer a medicine.

When doctors from Local Care Direct are providing medical cover to HVMH (out of hours) the doctor may choose to instruct a medicine to be administered without visiting the hospital. An instruction to administer the medicine signed by the doctor should be faxed to the ward. This fax must be kept with the patient‟s Prescription Chart and Administration Record. Doses administered must be recorded on the patient‟s Prescription Chart and Administration Record. A signed prescription must be written onto the patient‟s Prescription Chart and Administration Record when the doctor responsible for the patient‟s care visits the ward on the next working day.

If the fax machine is not working or is not printing out clearly a verbal message may be accepted by the nurse in charge in accordance with the above guidance, and following the procedure below.

The fax machine should be repaired as soon as possible

Controlled drugs must never be prescribed by use of a verbal order

How to Accept Verbal Orders

A practitioner competent in the administration of medicines may accept a spoken instruction from a prescriber for the administration of a single dose of medicine or for doses to be given until a doctor will be able to visit the patient. The instructions must be spoken back to the prescriber and reconfirmed by him/her. Where two practitioners are present on the ward they must both carry out the above practice.

The practitioner receiving the verbal instruction must record the order on the patient‟s Prescription Chart and Administration Record on the once only section detailing:

The date

The time

The prescribers name written in BLOCK CAPITALS

The signature and printed name of the practitioner(s) receiving the order

The words “Verbal Order”

Details of the medicine

Any previous prescription for the medicine must be cancelled, signed and dated. The reason for the cancellation must be documented in the clinical record.

The practitioner accepting responsibility for the order must ensure that he/she understands it fully and that he/she is fully conversant with the medicine and prescribing details before administering the dose of the medicine. If the practitioner

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is uncertain of any aspect he/she must not accept the order and make this known to the prescriber.

The practitioner must record in the patient's clinical records "verbal order by telephone" and provide details of the date, time, message and the name of the prescriber. The prescriber, or another doctor, must sign the verbal order preferably within 24 hours of the verbal order being issued and no later than the next working day.

1.20 Prescribing by Dieticians

Dietary products are considered to be borderline substances. Dieticians are authorised to initiate the use of dietetic products by writing the item on the Prescription Chart & Administration Record. The entry on the prescription must detail:

The product name, the dose, the route, the frequency and any special instructions

Start and stop dates

The printed name and signature of the responsible dietician with a contact bleep/telephone number

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SECTION 2 – ORDERING MEDICINES

2.1 Stock Drugs

Wards keep a stock of medicines which are commonly used and a limited stock of those for use in medical emergencies. The stock list is agreed between the ward manager and the ward pharmacist. This list is reviewed at least annually.

Stocks are ordered from the pharmacy at HRI using the pre-printed requisition form. The registered nurse in charge of the ward must sign the order

The nurse in charge of the ward is responsible for ensuring that sufficient stock is ordered from the Pharmacy at Huddersfield Royal Infirmary, and that existing stock is in date.

The nurse in charge of the ward is responsible for obtaining additional stocks to meet unusual demands by use of a signed Pharmacy Requisition form which can be faxed to pharmacy at HRI if urgent.

Controlled Drugs are dealt with in section 6

2.2 Non-Stock Drugs

Wherever possible, patient‟s own medicines must be administered. Where patient‟s own medicines are unavailable, or are unsuitable for use, or if a medicine is newly prescribed, pharmacy will dispense the item(s) after clinically checking a valid prescription. Patients own medicines must never be shared with other patients.

The visiting ward pharmacist (from pharmacy at HRI) will review new prescriptions at each ward visit, (normally twice a week), and assess the requirement for new medicines to be dispensed. The review will also assess safety and appropriateness of the prescription as well as compliance with the formulary and other good practice guidelines. Repeat supplies will also be dispensed when needed.

Where non-stock drugs are required urgently, or before the pharmacist‟s next visit, the nurse must check the Prescription Chart and Administration Record to ensure that the patient details and the ward are correctly written on the front page. The Prescription Chart and Administration Record must then be faxed to pharmacy at Huddersfield Royal Infirmary, together with an indication of what is required. All pages of all current Prescription Chart and Administration Records for the patient must be faxed.

Arrangements for obtaining urgently required non-stock drugs, out of hours, are described in section 15.

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SECTION 3 - TRANSPORT AND RECEIPT OF MEDICINES

3.1. Security and Transportation

Whilst medicines are awaiting transport they must be stored securely.

Medicines are transported between hospital sites in security sealed or tamper evident containers, such as ward drug boxes or pouches. Where ward drug boxes are used the access keys must only be held by pharmacy and the receiving location. The pharmacy department at HRI supplies medicines to HVMH using scheduled hospital transport, or a taxi booked through the hospital transport service. Delivery of medicines that are urgently required outside the normal transport schedules will be arranged in conjunction with the transport department or HRI switchboard

Deliveries of medicines to wards must be unpacked on receipt, to ensure safe, secure and appropriate storage.

Items to be returned to pharmacy must be returned in secure containers. If fridge items need returning, the ward pharmacist should be asked to arrange this to ensure the cold chain is maintained.

While medicines are in transit the person delivering the package is responsible for the security of the items they are delivering.

Where medicines are transferred from pharmacy to another location it is good practice to keep a record of the person accepting responsibility for delivery of the „package‟ and a record of the person accepting responsibility for receipt of the „package‟ (audit trail).

See controlled drug section for advice related to transport and receipt of CD‟s.

3.2 Receipt of Medicines

The nurse in charge is responsible for ensuring that receipts are dealt with promptly and that

Receipts of stock medicines are checked against the itemised delivery note.

The note is signed to indicate correct delivery.

Discrepancies are followed up with pharmacy, immediately.

Medicines are immediately and securely stored in the designated place.

Medicines requiring cold storage must be placed in the fridge immediately after receipt.

The ward manager or deputy must retain delivery notes for 1 month in an agreed location.

HRI Pharmacy does not provide a delivery note for medicines dispensed for named patients.

If medicine(s) are received at ward level for an unknown patient the pharmacy department at HRI must be informed immediately.

3.3 Returns to HRI Pharmacy

Unwanted medicines, which are to be returned to HRI Pharmacy, must be stored securely on the ward either in a locked pharmacy box or cupboard until they are collected. Only medicines which are still in date and were originally supplied by HRI pharmacy can be returned.

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SECTION 4 – NEWLY ADMITTED PATIENTS AND PATIENT’S OWN MEDICINES

4.1 On Admission

Patients are requested to bring in all medicines that they are currently taking. This includes medicines bought by themselves, by others for them, and herbal medicines. These medicines should be used (with the patient‟s consent), during the patients stay if they are written on the patients Prescription Chart and Administration Record, and signed by the doctor. This prevents avoidable waste and ensures patient safety.

Advice regarding the checking of and re-use of patient‟s own medicines can be found in the Calderdale and Huddersfield NHS Foundation Trust „‟Policy for the Self-administration and Re-use of patients Own Medicines”. This policy can be referred to by LCP staff at HVMH as an example of good practice.

All newly admitted patients will be seen and clerked in by the receiving GP within 4 hours of admission. Care must be taken to ensure that newly admitted patients do not miss essential doses of medicines while they are waiting to be clerked in.

The nurse, with the patients‟ permission, should take custody of all medicines brought in, and store them securely in the ward medicines trolley or cupboard. If the patient does not agree to this, the GP who will be responsible for their care whilst at HVMH should be contacted for advice. Inhalers and GTN sprays should usually be left with the patient. Eye drops and preparations for topical use may also be left with the patient, if that is their wish.

If a completed Calderdale and Huddersfield NHS Foundation Trust Prescription Chart and Administration Record has come with the patient, the nurse should give doses of medication as prescribed until the doctor arrives to clerk in the patient. If a copy of a CHFT discharge prescription has also come with the patient the nurse must check that it matches the prescription chart.

If there are differences between the discharge prescription and the Prescription Chart and Administration Record the nurse must check with the doctor before administering medicines which are on the prescription chart but not on the discharge prescription. The nurse must show the doctor the discharge prescription as well as the Prescription Chart and Administration Record when the patient is clerked in.

If the patient arrives from HRI or CRH without a completed Calderdale and Huddersfield NHS Trust prescription and administration record, the nurse will ring the ward from which the patient has been transferred, and request it to be sent by hospital transport or taxi.

When patients are admitted from other NHS Trusts a suitably labelled supply of medicines should come with them. The nurse must ensure that the doctor sees the discharge prescription together with any other patient notes.

There must be confirmation that the medicines have been stored appropriately prior to admission, for example, items that require refrigeration must have been stored in a refrigerator.

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4.2 Medicines Reconciliation

Medicines reconciliation must always be carried out at the point of admission.

The doctor clerking in the patient should have access to all medicines brought in by the patient and all relevant documentation as follows:

For patients transferred from CHFT - current prescription chart and administration record, current notes, and discharge prescription (if one has been written).

For patients transferred from other acute trusts – discharge prescription form plus any other written information relevant to medicines.

For patients admitted directly from home - record of current medicines from GP surgery

It is the nurse‟s responsibility to ensure that the above documentation is available to be seen by the admitting doctor. The nurse must point out any discrepancies they have noticed between drugs received and records, or between prescription chart and discharge prescription.

Medicines reconciliation should include discussion with the patient or carer to check whether medicines are taken as prescribed, or whether any other medicines, including herbal remedies, are taken regularly.

The admitting doctor must list the current medication in the patient notes and document any changes made on admission.

The Ward Pharmacist will confirm at their next visit that medicines reconciliation was carried out at the point of admission and re-check the medicines and documentation as listed above. Any discrepancies or queries are referred as appropriate to the doctor.

4.3 Non Formulary Medicines

A patient may be admitted who is maintained on a medicine not approved by the South West Yorkshire Area Prescribing Committee. The following options can be considered if the patients own supply is not available, unsuitable for use, or is used up during their stay:

The doctor can be asked to modify the patient's prescription to the nearest equivalent approved medicine or

HRI Pharmacy can be asked to make a one off purchase. (This may not be appropriate for a medicine where there is an agreed alternative).

The patient‟s GP may wish to provide prescriptions for further supplies of a medicine.

4.4 Storage of Patients Own Medicines

Patients own medicines must be stored in their named compartment in the ward medication trolley. Any medicine which will not fit in the compartment, or is not in current use, must be stored in the medicine cupboard in a bag with the patients name written on. There should only be one named bag for each patient. If 2 bags are needed (e.g. for bulky medicines) the bags must be clearly marked „1 of 2‟, „2 of 2‟ etc..

Medicines requiring cold storage must be stored in the ward‟s medicine refrigerator. The patient‟s name must be on the container.

It is the responsibility of the nurse to ensure that patients who are keeping their own supplies of inhalers, eye drops and preparations for topical use are

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keeping them in an appropriate place. This is to ensure the integrity of the medicines and the safety of other patients.

It is the responsibility of the nurse to ensure that if a patient is transferred to a new location all of their medicines are transferred with them.

4.5 Discharge Procedure for Patient’s Own Medicines

Advice regarding the use of patient‟s own medicines for discharge can be found in the Calderdale and Huddersfield NHS Foundation Trust „‟Policy for the Self-administration and Re-use of patients Own Medicines”. This policy can be referred to by LCP staff at HVMH as an example of good practice.

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SECTION 5 - STORAGE AND SAFEKEEPING OF MEDICINES The LCP Head of Medicines Management is responsible for establishing systems for the safe and secure storage of medicines to ensure the security and quality of medicines are maintained.

The ward manager or nurse in charge is responsible at all times for ensuring these systems are followed and the security of medicines is maintained.

CHFT Pharmacy staff must be involved in approving the design and location of all ward medicine storage cupboards and for regularly monitoring storage arrangements.

All internal and external medicines, disinfectants, and reagents must be stored in lockable cupboards, trolleys (which are chained to the wall) or other secure cabinets or refrigerators which are reserved solely for medicinal products and must be locked when not in use. This includes medicines for self-administration and for discharge. The only exceptions to this requirement are medicines for clinical emergencies, intravenous fluids, sterile topical fluids, dietetic products, some medicines for self-administration and medicated dressings which, because of their bulk, are stored in a clean area (as agreed between the ward manager and an authorised member of the pharmacy staff).

Cupboards for internal medicines (other than medicines for self administration) must be fixed to a wall and comply to British Standard. (BS 2881:1989)

Internal medicines must be stored separately from medicines for external use. Medicines must not be transferred from their original container to another, or taken out of their original container and left loose.

The storage of medicines must minimise the risk of selection or reconstitution errors, as far as is possible within current storage facilities.

Medicines awaiting return to pharmacy or disposal must be stored securely. They must not be left on open surfaces in the treatment room. If they are put into the pharmacy box, the box must be locked.

5.1 Control of Substances Hazardous to Health Regulation (COSHH)

Some medicines are, by their nature, hazardous. It is the responsibility of the ward manager to perform an assessment of hazard and risk of medicines kept on the ward. The assessment forms part of the overall COSHH assessment system that is required by LCP. Specific product safety information can be obtained from the manufacturer.

5.2 Position of Cupboards and Trolleys

Cupboards must be sited where convenient for staff, allowing adequate space and permitting surveillance to afford maximum security against unauthorised entry. Cupboards must not be sited where they may be subjected to higher than average humidity or temperature. Reagent cabinets must be sited in areas where testing is carried out.

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5.3 Storage Accommodation

Clinical areas may have some or all of the following lockable, medicine storage units.

Controlled drug cupboards – refer to section 6.

Internal medicine cupboard(s) - for the storage of tablets, liquid medicines, injections etc.

External medicine cupboard(s) - for the storage of creams, lotions etc.

Medicine refrigerator.

Reagent cupboard(s) - situated in the area where urine testing is carried out.

Medicines for clinical emergency - must be readily accessible and in a position to afford supervision to prevent unauthorised access. These must be held in a tamper evident box and must not be in a locked cupboard. If a box is opened, even if the contents have not been used, pharmacy at HRI must be informed. A replacement box will then be supplied as soon as possible. The ward pharmacist will collect the opened box at their next visit. Pharmacy at HRI keep a record of expiry dates of these boxes and the ward pharmacist will bring a replacement box if the one held on the ward is due to expire.

Enteral feeding products must be stored in a clean area of the ward or in the ward fridge if appropriate. They do not need to be locked up.

Cupboard or designated clean area for intravenous fluids and sterile topical fluids.

Medicine trolley - this is for the storage of ward stock and items dispensed for individual patients as agreed with the ward pharmacist. The medicine trolley must be locked and secured to the wall.

The following medicines may be stored in the bedside locker: GTN spray and inhalation therapies, which must be accessible to the patient if needed urgently.

5.4 Refrigerated Storage

Medicines are not to be stored together with food or pathological specimens but in a separate locked fridge. Medicines requiring storage below room temperature will be marked "Store between 2ºC and 8ºC” or “Store in a refrigerator."

Items requiring refrigerated storage must be placed in a specially designated medicines refrigerator immediately on receipt.

The ward manager is responsible for ensuring that:

Refrigerators used for storage of medicines contain continuous temperature monitoring devices capable of recording maximum and minimum temperatures.

Staff who may access the refrigerator are properly trained.

Items other than medicines are not placed in the medicines refrigerator.

A member of ward staff, assigned by the ward or nurse in charge must record the minimum and maximum temperatures once a day on a log sheet kept by the refrigerator. A copy of the log sheet should be faxed to the LCP Medicines Management Team at the end of every month. Log sheets must be retained for a period of 2 years.

The assigned member of staff must re-set the monitoring device after each reading.

Should either the minimum or maximum temperature be outside the range 2 C to

8 C, this person must inform the nurse in charge who must seek immediate advice from pharmacy at HRI.

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If a breach of fridge temperature occurs outside pharmacy working hours medicines from the fridge must not be used until pharmacy can be contacted. If possible they should be held in bond in a fridge which is operating correctly until advice is available. If there is an urgent need for one of the affected medicines to be administered “out of hours” the on call pharmacist should be contacted.

Refer to „Guidelines on the Storage and Handling of Vaccines and Other Medicines Requiring Cold Storage – The Cold Chain‟ for further information. This can be found on the NHS Kirklees website under the Locala section.

5.5 Flammable Liquids

These must be stored in a metal cupboard or on a metal tray within a locked cupboard in order to contain any spillage.

5.6 Medical Gases

Maple Ward keeps cylinders of Oxygen and Medical Air which are supplied under the contract for HVMH. Medical gases are not supplied from CHFT. Medical gases provided in cylinders must be transported in approved cylinder trolleys, and must be placed / stored in a safe manner. When they are not in use, they should be stored in a safe location. All staff involved in handling medical gases, including portering staff, must have received appropriate training. Currently, KIER (the company contracted to provide portering services) are responsible for the training of portering staff on Maple Ward. There is currently no piped supply of medical gases. Please see CHFT guidance as an example of good practice. Available at: http://nww.cht.nhs.uk/index.php?id=4849&policy=166 .

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SECTION 5a - CUSTODY AND SAFEKEEPING OF MEDICINE KEYS

The ward manager, or in his/her absence, the nurse in charge is responsible for the safekeeping of medicine storage keys and must at all times ensure that safe systems are followed and the security of medicines is maintained. When these keys are to be passed to a nurse, or an authorised staff member from Calderdale and Huddersfield NHS Trust/ LCP Medicines Management Team, this must be person to person.

The treatment room is locked by an electronic fob system. Staff leaving the room must ensure that the door closes fully so that the lock operates. Staff other than registered nurses, who have fobs enabling them to enter this room must not be able to access medicines.

The ward manager must take precautions to ensure that staff do not leave the ward with any ward keys. The names and contact telephone numbers of all qualified nursing staff on the ward be available. Every effort must be made to retrieve the keys should a member of staff go off duty with them. Should access to medicine cupboards be required before the keys are retrieved the nurse in charge must obtain the duplicate set of keys via the ward manager who is responsible for the safe custody of the duplicate set of keys.

If duplicate keys are not available the cupboard(s) must be broken open and a new lock(s) fitted. In this instance the nurse in charge must inform the Intermediate Care Services Manager, (or if not available report to the Director or Deputy Director on call), notifying the ward pharmacist as soon as possible during normal hours. A clinical incident form must also be completed.

KEYS

Medicine Keys

The keys for the external medicine cupboards, internal medicine cupboards, medicine refrigerator, Controlled Drug cupboard, medicines trolley and pharmacy transport boxes must be kept together on one key ring reserved solely for these keys.

An authorised practitioner must hold the keys.

Keys for the Controlled Drug Cupboard

Controlled drugs keys must be held by the nurse in charge or a practitioner nominated by them. Responsibility remains with the nurse in charge and the keys must not be handed to medical staff (see section 6 Controlled Drugs for the exception).

Keys for the Reagent Cupboard

The key to the reagent cupboard may be kept separately and in a place designated by the ward manager.

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SECTION 5b - LOSSES OR DISCREPANCIES OF MEDICINES

The practitioner discovering any loss of other medicines must report the loss, immediately, to the Intermediate Care Services Manager, (or if not available report to the Director or Deputy Director on call), the ward manager, and to the pharmacy at HRI, who can then decide on a further course of action. The practitioner discovering the loss must complete a LCP clinical incident form. Where theft is suspected, the LCP Head of Medicines Management may institute arrangements that require records to be kept of all doses of the affected medicine(s), supplied and administered on that ward.

For controlled drugs see section 6.

Checks by Pharmacy Staff

Designated Pharmacists and named members of Calderdale and Huddersfield NHS Foundation Trust/ LCP Medicines Management staff are authorised to undertake stock checks in wards at HVMH. Checks of Controlled Drugs will be undertaken at not less than six monthly intervals, see section 6. Checks of other stocks will be undertaken where circumstances warrant.

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SECTION 6 - CONTROLLED DRUGS (CDs)

"Controlled Drug" means a drug in classified Schedule 1, 2, 3, 4, or 5 of the Misuse of Drugs Regulations 1985 (as amended).

Schedule 1 Controlled Drugs, e.g. LSD and cannabis may only be possessed or used by persons with a Home Office licence for research or other special purpose.

Schedule 2 includes the opiates, the major stimulants, secobarbital and 6 other substances e.g. amphetamine.

Schedule 3 includes Temazepam, the barbiturates, Buprenorphine, Midazolam, Pentazocine and Flunitrazepam.

Schedule 4 contains anabolic and androgenic steroids and most of the benzodiazepines.

Schedule 5 contains preparations of certain Controlled Drugs e.g. Codeine syrup, Pholcodine and Morphine 10mg in 5ml, which are exempt from full control when present in medicinal products of low strength.

Staff at HVMH should follow The Calderdale and Huddersfield NHS Foundation Trust Policy which does not differentiate between the schedules for controlled drugs used on the wards.

Schedule 3 and Morphine 10mg/5ml from Schedule 5, and potassium concentrate solution and high strength potassium infusions (greater than 40mmol/L) are treated the same as Schedule 2 Controlled Drugs.

General comments on Controlled Drug Registers and Order books

The ward stocking Controlled Drugs must have an order book and a Register, which must be stored in a locked medicines cupboard.

When ordering oral opiates the brand name should be used

The index and the title at the head of each page of the register must have the name of the medicine, form and strength, and for oral opiate the brand name.

Entries must be made in indelible black ink.

Liquid paper must not be used.

Incorrect entries must not be crossed out but bracketed and error written and the mistake initialled

No pages or parts of pages must be removed from the Register

Cellotape and staples must not be used on pages of the Controlled Drug register

Full registers must be retained and stored locally for 7 years from the date of the last entry. (On the front cover of completed registers state the date the last entry was made).

Order books must be retained and stored locally for 2 years from the date of the last entry.

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Additional Information

Potent opiate analgesics are frequently involved in serious medication errors, often because of incorrect dose calculations. A wide range of products of differing potencies, dosage forms and release characteristics are available, this can be confusing to inexperienced staff and contributes to medication errors. In particular, confusion between different strengths of oral morphine has caused a number of fatalities. Many opiate preparations are derivatives of morphine therefore their names often contain a common stem. This can lead to confusion, particularly when medicines with similar sounding names have greatly differing potencies. For example;

Morphine

Diamorphine

Hydromorphone

Care must also be taken when selecting the correct strength of medicine, as packaging is often very similar.

Other preparations where care must be taken are opiate patches, such as fentanyl. Many of these patches are difficult to see when applied to a patient‟s skin. Before a new patch is applied, it is important to identify and remove all previous patches. It is also recommended that patches should be marked with a black marker pen to make them more easily identified in the ward setting, this will help to avoid patches being applied without the previous patch being removed (there have been instances of opiate overdose due to failure to remove old patches).

Controlled drugs to be administered to inpatients are prescribed on the Calderdale and Huddersfield NHS Foundation Trust prescription chart and administration record in the same way as any other medicine. It is particularly important that prescriptions for CDs are clear, complete, legible and unambiguous. Verbal messages are not acceptable.

Prescriptions for multiple routes of administration must be written separately e.g. Morphine oral/IV is not acceptable. The IV and the oral dose must be prescribed separately.

IV opiates are not prescribed routinely at HVMH. If a situation arose where they needed to be prescribed the guidance given in the Calderdale and Huddersfield NHS Foundation Trust document „Prescribing and Administration of Intravenous Opioids in the Trust‟ should be followed.

Oral sustained release opiates are a particular source of error and care must be taken to avoid any possible ambiguity when prescribing these drugs. Including the brand name on the prescription and dispensing label will aid in the correct identification of the correct formulation to be dispensed or administered. For example, Oxycontin contains sustained release oxycodone and Oxynorm contains immediate release oxycodone.

Where the formulation, dose or drug is changed on prescription, the ward staff, and prescribing doctor must check to ensure the revised drug regime is in an appropriate dose in relation to previous therapy (many errors occur when opiate drugs are changed, or the route of administration is changed in relation to dose conversions). If in any doubt, contact the medicines information department at CHFT.

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Note

A Doctor must not administer or authorise the supply of Cocaine or Diamorphine, their salts or Dipipanone to an addicted person except for the purpose of treating organic disease or injury unless he or she is licensed to do so by the Secretary of State.

At HVMH non-medical prescribers may only prescribe controlled drugs when these have been initiated by a medical practitioner, and the continued use is clearly documented in the patient‟s clinical management plan.

6.1 Discharge Prescriptions for Controlled Drugs

Discharge prescriptions for Schedule 2 and 3 Controlled Drugs, excluding Temazepam tablets and morphine solution 10mg in 5ml, must be written in accordance with legal requirements. The Calderdale and Huddersfield NHS Foundation Trust Controlled Drug prescription form is available for use on the ward at HVMH. All Controlled Drugs must also be written on the Medication and Discharge Summary.

Prescriptions for controlled drugs must be written in indelible black pen, in BLOCK CAPITALS, signed, and dated by the prescriber.

The prescription must include:

a) The name and address of the patient.

b) The name, form, and strength of the Controlled Drug e.g. Morphine Sulphate (name), injection (form), 10mg (strength); morphine (name), slow release capsules (form), 30mg (strength).

c) The dose and frequency. For regular medicines both the dose and frequency must be stated. For prn medicines the dose must be stated and guidance for the time interval must be stated. „As directed‟ is not acceptable

d) The total quantity of the Controlled Drug to be supplied (i.e. the total number of tablets or millilitres of liquid) in both words and figures.

e) Signature of the prescriber

f) Printed name of the prescriber

g) Date prescribed

The preparation must exist in the form and strength prescribed. Any alterations and amendments must be made by the same doctor and signed.

Prescriptions for different doses of the same Controlled Drug must be written separately.

A discharge prescription for a CD should ideally be written in time for the ward pharmacist to collect the completed form at their next visit and arrange for the dispensed CDs to be delivered on the next day.

If this is not possible the completed CD prescription form should be faxed to HRI pharmacy and arrangements made by phone for the CDs to be dispensed and delivered. HRI pharmacy staff will advise whether the ward pharmacist will collect the original form at their next visit or whether it should be sent to HRI pharmacy by transport.

If the pharmacist on duty at HRI does not consider the faxed prescription to be acceptable they may ask for the original to be sent by transport.

The original completed CD prescription form must be kept in a secure place on the ward until it has been collected by the ward pharmacist or sent by transport. A

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completed CD prescription form must be transported in a locked box or sealed tamper evident envelope.

Controlled Drugs, which are part of the discharge medication, must be signed for at HRI pharmacy by an authorised messenger, as accepted for delivery to HVMH. The authorised messenger will usually be a member of The Calderdale and Huddersfield NHS Foundation Trust Transport department, or a taxi driver booked through the Transport Department. See section 6.3

Once received on the ward at HVMH the CD for discharge must be entered in the Controlled Drug register for patients own medicines, using a separate page for each item. (See section 6.6, Receipt and Storage of Patient‟s Own Controlled Drugs).

At the time of the patients discharge the CD must be booked out of the register before it is handed to the patient. This register entry must be witnessed.

6.2 Ordering Stock Controlled Drugs

The ward manager is responsible for ensuring that the appropriate range and stock levels of Controlled Drugs are maintained and managed in the clinical area and in conjunction with the relevant medical and pharmacy staff.

The nurse in charge must request Schedule 2 and 3 Controlled Drugs in a Controlled Drug Order book. Only nurses whose signatures have been registered with HRI pharmacy department can sign a C.D. order1. The ward manager is responsible for registering new members of staff as authorised signatories and must countersign each signature to be registered. The ward manager is also responsible for keeping the list of registered signatures up to date, removing signatures promptly as nurses leave.

Schedule 4 and 5 Controlled Drugs may be ordered in the same way as other medicinal products except Morphine 10mg in 5mls, which must be ordered in the Controlled Drug Order book.

The nurse in charge must complete the request in BLOCK CAPITALS and must:

Ensure the carbon paper is inserted correctly

State the name of the hospital and ward

State the name, form and strength of the medicine being ordered

State the actual quantity (not a box)

Sign and print name

Date the requisition

Only one preparation must be requested per page. Only two order books should be in use at HVMH at any one time.

A copy of each order must be retained in the order book by the ward. The signature for receipt on the ward is on this copy page. Once full the order book must be retained locally for two years. The original order will be retained by the pharmacy at HRI for two years.

Routine ordering of Controlled Drugs should ideally be carried out on the day the ward pharmacist visits.

The CD order book should be kept on the ward for collection by the ward pharmacist. The CDs ordered will normally be delivered on the next working day. If the CDs are required before the next visit by the pharmacist, the CD book can be sent to

1 Pharmacy provide the documentation for registering signatures.

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pharmacy at HRI, preferably in a locked pharmacy box. Pharmacy at HRI must be phoned, to inform them that a CD order is being sent, and the time when the CD will be needed on the ward.

If stock CDs are needed very urgently (e.g. later the same day) the order can be telephoned to pharmacy at HRI. The signed order must be kept on the ward for the pharmacist to collect at their next visit, or sent to pharmacy at HRI if this is requested by pharmacy.

CDs ordered by telephone will be delivered together with a page from a CD order book kept in pharmacy at HRI for this purpose. The driver will ask the nurse to sign for receipt (see section 6.4). The nurse must retain the signed page from the pharmacy book together with the signed order in the ward CD order book. Any other delivery paperwork must also be kept. The CDs are booked into the register in the usual way. The page numbers from the ward book and the pharmacy book must both be recorded in the register.

6.3 Stock List of Controlled Drugs

The ward has a list of Controlled Drugs which are routinely held as ward stock. The ward manager and the ward pharmacist are responsible for the content of this list, which is updated in line with current usage of CDs. CDs on the stock list are ordered as described in section 6.2. If CDs are prescribed and are not held as ward stock, these will only be supplied against a prescription together with a signed CD order. The prescription can be either seen by the Ward Pharmacist, or faxed to HRI pharmacy if needed between visits. Stocks of CDs which are not on the approved stock list must be disposed of as soon as possible when there is no longer a current prescription for them.

6.4 Collection and Transport of Stock Controlled Drugs

Only hospital transport staff or authorised taxi drivers booked through hospital transport or hospital switchboard can collect controlled drugs for HVMH from the pharmacy department at HRI. Taxi drivers are only used at times when no hospital transport is available.

The transport or taxi driver will sign to accept the CDs for delivery. They should be made aware of the number of containers they are accepting, but not the exact nature and quantity of the contents. The person who has signed is responsible for the Controlled Drugs while in transit until they are received on the ward and signed for by a registered nurse. See 6.5 below

Controlled Drugs must be transported in tamper evident pouches or locked boxes which conceal their identity. When hospital transport is delivering CDs a locked box must be used if one is available. Taxi drivers will be given a sealed tamper evident pouch and will be instructed to obtain a signature for receipt of the contents on documentation supplied by the pharmacy which will then be retained by the nurse at HVMH. (This is in addition to any signatures required on their own company‟s documentation)

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6.5 Receipt of Stock Controlled Drugs

A registered nurse is responsible for signing for receipt of Controlled Drugs on the ward as soon as the transport or taxi driver delivers them. Receipt must be signed for while the driver is still present Until this is done, the person who has signed „accepted for delivery‟ is still responsible for the Controlled Drugs. See section 6.4 The nurse signing for receipt must check the number of sealed containers of CDs received, against the pharmacy delivery documentation to confirm it is correct. The registered nurse who has signed for the Controlled Drug must:

Lock the CDs into the Controlled Drug cupboard immediately on receipt to the ward, even if it is not possible to make the register entry immediately.

Retain all delivery paperwork in a secure place.

Check the number of units of Controlled Drugs received and record them in the Ward Controlled Drugs Register in the presence of a second nurse. If only one registered nurse is on duty at HVMH (e.g. on night duty) an auxiliary nurse can act as the witness. See 6.13 for further information on registration status and witnessing CD entries. If this cannot be done immediately on receipt, it must be done at the earliest opportunity.

Each preparation has its own section in the Controlled Drugs Register. For example a Diamorphine 5mg syringe and a Diamorphine 5mg and Haloperidol 2.5mg syringe should be recorded on separate pages. The nurse receiving Controlled Drugs must ensure the following details are entered in the correct section of the record book:

Date of receipt

Requisition Number

Quantity received

Running total

The signatures of the receiving nurse and the witness

If broken ampoules are received they must be entered into the Ward Controlled Drug Register as part of the total stock. It must be reported to the pharmacy at HRI. Ideally the broken ampoules must be kept until the ward pharmacist can witness the destruction and record in the ward Controlled Drug Register. Where this is impractical (loose broken glass, pharmacist not available) the nurse in charge may destroy and record in the Ward Controlled Drug Register and another registered nurse must witness this.

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6.6 Unwanted Stock Controlled Drugs

Unwanted stock Controlled Drugs must not be returned to pharmacy. They must be disposed of as documented in section 6.15.

6.7 Receipt and Storage of Patient’s Own Controlled Drugs

When patients bring their own Controlled Drugs into hospital they are subject to the same checks and controls as stock Controlled Drugs. Their receipt, use, and return or disposal must be documented in the Controlled Drugs Register specifically for patients own Controlled Drugs. A separate numbered page must be used for each item.

The receipt must also be documented on the Prescription Chart and Administration Record.

If a patient is admitted with a monitored dosage system containing Controlled Drugs it must be stored intact in the Controlled Drugs Cupboard and a record must be made in the Ward Controlled Drugs Register.

Controlled Drugs dispensed for discharge and supplied to the ward must be documented in the Controlled Drug register for patients own CDs and signed in and out in the usual manner.

The nurse receiving CDs for discharge must lock them in the CD cupboard immediately on receipt from transport in the same way as for stock CDs.

See section 6.16 for the transfer of patient own drugs between HRI and HVMH.

6.8 Storage of Controlled Drugs

Controlled Drugs must be stored in Controlled Drug Cupboards. These are reserved solely for the storage of Controlled Drugs and bolted to a solid wall. These cupboards may be separate from others or be inside other locked medicine cupboards used to store internal medicines. Controlled Drug cupboards may be connected to a red warning light to identify when the door is open. The cupboards must be constructed to conform to the current British Standard and the lock must not be the same as any other lock in the hospital.

6.9 Safe Custody of Controlled Drug Keys

The Controlled Drug keys must be kept on the main ward medicine key ring and held by the nurse in charge or practitioner nominated by them. Responsibility remains with the nurse in charge. The key must not be handed over to medical staff, auxiliary staff or other health professional for any reason.

6.10 Loss of Controlled Drug Keys

If the Controlled Drug cupboard keys are lost the locks must be changed as soon as possible. The Intermediate Care Services Manager and the ward pharmacist must be notified and a clinical incident form completed. Out of hours inform the Clinical Manager, or if not available the Director or Deputy Director on call, and inform the ward pharmacist and Risk Management department on the next working day. The loss of the keys must also be notified to the Controlled Drugs Accountable Officer.

6.11 Stock Balances of Controlled Drugs

The ward manager is responsible for ensuring the checks described below are carried out. A record of such checks in the register must be made. Checks must be undertaken at least once every twenty-four hours, for both ward stock and patients own Controlled Drugs.

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Working from the Controlled Drug register check each page individually and check against the actual stock balance. Care must be taken to ensure that blisters that appear intact contain a dose. The checking procedure must also be carried out in such a way that any controlled drug which had not been entered in the register would be identified.

A registered nurse authorized by the nurse in charge must check with a second nurse, and a record of the checked balances made in the Controlled Drugs Register by:

Inserting the date

Documenting “Checked and Correct”

The signatures of both nurses

Stock balance

6.12 Pharmacy Stock Checks

The ward pharmacist must check Controlled Drug recording, storage and administration records every six months. Procedures and documentation for this will follow those used in Calderdale and Huddersfield NHS Foundation Trust. This must be undertaken with a registered nurse acting in the capacity of a witness. A copy of the six monthly check will be forwarded to the Ward Manager and the LCP CD Accountable Officer. Should any issues be raised the next check may be brought forward in agreement with the ward manager.

6.13 Administration of Controlled Drugs

See section 7 for general guidance about drug administration.

IV opiates are not prescribed routinely at HVMH. If a situation arose where they needed to be prescribed and administered the guidance given in the Calderdale and Huddersfield NHS Foundation Trust document „Prescribing and Administration of Intravenous Opioids in the Trust‟ should be followed.

All dose calculations and administration of Controlled Drugs must be double-checked.

Administration of CDs must be carried out by a Registered Practitioner. This means a nurse who holds First Level Registration or a Second Level nurse who has completed a period of education and is deemed competent to function as a First Level nurse in relation to Controlled Drugs.

A second nurse must carry out a check. The second checker must be a registered nurse or a student nurse, except at times when only one registered nurse and no student is on duty. At these times an Auxiliary Nurse can act as the witness as long as the registered nurse and the auxiliary are confident that the auxiliary is suitably experienced and competent to do this.

The nurse must check the actual stock balance against the balance in the ward Controlled Drugs Register before and after the dose is removed from stock. If incorrect refer to section 6.14

An entry must be made in the ward Controlled Drugs Register, including:

date and time of administration

name of patient

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dose administered

full signature of the practitioner and the witness

new stock balance

Any medicine prepared and not used must be destroyed in the presence of a second practitioner, or authorised auxiliary nurse witness. The entry made in the Controlled Drugs Register and signed by both practitioners must indicate the action taken. An expanded explanation must be documented in the nursing records.

An oral syringe must be used when administering liquid Controlled Drugs.

6.14 Discrepancies with Controlled Drugs

Any discrepancies in the delivery of Controlled Drugs must be notified to the pharmacy at HRI immediately. A full investigation by the ward in conjunction with pharmacy at HRI will be undertaken. A clinical incident form instigated by the person reporting the loss must be completed.

In the event of a discrepancy between the stock balance and register for Controlled Drugs, the nurse in charge must immediately and thoroughly investigate the loss or error. A missing entry or incorrect calculation or balance transfer must be sought. Confusion with other similar preparations must be excluded. The action taken and the outcome of the initial investigation must be documented on the appropriate page of the Controlled Drugs Register. A clinical incident form must be initiated by the person reporting the discrepancy and the ward manager informed as soon as possible. The ward pharmacist at HRI must be informed on the next working day.

Any anomalies with the integrity of the register or the quality of the information reported in the register must be reported to the ward manager who must fully investigate the concerns raised and discuss with the ward pharmacist. The person raising the concern must initiate a clinical incident form.

Should the discrepancy/anomaly not be resolved the Intermediate Care Services Manager and the pharmacy at HRI must be informed. If out of pharmacy working hours the Intermediate Care Services Manager or the Director or Deputy Director on call must make a judgement as to whether the on call pharmacist needs to be informed immediately or whether the ward pharmacist could be informed the next working day. The ward pharmacist must inform the Clinical Director of Pharmacy at Calderdale and Huddersfield NHS Foundation Trust at the earliest opportunity.

In all instances where a discrepancy cannot be resolved quickly, the LCP Controlled Drugs Accountable Officer MUST be informed immediately so that additional resources can be deployed to assist with resolution / investigation as necessary.

Where theft of Controlled Drugs is suspected one of the following will notify the police on behalf of the organisation:-

Designated person in charge of Holme Valley Memorial Hospital

LCP Controlled Drugs Accountable Officer (or other nominated officer acting on his / her behalf)

Director of Corporate Services and Nursing.

Deputy Director of Nursing and Professional Development.

Assistant Director of Corporate Services and Risk.

Once the police have been notified all the individuals listed above must be informed.

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The following must also be informed of the police involvement immediately.

Clinical Director of Pharmacy, Calderdale and Huddersfield NHS Foundation Trust

Intermediate Care Services Manager

Incidents that occur in a clinical area (resolved or not) must be seen as a learning opportunity and reviewed in ward meetings. The ward pharmacist will provide support if appropriate.

6.15 Disposal of Controlled Drugs

Controlled Drugs must be destroyed in accordance with the recommendations laid down in the Misuse of Drugs Regulations.

All expired CDs, and any which are no longer required must remain in the Controlled Drug cupboard and be included in the total stock balance in the register until the ward pharmacist or pharmacy technician is available to witness the destruction, or arrange return to pharmacy if appropriate. This applies to stock CDs, patients own CDs and syringe driver solutions prepared by pharmacy.

Expired and unwanted stock, or unwanted patient‟s own controlled drugs, must be destroyed as soon as possible on the ward by a Senior Nurse who has been nominated by LCP CD Accountable Officer. This must be witnessed by a registered nurse nominated by the ward manager.

An appropriate entry must be made in the Ward Controlled Drugs Register by:

Inserting the date

Documenting “Checked and destroyed „x‟ units”

Signature of the qualified nurse and pharmacist or pharmacy technician

New stock balance

Individual doses of Controlled Drugs, which have been prepared on the ward but not administered should be destroyed on the ward in the presence of a second person that may be a pharmacist, a doctor or an authorised nurse or auxiliary

For part used ampoules - document in the Controlled Drug register the amount administered and the amount wasted.

For part used epidural infusions and PCA syringes indicate on the PCA and epidural nursing administration/observation charts the amount wasted.

For part used syringe drivers record on the syringe driver chart the amount wasted.

Used patches (E.g. Fentanyl) still contain some Controlled Drug and must be folded in half with the adhesive sides together and then cut and put in a clinical waste bag.

Methods of Destruction: - LCP CD Accountable Officer will advise on methods of destruction. Methods advised may be subject to change in line with new waste disposal regulations.

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6.16 Transferring Patient’s Own Controlled Drugs between HRI or CRH and HVMH

Patients own Controlled Drugs must be transferred with the patient.

At HRI and CRH the nurse in charge and either a second nurse or member of pharmacy staff must sign the CDs out of the patients own register as transferred with the patient to HVMH. The nurse in charge at HVMH must be notified that CDs will be coming with the patient. It is good practice to state the quantity being transferred so that safe receipt can be confirmed. The nurse in charge at HVMH on receipt of the CDs must immediately lock them into the CD cupboard and enter into the patient own Controlled Drug register. A second authorised nurse must witness the entry.

If the patient is moving from HVMH to HRI or CRH the above procedure should be reversed. The entry into the register at HVMH should include which ward the patient is transferring to.

6.17 Student Nurses

Student nurses must be exposed to the skills in the ordering, checking and administering of Controlled Drugs providing they are continually supervised throughout the process. The qualified nurse must supervise the student nurse in all of these areas and effectively act as lead or second checker. i.e. One student nurse and one qualified nurse involved in the process.

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SECTION 7 – PREPARATION AND ADMINISTRATION OF MEDICINES Medicinal products may only be administered to a patient:

On the written instructions of a doctor, dentist or non medical prescriber.

By a verbal instruction, in exceptional circumstances, in accordance with section 1.19

On the verbal instruction of a doctor who is present with a patient in the case of a cardiac arrest or similar emergency.

By a nurse working under the Symptomatic Relief Policy.

Care must be taken to ensure that newly admitted patients do not miss essential doses of medicines while they are waiting to be clerked in. Medicines brought in with the patient should be put into safe storage. Nurses should be aware of the medicines brought in so that the patients can continue their regular medication until prescribed on the Prescription Chart and Administration Record, unless the nurse in charge has reason to believe it should not be continued or the medication cannot be identified.

Medicines must only be prepared, checked or administered to a patient by the following categories of healthcare staff:

Nurse

A medical or dental practitioner

A practitioner in training, but only under the direct supervision of a qualified practitioner who remains responsible for ensuring that the correct procedure takes place

Other employees who are specifically authorised

See section 14, „Parenteral Therapy‟, for specific staff training and responsibilities with intravenous medication.

Nurses at HVMH are not authorised to administer IV opioids.

7.1 Preparation of Medicines

Errors can often occur during the preparation of medicines for administration, particularly where dose calculation is involved. In the majority of cases, medicines are supplied to wards from pharmacy in a ready-to-use form, where no further dilution or dose calculation is required.

Where the preparation of medicines is performed outside the Pharmacy Department, the following points must be observed:

Read the prescription carefully. Determine the name of the medicine, dose, diluent, and route for administration and the expiry date of the prepared medicine. Refer to the package insert or Summary of Product Characteristics (data sheet) if necessary.

If a dose calculation is required this information must be included as part of the prescription either by the doctor or the pharmacist so that the practitioner administering the dose is clear about the actual amount to administer

If the practitioner is unclear as to the correct medicine, diluent or precise method for medicine preparation, he/she must obtain this information from the package insert, data sheet or pharmacy department before proceeding.

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It is good practice for medical or nursing staff to obtain a second practitioner check when calculating, preparing and administering medicines.

Ideally, large volume infusions of medicines should not be prepared at ward level. The Additives Unit at HRI should be requested to prepare the infusion. If it is necessary in an emergency out of pharmacy opening hours for an infusion to be prepared on the ward, there should be liaison between the nurse in charge, the prescribing GP and the on call pharmacist.

Should it be necessary to prepare an intravenous infusion at ward level, ideally, it should be in an area separated from direct patient contact. Preparation should take place as one continuous process, followed through to completion. These precautions reduce the risk of microbial contamination and interruptions, which can lead to medicine errors. If an infusion is prepared at ward level it must be identified with a completed yellow additive label. Infusions prepared at ward level have a maximum expiry of 24 hours from preparation.

Smaller volume (bolus) intravenous injections can be made up on the ward following the guidance above. Alternatively the Additives Unit at HRI can be asked to make up the injection. The nurse in charge should liase with the pharmacy at HRI to decide the appropriate course of action when intravenous injections are prescribed.

7.2 Checking the Preparation and Administration of Medicines

The preparation and administration of medicines does not routinely need to be checked by two qualified practitioners except in the following areas and circumstances:

Intravenous fluids

Intravenous medicines

Controlled Drugs

Insulin

Potassium concentrate solutions (greater than 40mmol per litre)

The setting up of infusion devices, for example the rate and volume to be infused.

Practitioners must seek a second independent check in circumstances outside their normal experience that they judge may present an unknown risk.

Where two practitioners are involved, the checking procedure must be a complete process. Both practitioners must check the selection, calculation (if appropriate) preparation and administration of the drug.

Where practitioners or doctors need to undertake calculations to prescribe or prepare medicines for administration, it is good practice to obtain a second check. In such circumstances the practitioner must clearly specify what is to be checked. The second practitioner must undertake the full calculation by his or her own method. They must not be asked to confirm the first practitioners answer until after they have performed the calculation.

7.3 Administration of Medicines

Errors of drug administration to inpatients are often due to selection of the incorrect patient or selection of the incorrect drug. Interruptions to the medicine preparation and administration process contribute to the likelihood of error.

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All staff administering medicines must understand the indications, risk, precautions and contraindications to each medicine, and must be competent to perform any necessary calculations. Employees administering medicines to patients will be held individually accountable for their actions.

Staff administering drugs must know the expected outcomes of the treatment, monitor the response to the treatment, and be able to inform the team caring for the patient of any relevant changes in the patient‟s condition. They must know about the potential interactions with food or other medication and what action must be taken when adverse effects occur.

Dose, volume and rate calculations should be carefully checked prior to administration of the medicine.

Staff must take steps to ensure that medicine administration, for any patient, can be completed without interruption.

Medicines to be given by the oral route and medicines to be given by the intravenous route must not be taken to the patient‟s bedside together.

If an error occurs in the administration of medication to a patient the actions described in section 12 must be followed.

Only medicinal products that have been issued or dispensed by HRI Pharmacy Department or patient's own medicine may be administered or supplied to a patient.

Medicines must not be decanted from one container to another (at ward level).

Strips of tablets in blister packs must not be removed from their original labelled carton.

Staff must only administer medicines that are correctly labelled with the name of the preparation. During the administration process the label must be read and reread at each stage of the preparation of the dose.

It is good practice for a nurse administering medicine to explain to the patient the name and purpose of each medicine at the time of administration. However because of time constraints this might not always be possible. If the nurse is asked by a patient or their relative or carer to explain what medicine is being given they should always provide this information.

Discussing the name, route and purpose of the medication at the time of administration can be an important additional safeguard.

Under no circumstances must dispensing labels be amended; the medicine must be relabelled in the pharmacy department.

Practitioners must not return decanted tablets or liquid into the original container.

Medicines dispensed for one patient must not be handed over to any other patient or used to administer doses to other patients.

Suspensions must be shaken properly before measuring the dose to ensure an even distribution of the active medicine in the bottle.

Medicines prepared in the pharmacy department for administration as an infusion may have an expiry in excess of 24 hours. When administered to the patient they maybe used for a maximum of 24 hours, then discontinued. A new infusion maybe commenced if appropriate.

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If there is any concern about any aspect of the medication or the dispensing label, the person administering the medicinal product must inform a pharmacist.

7.4 Administration Check-list

Before any medicinal product is administered the prescription must be read carefully and the following must be checked:

The patient's identity by checking the patient‟s wristband. If a wristband is not in place ask the patient their name and date of birth, which must be checked against the prescription chart.

If the patient does not have a wristband one must be applied. If the patient has very friable skin a special soft wristband should be used.

The correct time to administer the medicine.

That the medicine has not already been given.

That the patient is not sensitive or allergic to the medicinal product.

That the correct product has been selected against the prescription (drug, form and strength)

The product's expiry date where one exists.

The suitability of the route of administration.

Any special instructions are being followed.

Whether any further information is required about the product.

For adults, doses of oral medicines are typically 1 or 2 tablets or capsules, or 5 or 10mls of liquid. Some injectable medicines are also presented in ampoules or vials corresponding to their usual adult dose. If an unusually large number of dose units appears to be needed this should alert staff to a potential error.

If there is any concern about any aspect of the prescription or any other particulars such as the drug, dose, route, indication, mix of drugs or gases, allergies, time or frequency of administration, the person administering the medicinal product must contact the prescriber or responsible doctor/dentist, prior to administration. If further clarification is required further advice or assistance can be requested from the ward pharmacist or pharmacy at HRI.

Medicines dispensed for an individual patient must be administered only to that patient unless otherwise authorised by a pharmacist.

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7.5 Documentation and Administration

The practitioner who has administered or supervised the administration of the medicine must, at the time of administration/supervision, complete and initial the appropriate column of the prescription chart.

For continuous Infusions the batch number of the infusion fluid and any additives must be entered on the Prescription and Administration Record.

See guidelines for completion of Calderdale and Huddersfield NHS Foundation Trust Prescription Chart and Administration Record

If a medicine is omitted the following codes must be entered on the prescription chart:

1. Patient away from ward

2. Patient could not take dose/receive dose

3. Patient refused

4. Dose not available

5. Omitted at nurse‟s discretion

6. Dr/prescriber requested omission

7. Self administered

8. Nil by mouth

The table on the back of the prescription chart „omitted or delayed doses‟ must also be completed when relevant.

Where medicines have been dispensed for individual patients or where a patient has brought in their own medicines, a record is entered in the pharmacy box against the prescription. If such an entry has been made the practitioner must make every effort to find the supply so that the dose can be administered.

Failure to record the administration of a medicine or an omission code constitutes a medication incident and must be reported on a LCP Clinical Incident Form. Records may be audited.

If the patient is absent from the ward, or has missed a dose for some other reason, the delayed dose can be administered at a later time provided a doctor or pharmacist has confirmed that it is appropriate to do so or that it is according to an agreed protocol. The actual time of administration must be clearly recorded on the prescription chart.

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7.6 Administration Devices

It is important that the correct vehicle for administering medication is used to avoid the administration of medication by the incorrect route. Staff giving any medication from a syringe must satisfy themselves that the medicine, dose and route of administration are all correct. When administering medicines to seriously ill patients with multiple lines, particular attention must be made to confirming the route of administration.

For Use

Solid Oral doses Medicine pot or medicine spoon

Liquids Medicine pot or for small doses less than 5ml or where accuracy is essential use the appropriate sized oral syringe.

Injections A parenteral syringe

Nebulisers For administration of part of a nebule use a parenteral syringe

Insulin An insulin syringe or insulin pen

Enteral Feeds See Calderdale and Huddersfield NHS Foundation Trust Medication and Enteral Feeding Guidelines

See section 14, „Parenteral Therapy‟ for further information.

7.7 Administering Medicines via an Enteral Tube

Prior to administering medicines via an enteral tube advice should be obtained from the Calderdale and Huddersfield NHS Foundation Trust Medication and Enteral Feeding Guidelines, or from a pharmacist.

It is also good practice that nursing staff explain to the patient that they are administering medicine via the enteral tube.

7.8 Crushing Tablets

Altering the route of administration or the form intended by the manufacturer makes the proposed method of administration unlicensed.

Medication must be given by the route and in the form intended by the manufacturer (i.e. tablets must not be crushed and capsules must not be opened) unless endorsed by the pharmacist, with an explanation written in the patient‟s clinical notes for healthcare staff. A member of the medical team must subsequently countersign the entry. This is to prevent inappropriate administration of medicines and to ensure that appropriate monitoring is in place.

In circumstances where the patient is unable to or having difficulty-swallowing tablets/capsules the practitioner must discuss the situation with the prescriber and the pharmacist. Further information about preparations that can be given in an unlicensed manner may be obtained from the pharmacist or Medicines Information or by referral to the Calderdale and Huddersfield NHS Foundation Trust Enteral Feeding Guidelines.

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7.9 Covert Administration

As a general principle, by disguising medication in food and drink, the patient or client is being led to believe that they are not receiving medication, when in fact they are. The registered nurse must ensure that what they are doing is in the best interests of the patient or client, and be accountable for this decision.

The Nursing and Midwifery Council (see footnote) recognises that there may be certain exceptional circumstances in which covert administration may be considered to prevent a patient or client from missing out on essential treatment. In such circumstances and in the absence of informed consent, the following considerations must apply:

The best interests of the patient or client must be considered at all times.

The ability of the patient to consent must have been considered in line with the Mental Capacity Act 2005.

The medication must be considered essential for the patient‟s or client‟s health and well being, or for the safety of others.

The decision to administer a medication covertly must not be considered routine, and must be a contingency measure only. A decision to do so must be reached after assessing and planning the care needs of the patient or client individually. It must be patient/client specific, in order to avoid the ritualised administration of medication.

There must be broad and open discussion among the multi-professional clinical team and the supporters of the patient or client, and the agreement that this approach is required in the circumstances. Those involved must include carers, relatives, advocates and the multi-disciplinary team (especially the pharmacist).

The decision and action taken, including the names of all those involved in the decision making process must be documented in the patient‟s notes and reviewed at pre-determined intervals

Regular attempts must be made to encourage the patient or client to take their medication. This might best be achieved by giving regular information, explanation and encouragement by an appropriate team member

For further guidance see The NMC position statement on the covert administration of medicines – Disguising medicine in food and drink, November 20072

7.10 Disguising and Mixing of Medicines Prior to Administration

Should a patient request that medication is administered, mixed with, for example jam, advice must be sought from a pharmacist prior to administration.

7.11 Unlicensed Medicines

Nurses may be required to administer unlicensed medicines. Prescribers and pharmacists are responsible for ensuring that LCP Policy for Use of Unlicensed Medicines is adhered to. See section 13 of LCP Medicines Management Policy: http://www.kirklees.nhs.uk/your-health/medicines-management/locala-policiesguidelines/

2 Accessed at: http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Covert-

administration-of-medicines/

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7.12 Nil by Mouth

Patients classified 'nil by mouth' prior to a diagnostic procedure, receiving an anaesthetic or undergoing ECT, must have all their prescribed oral medicines administered to them at the prescribed time unless specifically advised otherwise by medical staff. The medicines should be taken with a small amount of water to enable the patient to swallow these medicines. Only medicines that have been clearly marked on the prescription chart may be omitted. It is the responsibility of the prescriber to provide clear instructions to the nursing staff concerning the omission of prescribed doses.

7.13 Staff Requiring Treatment for Minor Ailments.

Staff may be referred to occupational health or purchase items from a local pharmacy. Medicines dispensed as ward stock or for individual patients must not be used to treat staff.

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SECTION 8 – MEDICINES AT DISCHARGE, LEAVE OR ON TRANSFERRING PATIENTS

There are specific risks involved in the provision of discharge medication. These include:

Patient confusion about their current regimen

Omission of required therapy

The possibility of duplicating therapy with drugs the patient has left at home

The possibility of the discharge communication being ambiguous, incomplete or delayed

Medical, nursing and pharmacy staff, all have a responsibility for minimising these risks.

8.1(a) Transfers from HRI or CRH

A discharge prescription is not needed. The prescriber must review the medication prior to the patient‟s transfer to ensure that any medication that is not required is stopped.

The treatment sheet and the appropriate medication from the patient‟s medication cabinet must be transferred with the patient and their belongings and medical notes. Medication should be packed securely and separated from other belongings.

8.1(b) Transfers to HRI or CRH

The treatment sheet and appropriate medication from the trolley, and any reserve supplies from the cupboard must be transferred with the patient and their belongings and medical notes. Medication should be packed securely and separated from other belongings.

8.2 Transfers to Other Trusts (including Hospices)

A discharge prescription must be written. This should be processed as stated below (see 8.4)

8. 3 Weekend Leave (or Otherwise)

The Prescription Chart and Administration Record must be checked. The patient can then be given their medicines from the trolley. The patient then returns the medicines when he/she returns to hospital. The nurse then makes note in the clinical records that the patient has custody of their medicines.

If the nurse does not feel this course of action is appropriate and would prefer to give the patient a smaller number of doses to take out, a discharge prescription for the required number of doses must be written.

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8.4 Processing Discharge Medication

It is the intention of the pharmacy service to provide routine discharge medication, where it is required, for all patients by the time of their planned discharge. This aim can only be achieved safely and efficiently with the full collaboration of medical, nursing, pharmacy and other ward staff.

A discharge prescription may be written in advance. Always check that no medication changes have been made since the discharge was written.

Patients will not normally require further medicines to be dispensed at discharge as The Calderdale and Huddersfield Trust operates a one stop dispensing policy at HVMH. Further details are available in The Calderdale and Huddersfield NHS Foundation Trust „The self-administration and Re-use of Patient‟s Own Medicines Policy‟.

Ready-labelled pre-packs of certain medicines are available, for use on discharge. The nurse is responsible for ensuring there is authorisation for supply, i.e. a Medication and Discharge Summary prescription signed by a doctor. The nurse must check the pack to be supplied against the prescription. The nurse must enter the patient‟s name and date of supply on the label and record the supply on the Medication and Discharge Summary.

A second practitioner must check all medicines supplied for discharge. Both practitioners must sign the bottom of the Medication and Discharge Summary.

Care must be taken that all the patient‟s medicine is found for discharge. This may involve checking the trolley (including sections where bulky medicines are stored), the cupboard of reserve supplies and the fridge.

Under the following circumstances the Medication and Discharge Summary will need to be faxed to pharmacy at HRI (if urgent) or given to the ward pharmacist when they visit:

If a compliance aid (monitored dosage system) needs to be supplied

If a reminder card is required

If eye preparations are required

If a patient is required to take a reducing/increasing dose of medication

If a medicine does not have correct dosage for discharge on the label

If a patient has less than 14 days supply of medication

New item (s) are prescribed that are not available as a TTO pack

If a Controlled Drug is required. A Controlled Drug Prescription Form will also need to be faxed or given to the ward pharmacist. This requirement applies to ALL controlled drugs which are treated as “full” CDs under CHFT policies (including oramorph and temazepam).

Any queries with a discharge prescription must be directed in the first instance to the prescriber or alternatively to the ward pharmacist.

To avoid delays in processing discharges in pharmacy it is essential that the Medication and Discharge Summary, clearly identifies the following information:

1. The patient‟s full name, title and date of birth

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2. The correct ward

3. NHS number

4. The planned time of discharge or the specific delivery time for the drugs to be sent to the ward.

Pharmacy staff will help in the planning process, with respect to discharge medicines and will dispense discharge medicines only when a pharmacist has reviewed the Medication and Discharge Summary, the Prescription Chart and Administration Record and any other supplementary prescription charts at the same time.

When faxing a discharge prescription to HRI pharmacy, the nurse must indicate, either by phone or by writing on the discharge prescription, which items require dispensing, and/or whether an MDS is needed.

Where medicines are dispensed they will be labelled with directions, together with any relevant information leaflets and a printed dosing reminder chart (where appropriate).

When the patient has been discharged the nurse must retain the green copy of the Medication and Discharge Summary on the ward for the ward pharmacist to collect at their next visit. The original of any faxed Controlled Drug prescription must also be retained. The other copies of the Medication and Discharge Summary must go to relevant recipients e.g. GP, patient etc.

Discharge Prescriptions which Include Warfarin

If warfarin is required for discharge, the prescriber must complete in full both sides of the pink Warfarin Prescription Sheet, including the section for „discharge medication‟, and the date of the next INR check.

HRI Pharmacy will not accept incomplete warfarin charts. The nurse supplying the discharge medication to the patient must ensure that the “Referral Pathway to Anticoagulant Services” is followed. A laminated copy of this CHFT policy is held on the ward.

The nurse must ensure that the discharge dose and next INR check are correctly written in the patient‟s yellow anticoagulant booklet, and that the patient, or their carer, is aware of this information.

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SECTION 9 - CONSENT

It is a general legal and ethical principle that valid consent must be obtained before starting treatment for a person. This principle reflects the right of patients to determine what happens to their own bodies, and is a fundamental part of good practice. For consent to be valid, it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question. Acquiescence where the person does not know what the intervention entails is not „consent‟.

The Mental Capacity Act 2005 sets out a statutory framework for making treatment decisions for people who lack the capacity to make such decisions themselves. The Act establishes overarching statutory principles governing these decisions, setting out who can make them and when. It sets out the legal requirements for assessing whether or not a person lacks the capacity to make a decision.

Where a person lacks the capacity to make a decision for themselves, any decision must be made in that person‟s best interests. The Mental Capacity Act introduced a duty on NHS bodies to instruct an independent mental capacity advocate, (IMCA), in serious medical treatment decisions when a person who lacks the capacity to make a decision has no one who can speak for them, other than paid staff. The Act allows people to plan ahead for a time when they may not have the capacity to make their own decisions: it allows them to appoint a personal welfare attorney to make health and social care decisions, including medical treatment, on their behalf or to make an advance decision to refuse medical treatment.

If an adult with capacity makes a voluntary and appropriately informed decision to refuse treatment, (whether contemporaneously or in advance), this decision must be respected, except in certain circumstances as defined by the Mental Health Act 1983. This is the case even where this may result in the death of the person (and/or the death of an unborn child, whatever the stage of the pregnancy).

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SECTION 10 – MONITORED DOSAGE SYSTEMS (MDS) When patients are admitted to HVMH with a monitored dosage system but no other supply of medicines, HRI pharmacy should be contacted at the earliest opportunity for medicines in labelled containers to be supplied. Until this supply arrives, the nurse should use their professional judgment to decide whether to administer medicines from the monitored dosage system.

They should always liase with the doctor responsible for the patients care at HVMH, and the Pharmacy at HRI if appropriate, as part of this process.

All monitored dosage systems for discharge will be supplied in accordance with the policies of Calderdale and Huddersfield NHS Foundation Trust and LCP.

Pharmacy at HRI require 2 working days notice to fill or provide a monitored dosage system for discharge.

If a patient was using a „Medidos‟ or „Dosette‟ type monitored dosage system prior to admission, the ward pharmacist will need to collect the device from the ward at their last visit before the discharge date, to allow pharmacy at HRI to refill it in accordance with the discharge prescription.

For patients using a „blister pack‟ or „sealed cassette‟ type monitored dosage system at home, pharmacy at HRI will provide and fill a disposable 7 day monitored dosage pack.

If it has not been possible for the ward pharmacist to collect the patients own monitored dosage system to be refilled for discharge, pharmacy at HRI will provide and fill a disposable 7 day monitored dosage pack. Two working days notice will usually be needed. The nurse in charge of the ward must remove and arrange for disposal of any medicines remaining in the patients own MDS and remove or cross through any labels or insert cards. The patient will take home their own empty MDS plus the temporary pack filled by HRI pharmacy.

Nurses are not authorised to fill patients own MDS packs on the ward.

If the monitored dosage system is refilled by a community Pharmacy when the patient is at home, the nurse co-ordinating the discharge arrangements for the patient must contact the relevant community pharmacist and the patients GP to restart the weekly supply system.

Section 11 Page 53

SECTION 11 – DISPOSAL OF MEDICINES NO LONGER REQUIRED It is the responsibility of all staff involved with the generation or handling of waste on LCP premises to be aware of the correct management and safety procedures associated with the waste produced.

Pharmaceuticals, which were originally supplied by HRI Pharmacy and no longer required on the ward, can be returned as long as they are still in date and are suitable for re-use.

All other medicines, such as medicines brought in by patients, expired medicines, part-used liquid medicines and contents of Monitored Dosage Systems (MDS), must be disposed of on the ward.

See section 6 for Controlled Drugs

Medicines awaiting return or disposal must be stored securely. Procedures for disposal of medicines may change in line with waste disposal regulations. Nurses should refer to LCP Waste Management Guidelines3 for advice relating to current procedures.

Section 12 Page 54

SECTION 12 - PATIENT GROUP DIRECTIONS (PGDs)

All medicines administered by a practitioner must be given on the authority of an authorised prescriber. In some areas certain medicines are routinely initiated by practitioners in accordance with a Patient Group Direction (PGD). This is a written procedure, authorised by the organisation in advance, such that it does not require a prescription written by a prescriber.

It is the responsibility of the Ward Manager to ensure that:

If medicines are administered without a written prescription then a valid and current PGD is available to guide practitioners in their area

The person supplying or administering the medicine has read and signed up to the PGD and received the training specified in it.

Copies of approved PGDs must be available in each area and must accurately reflect practice in that area.

A record of administration under a PGD must be entered on the Prescription Chart and Administration Record for the patient.

The Manager for Intermediate Care Services and the ward manager are responsible for ensuring that PGDs are reviewed. The ward pharmacist will remind the Manager for Intermediate Care Services, two months in advance of the review date.

Section 13 Page 55

SECTION 13 – MEDICATION ERRORS The systematic reporting of medication errors is designed to protect patients, staff and healthcare organisations as well as to identify areas where improvements in practice need to be made. It is not designed to apportion blame or as part of the disciplinary process. LCP endorses a fair and just culture.

Please refer to section 12 of LCP Medicines Management Policy4 and LCP Incident Reporting Policy/Procedure for the Initial Management and Reporting of Incidents and Near Misses.

13.1 Reporting Mechanism

All staff must be familiar with LCP Incident Reporting Procedure and must be actively encouraged to report incidents/near misses.

All incidents must be dealt with sensitively.

In the case of “near misses” it is still important that a LCP Incident Report form is completed so that an appropriate review of procedures, training, documentation and other factors can be undertaken. Near misses are often a warning sign of errors waiting to happen.

Incidents on the ward at HVMH involving medicines must also be reported to Pharmacy Department at HRI. This will be done via the ward pharmacist if possible. If the ward pharmacist is not available contact the inpatient dispensary at HRI on 01484 347123 or 01484 342422

13.2 Medical Review of the Patient

The well being of the patient is of prime importance following a medication incident. The incident must be reported as soon as possible to the appropriate GP or senior medical professional who will decide whether any further action is needed in respect of patient management. Details of the incident must be documented in the patient‟s clinical notes and an incident form completed. The Manager for Intermediate Care Services, the ward manager and pharmacy at HRI must be informed as soon as possible.

The doctor responsible for the patient‟s care will explain events to the patient, (if appropriate), and to relatives/carers, and will instigate a new plan of care if appropriate.

All medicine containers, syringes, infusions and administration equipment must be retained for examination where necessary.

13.3 LCP Serious Untoward Incident Procedure

All staff should be aware of this procedure. Copies are available from the LCP Governance and Quality Team.

LCP policy is that learning follows medication incidents and near misses reported.

There is liaison between LCP and Calderdale and Huddersfield NHS Foundation Trust to ensure that medication related incidents are reported to both organisations where appropriate.

4 LCP Medicines Management Policy is available from the NHS Kirklees website under the Locala

section.

Section 14 Page 56

SECTION 14 – SECURITY AND SAFE HANDLING OF MEDICINES RELATED STATIONERY

14.1 Controlled Stationery

Controlled stationery is any stationery, which, in the wrong hands, could be used to obtain medicines fraudulently.

Stationery which is to be treated as controlled stationery by all staff on the ward at Holme Valley Memorial Hospital is listed below:

Controlled Drug Prescriptions pads*

Prescription Chart and Administration Record

Supplementary Prescription Charts

Controlled Drug Order Books

Controlled Drug Registers

Pre-printed Stock Lists/Requisitions

Discharge Prescription pads

High risk controlled stationery is uniquely numbered and needs to be fully accounted for with a full audit trail.

14.2 Responsibilities

Stocks of controlled stationery and other medicine related stationery will be supplied by the pharmacy department at HRI. Designated persons within the pharmacy are responsible for ensuring that good practice with regard to the issue of all stationery is adhered to.

It is the responsibility of the ward manager to ensure safe and secure handling of controlled stationery in their area.

It is the responsibility of the nurse in charge to ensure:

The security of controlled stationery following receipt from the pharmacy department. i.e. that it is locked in a secure location and only accessible to authorised staff.

That any unwanted controlled stationery is returned to the pharmacy department

14.3 ORDERING STATIONERY

14.3.1 Controlled Drug (CD) Order Books, Registers and CD Prescription Forms

Controlled drug order books, registers and CD prescription forms are ordered from HRI pharmacy by the nurse in charge. The order is written on a page of the current CD order book.

14.3.2 Other Controlled Stationery

All other controlled stationery can be obtained from the pharmacy at HRI, either by ordering on the stock item requisition form or asking the visiting ward pharmacist.

Section 14 Page 57

14.3.3 Pharmacy Records

The pharmacy department at HRI will keep a record of all issues and returns of high risk controlled stationery, including:

Date of issue/date of return

Serial numbers of the prescription pads issued/returned

Exact Location supplied/returned from

Identity of the person requesting/returning

Identity of the person issuing/receiving

Running Balance

These records are examined at six monthly intervals by pharmacy and any anomalies investigated.

All controlled stationery will be recorded on the pharmacy computer and booked to the end user.

14.4 Storage of Controlled Stationery

When not in use all high-risk controlled stationary must be stored securely in a locked cupboard/drawer. Prescription pads must be returned to the locked cupboard/drawer after use.

Controlled Drug Order books, registers and prescriptions must be stored in a locked cupboard/drawer when not in use (ideally the Controlled Drug cupboard).

Care must be taken with the storage and access to all other controlled stationery to avoid theft or the potential for misuse.

14.5 Transport of Stationery

All stationery will be transported from pharmacy in a sealed tamper evident wallet or box. C.D. order books and registers must be signed for on receipt.

14.6 Loss or Theft of Controlled Stationery

Loss or theft of any controlled stationery must be reported immediately to the person in charge of the ward, to the pharmacy at HRI and the Intermediate Care Services Manager (or if not available report to the Director or Deputy Director on call).

A LCP incident form must be completed. A thorough investigation must be undertaken into the incident and appropriate personnel informed of the loss or theft.

14.7 Return of High Risk Controlled Stationery

Return of high risk controlled stationery to pharmacy at HRI must be arranged with the ward pharmacist to allow pharmacy records to be updated.

Section 15 Page 58

SECTION 15 – PARENTERAL THERAPY

Parenteral therapy involves certain inherent risks, which staff must take every precaution to avoid. All staff involved with prescribing, preparation or administration of parenteral therapy must receive specific training that is relevant to their responsibilities.

The Ward Manager is responsible for ensuring that nursing staff undergoes such training.

Staff must ensure that they have received adequate training and are confident they know how to use devices safely and administer and monitor the therapy safely.

Devices must have a risk classification of „high risk‟

Devices should be designed to be simple to set up, easy to use and have good safety features and alarms that alert users to problems.

The device used should be appropriate for the drug being administered and the patient receiving the drug.

Staff must be trained and competent in their use, this will include knowledge of: how to set the device up, how to get air out of the system and know what the alarm systems mean and how to respond to them. They should not be obliged to set up a pump that they have not been trained to use.

Pumps that are used to deliver intravenous medicines must not be used for enteral fluids.

The distal ends of all lines must be labelled to ensue that the site of access for medicine administration can be positively identified.

15.1 Intravenous Therapy

Training relating to parenteral therapy for nurses at HVMH is arranged in liaison with LCP and should be provided at recommended regular intervals.

Calderdale and Huddersfield NHS Foundation Trust has the following policies, principles, documents and training programmes available and these can be referred to as examples of good practice:

Administration of Medicines training package

Cannulation and Phlebotomy training package

Workbook for Medical Devices

Policy for the care and maintenance of peripheral, central intravenous catheters and arterial lines

Prescribing and Administration of Intravenous Opioids in the Trust

The documents and training are available through the Clinical Facilitators for Parenteral Therapy based at Calderdale and Huddersfield NHS Foundation Trust.

Advice and information on aspects of intravenous therapy can be obtained from the ward pharmacist or from the pharmacy aseptic services department and medicine information at HRI

Section 15 Page 59

15.1.1 Central Intravenous Additive Service (CIVAS) at HRI

At HVMH, medicines to be given via syringe drivers, (e.g. for palliative care), are usually made up on the ward. Pharmacy at HRI should be contacted if advice is needed regarding the preparation of a syringe driver solution. Alternatively, the pharmacy department at HRI provides a limited CIVAS service. The CIVAS service is primarily targeted at those drugs which are difficult to prepare on wards i.e. those, which are hazardous, difficult to dissolve, require calculations or multiple manipulations or are for vulnerable patients.

Other drugs may be prepared in a ready to administer form, provided they are stable for at least 24 hours.

The CIVAS service ensures the therapeutic and microbiological integrity of the prepared doses.

15.2 Syringe Drivers

Guidelines for the use and management of syringe drivers in palliative care should be available on the ward.

15.3 Single Use Containers

Single use containers of injectable products are for use for one patient only.

At ward and clinical area level injections licensed for single use must not be used on more than one occasion, either for one or several patients. Any volume remaining must be discarded after single use.

This applies regardless of the presentation (ampoule, vial, loaded syringe, infusion bag, etc) and also includes situations where a single use product is given non-parenterally, such as for diluting nebuliser solution or flushing nasogastric tubes.

The use of devices, which facilitate multiple access into bags, or bottles of infusion solution, such as multidose adapters or needles with three-way taps, is absolutely forbidden in all clinical areas. Any exceptions to this policy must be authorised by LCP Medicines Management Committee.

15.4 Multidose Containers

Multidose containers are products which contain a combination of a drug and an antimicrobial preservative, and are labelled for multidose use.

The fact that it is possible to remove a drug from a vial more than once via a septum or bung does not in itself mean a product is suitable for multiple use. If unsure the practitioner must check the Summary of Product Characteristics or check with a pharmacist.

Injections licensed for multiple use must be used in accordance with their Product Licences. A new needle and syringe should be used for each withdrawal, even if a single dose requires more than one withdrawal.

Multidose containers must be labelled with the following information when use commences:

Date use commenced

The expiry date

Section 16 Page 60

SECTION 16 – OUT OF HOURS MEDICINES

The On-call Pharmacy Service

If medicines or pharmaceutical advice are urgently needed „out of hours‟, nurses at Holme Valley Memorial Hospital can contact the on-call pharmacist via the switchboard at HRI.

The Pharmacist will provide advice and arrange supplies of medicines as appropriate. This service is not intended to be used to process discharge medication, which must be planned in advance.

HRI Pharmacy opening hours are:

Monday to Friday – 8.45am to 5pm

Saturday, Sundays and Public Holidays – 9am to 12noon

Section 17 Page 61

SECTION 17 – DRUG FORMULARY

The drug formulary has been developed in conjunction with staff from both the Calderdale and Huddersfield Foundation NHS Trust and local Healthcare provider organisations within Calderdale and South Kirklees. Its purpose is to enable all prescribers to provide evidence based, cost effective care to the people of Calderdale and Huddersfield.

The drug formulary contains current guidance on prescribing and choice of drugs, and is reviewed on a regular basis.

The formulary is held on the Calderdale and Huddersfield Foundation NHS Trust intranet at http://intranet/formulary/, or on the internet at www.formulary.cht.nhs.uk . Access to the formulary can be made through the links above or the links on the Trust Intranet homepage. The formulary contains links to other appropriate evidence-based reference sources, including the BNF.

Prescribers at HVMH are expected to adhere to the guidance in the formulary, which has been approved by the CHFT and NHS Kirklees and adopted for use by LCP Medicines Management Committee.