Community Wards (Beverley, Hornsea, Withernsea) Guideline for ...

Community Wards
(Beverley, Hornsea, Withernsea) Guideline for
the use of Patients’ Own Drugs (PODs) and
Medicines Reconciliation.
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Ref No CP59
Version 2
Ratified by: Evidence Based Practice Group
Date ratified: 14 th September 2009
Name of Author: Fiona Hammond, Ann Wetherill, Di Ledger
Director: Director of Quality & Professional Services
(Executive Nurse)
Date Issued: 1st July 2009
Review Date: September 2011
VALIDITY STATEMENT
Only the electronic copy of this document is guaranteed to be the currently
valid version. Downloaded versions must be regularly checked for validity,
this is the responsibility of the individual user.
Page 1 of 23

CONTROL SHEET
Guidelines Title: Community Wards Guidelines for the use of Patients’
Own drugs (PODs)
Intended Recipients: Community wards, Locality Matrons, Prescribers
for the community wards in Beverley, Hornsea and Withernsea.
Is the Guideline new or
for review?
New: Yes Review:
Name of co-authors/contributors: Fiona Hammond, Ann Wetherill and
Di Ledger
Contributions from Jackie Matthews and Nick Borrill
Name of Sponsoring Executive: N/A
Training/Resource implications: Training provided by community
services medicines management team.
Audit/Monitoring Arrangements: Monitoring conducted by the
community services medicines management team. Audit conducted as
per the clinical audit annual plan.
Reviewed by Evidence Based
Practice Group
Date: 14 th September 2009
Approved by Medicines
Management Group
Date: 17/3/2010
All new Policies need Community
Services Committee/Board approval
Date: N/A
Implementation Date: 1 st July 2009
Review Date: September 2011
Name of the person responsible for the review: Fiona Hammond
How will this protocol be disseminated? Via Team Brief. Copy to be
placed on the Trust Web-site and on Policy Data base on the V Drive
Indicate where the protocol will be
stored
Has an equality assessment been
carried out?
V drive
Yes
Page 2 of 23

CONTENTS
1. Introduction 4
2. Definitions 4
3. Scope 4
4. Equality and Diversity 5
5. Roles and Responsibilities 5
6. Training 6
7. Procedure for the use of patients’ own drugs (PODS) 6
7.1 On admission (Collection & Checking)
7.2 Use of POD’s at NHS East Riding of Yorkshire
Community Hospitals
7.3 Ordering further supplies
7.4 Patients’ own controlled drugs
7.5 Discharge with POD’s
8. Communication and Documentation 10
9. Risk Management 11
10. Monitoring and Audit 12
11. Implementation 13
12. References 13
Appendices:
A. Patient consent form
B. Criteria for assessing PODs
C. POD’s medication checklist
D. Medication destruction form
E. Patient discharge leaflet
F. Employee record
Page 3 of 23

1. INTRODUCTION
The implementation of Patients’ own drug (POD’s) processes was
recommended by the Audit Commission in the document “Spoonful of
Sugar” and address a requirement of the National Service Framework
(NSF) for Older People to introduce ‘one stop dispensing/dispensing for
discharge’ schemes. The process has been shown to reduce waste
and be cost effective, in addition to improving medicines management
by patients.
This guideline has been produced to ensure the standardised, efficient
and safe use of patients’ own drugs (POD’s) within Community
Hospitals in East Riding of Yorkshire Community Services, and that all
medication a patient is currently taking is correctly documented on
admission and at each transfer of care.
All inpatients of the Community Hospital identified in the title will have
any medicines they bring to the hospital assessed for suitability for use
according to this protocol. It will be used in conjunction with NHS East
Riding of Yorkshire Community Services Policy for the Management
and Administration of Medicines and the Nursing and Midwifery Council
(NMC) Code of Professional Conduct, Guidelines for Records and
Record Keeping, Standards for Medicines Management, and
Guidelines for the Administration of Medicines.
2. DEFINITIONS
Medicines reconciliation is a process designed to ensure that all
medication a patient is currently taking is correctly documented on
admission and at each transfer of care. It encompasses:
• Collection of the medication history from a variety of sources
(usually a minimum of 2).
• Assessing concordance with treatment-as-prescribed prior to
admission and identifying potential for partial or non-compliance.
• Checking that medicines prescribed on admission for the patient
are correct. The “checking” step involves ensuring that the
medicines and doses that are now prescribed for the patient
accurately reflect the sources consulted.
• Communicating any changes in medicines so that they are
readily available to the next person(s) caring for the patient.
Communication must include reasons for the change(s) and any
follow-up requirements. There must also be a written record in
the patient’s medical record and/or on the prescription chart.
Page 4 of 23

3. SCOPE
This guidance should be used when a patient is admitted to an
identified Community Hospital.
This guidance promotes best practice relating to the use of Patients
own drugs and is intended for use by all staff employed by Community
Services.
The aim of this guidance is to;
• Promote the use of POD’s which are both in good condition and
are still appropriate for the patient’s treatment.
• Avoid drug wastage, duplication of discharge medication,
support self care, and improve a patient’s understanding of their
medical condition.
• May highlight problems with patients’ compliance which can be
addressed to facilitate safe discharge and reduce unnecessary
readmissions due to medicine related issues.
4. EQUALITY AND DIVERSITY
In developing this guidance, an equalities impact assessment has been
undertaken. An adverse impact is unlikely, and on the contrary the
procedure has the clear potential to have a positive impact by enabling
improved communication between staff and patients, faster local
system of medication procurement, waste management and reduction
and an improved patient care and healthcare experience. If at any
time, this guidance is considered to be discriminatory in any way, the
author of the guidance should be contacted immediately to discuss
these concerns.
5. ROLES AND RESPONSIBILITIES
5.1 Chief Executive
The Chief Executive of the Trust has overall responsibility for the
safe and secure handling of medicines by staff employed by
Community Services.
5.2 The Assistant Director for Medicines Management
The Assistant Director for Medicines Management oversees the
medicine management on behalf of the Chief Executive. This is
managed in Community Services through an internal Service
Level Agreement.
5.3 Community Services Medicines Management Team
Medicines reconciliation whenever and wherever possible
should involve pharmacists and pharmacy technicians.
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5.4 Managers
The ward manager of the Community Hospital is responsible for
ensuring that all staff are aware of the guidance and follow its
contents.
It is the responsibility for managers to ensure that their staff are
made aware of this guidance.
It should be included in the local induction programme.
It is the responsibility of a manager to identify to new staff, key
aspects of the guidance which relate to their area of work.
Managers will ensure that training needs for staff in medicine
management are identified and delivered through the
Community Services annual performance and development
review linked to the Knowledge and Skills Framework.
5.5 All Staff
6. TRAINING
Medicines Reconciliation is the responsibility of all staff involved
in the admission, prescribing, monitoring, transfer and discharge
of patients requiring medicines.
The staff carrying out medicines reconciliation must be appropriately
trained. The Community Services Medicines Management team have
developed a training package which must be accessed by all
healthcare staff involved in the Patient’s Own Drug process.
It is the responsibility of a manager to identify to new staff, key aspects
of the guidance which relate to their area of work. Training should be
included in staff induction programmes.
7. PROCEDURE FOR USING PATIENTS’ OWN DRUGS
All patients admitted onto a community should be encouraged to bring
their own medications into hospital.
Medication brought onto a ward will be assessed by a registered nurse
using the appropriate documentation and following the procedure laid
out in Appendix B.
Medication that is suitable and appropriate to the patient’s treatment
can be used once a consent form has been completed. (Appendix A)
Page 6 of 23

7.1 On admission (Collection & Checking)
The nurse should check that the patient has brought in their own
medications and identify the medications condition. Ascertain
how the patient has been taking the medication to assess
partial/non-compliance.
Every effort should be made to ensure that the patient has their
own supply of medications when admitted onto the ward.
If the patient has no medications with them or all of the patient’s
medications are of poor condition then a new supply will need to
be obtained.
On occasions it may not be possible to get a full history from an
unwell patient who may still require a prescription to be written.
Every effort should be made to ensure that such a prescription is
safe and appropriate to the needs of the patient and that a full
history is obtained at the earliest opportunity. Details of the
exceptional circumstance and subsequent decision to treat must
be recorded in the patient’s notes.
Explain the POD scheme to the patient.
Obtain patient consent for POD’s use and destruction.
(Appendix A).
If the patient refuses or is unable to give consent for the POD’s
to be used then a new supply of medications for use will need to
be obtained.
The nurse should assess the POD’s using the set criteria and
checklist. (Appendix B). (Appendix C).
Patients admitted may have been receiving their medication
from a multi-dose compliance aid e.g. weekly NOMAD cassettes
or monthly MANREX systems. These can be regarded as
patients’ own medication only if they have been dispensed by a
pharmacy and are sealed. Medication that has been put into
cassettes by relatives or carers cannot be accepted as patients’
own medication.
For a POD to be acceptable it must satisfy all sections of
the criteria.
Review of medicines prescribed by a member of the pharmacy
team. This should usually occur within 72 hours of admission.
Page 7 of 23

7.2 Use of POD’s
Any medication suitable for use should be labelled with a yellow
sticker by the nurse. The nurse should then sign and date this
sticker.
Any queries that arise regarding the use of POD’s should be
directed to the Medicines Management Team.
Any remaining medicines that are deemed unsatisfactory for use
should ideally be destroyed or returned to a community
pharmacy for disposal. Details of any medications to be
destroyed should be entered onto the medication destruction
form. (Appendix D). This form should be signed by both the
nurse and a witness to the destruction. If the patient does not
consent to the medicines being destroyed the medications
should be left in the patient locker clearly segregated from those
to be used and clearly labelled “unsuitable for administration”.
Where possible the patient’s relatives or representatives should
be encouraged to take the medication home and return them to
a community pharmacy for destruction, or disposal of in a DOOP
bin.
Any POD’s to be used should be stored in the patient’s
individual bedside locker. Any medications that require special
storage e.g. fridge items or controlled drugs need to be stored
appropriately as per the policy for Medicines Management policy
and a record made detailing their separate storage. If the locker
is full the medication should then be stored in a designated area
on the ward again recording the separate storage. All storage
areas for POD’s should be kept locked and keys kept under the
control of the ward manager.
POD’s should never be administered to any other patient
Only POD’s that have a signed yellow sticker and have been
checked against the patient’s prescription can be administered.
Any administration of medication will be recorded on the
patient’s drug chart. Any administration of controlled drugs will
also have to be recorded after each administration in the
controlled drugs register in a separate POD’s section.
Over the counter medications brought in by the patient should
not be administered under a POD unless they have been
prescribed by a doctor.
If treatment is altered, POD’s should be re-labelled by a
dispensing contractor. Alterations to labels and directions should
Page 8 of 23

not be made by ward staff. If re-labelling is not possible the
medication should be re-ordered using the ward FP10. Once this
new supply of correctly labelled medication is received then the
wrongly labelled medicine should be recorded onto the
medication destruction form then destroyed or returned to a
community pharmacy for destruction.
7.3 Ordering Further Supplies
POD’s should be checked at least once weekly to determine the
need for further supplies.
If a further supply of medication is needed then the ward FP10
prescriptions should be used. FP10s should be used to generate
a prescription for the specific named patient at that ward
address for the required medications and the supply obtained
from a community pharmacy that is suitable for the patient.
If a further supply is needed then all of the patient’s medications
quantities should be assessed and if appropriate a single order
placed. This will ensure the patient has enough for the inpatient
stay and a supply for discharge.
If the patient has a controlled drug on their drug chart this should
be ordered via the same ward FP10 route.
The ward should keep a record of FP10 usage. Recording the
date, the prescription serial number, the prescribers name, the
patient’s name and which medications have been ordered.
If the patient is prescribed a RED drug, as classed by Hull &
East Riding prescribing committee, then this drug will have to be
obtained via the hospital specialist. If the patient is prescribed a
clinical trial medication then this will have to be obtained via the
clinical trial. (Never destroy clinical trial medication).
When the further supplies are received onto the ward from the
community pharmacy the medications should be checked
against the wards record of the order then checked against the
patient’s drug chart. Once medications have been checked as
correct a signed and dated yellow sticker should be attached to
each medication and then the medications should be placed into
the patient’s individual locker, ensuring items requiring special
storage are stored appropriately.
7.4 Patients Own Controlled Drugs
Any POD’s that are controlled drugs should be counted and
recorded in the ward patients’ own controlled drugs register in
Page 9 of 23

separate patient sections. These controlled drugs should then
be stored in the ward patients’ own controlled drugs cabinet.
Any POD’s that are controlled drugs deemed unsuitable for use
should be recorded onto the medication destruction form with a
comment “awaiting CD destruction” as the controlled drugs will
be destroyed at a later date by an authorised person.
All POD’s that are controlled drugs for destruction should be
recorded in the ward patients’ own controlled drug register and
then destroyed by an authorised person and witnessed.
Any POD’s that are controlled drugs awaiting destruction must
be clearly labelled as “patient CD for destruction” and stored in
the ward patients’ own controlled drugs cabinet and segregated
from normal POD’s controlled drugs to avoid potential
administration errors or re-use.
7.5 Discharge with POD’s
POD’s must never be returned to the patient on discharge
without an assessment by a registered nurse or GP. This is to
ensure that the POD’s returned are correct according to the
patient’s prescription.
Discharge should be with a minimum of 14 days supply.
Any controlled drugs to be returned to the patient should be
recorded in the wards patients’ own controlled drugs register
under the separate patient section.
The patient may be given a leaflet detailing their discharge
prescription and details of where to obtain their next supply of
medications. (Appendix E).
A member of staff must check the locker is empty following
discharge to ensure there is no risk of the next patient receiving
incorrect medications.
8. COMMUNICATION AND DOCUMENTATION
Communicating is the final step in the process, where any changes that
have been made to the patient’s prescription are documented and
dated, ready to be communicated to the next person responsible for the
medicines management care of that patient. Examples might include:
• When a medicine has been stopped, and for what reason.
• When a medicine has been started and for what reason.
• The intended duration of treatment.
• When a dose has been changed and for what reason.
Page 10 of 23

8.1 Communication following admission.
This is the responsibility of the admitting practitioner.
• Documentation should always be made in the patient
medical record, noting sources used and dated and signed
by the admitting practitioner.
• Prescription chart (list of medicines prescribed to be
administered) annotated on the front at initial prescription to
show “history taken, sources checked, the date and name of
the practitioner”.
• Intentional medication changes should always be
documented in the patient medical record and on the
prescription chart. Reasons for change should be
documented in the medical record.
• A summary of the actions as a result of the medicines
reconciliation should be included.
• Name, signature and contact details of the individual carrying
out the reconciliation. Where changes have been made to
the prescription chart these should also be appropriately
documented.
8. RISK MANAGEMENT
8.1 Discrepancies
Part of the checking process includes the identification of any
discrepancies. A discrepancy can be defined as any difference
between the medicines the patient had been taking in their
previous care setting and the medicines prescribed in their new
care setting.
Discrepancies may be considered as:
• Intentional
• Unintentional
Intentional discrepancies can be defined as any difference
between the medicines the patient was taking prior to admission
and the medicines prescribed in their new care setting that have
been changed intentionally and agreed with the clinician(s)
responsible for the patient’s care.
Unintentional discrepancies (errors, omissions or unintentional
additions) can be defined as any difference between the
medicines the patient was taking prior to admission and the
medicines prescribed in their new care setting that is not a
conscious change.
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8.2 Reconciling Discrepancies
In the event that a discrepancy is discovered, healthcare staff
must reconcile the discrepancy before administering medication.
This may be by contact with the patient’s own GP Practice or the
issuing hospital, for clarification.
Unintentional medication changes should be discussed with the
prescriber and documented in the patient’s medical record and
(if appropriate) on the prescription chart with recommendations
for follow up.
An incident form should be completed.
8.3 Medication Errors
If a medication error occurs related to the use of patients’ own
drugs, the procedure outlined in NHS East Riding of Yorkshire
PCT Policy for the Management and Administration of Medicines
should be adhered to and a report made as per the Adverse
Incident Reporting Policy and Procedures.
9. MONITORING AND AUDIT
The patients’ own drug scheme will be evaluated using the following
indicators:
Monitoring will also be undertaken via adverse incident reports and an
annual clinical audit. In addition the following may be implemented.
• Number and percentage of patients’ using their own
medication during their inpatient stay.
• Number and percentage of patients’ own drugs not suitable for re-
use and the reason why.
• Drug expenditure by the community hospital and expenditure
on medicines destroyed.
10. IMPLEMENTATION
This guideline will be shared with staff via Team Brief, the Community
Services intranet and the Community Services website.
11. REFERENCES
NPC, Medicines reconciliation, A guide to implementation.
NICE in conjunction with NPSA, Technical patient safety solution for
medicines reconciliation on admission of adults to hospital, December
2007.
Page 12 of 23

Audit Commission, A spoonful of sugar – Medicines Management in
NHS Hospitals.
Page 13 of 23

Appendix A.
Dear Patient,
Page 14 of 23
Attach addressograph or
Name
Address
Date of Birth
At NHS East Riding of Yorkshire Community Hospitals we operate a protocol of
using your own medicines. This allows you to continue with familiar tablets and
other treatments and helps to avoid waste.
We will obtain supplies of any new medications you require from a local
community pharmacy and when you go home we will ensure you receive a
supply of all your current medications.
Your medicines may be changed while you are here and therefore we may
need to dispose of your old ones.
If you are happy for us to use your medicines (for your treatment only), obtain
supplies, and destroy any medication not suitable, please sign below.
SIGNED ……………………………………………………….DATE………………..
I confirm that I have explained the use and destruction of patients’ own drugs to
this patient.
Signature………………………………………………………………………………..
Print Name………………………………………………………………………………
Job title…………………………………………………………………………………..
Date………………………………………………………………………………………

Appendix B.
CRITERIA FOR ASSESSING PATIENTS’ OWN DRUGS (PODs)
These criteria are intended to guide staff through the assessment of patients’ own
drugs (PODs). For a POD to be suitable for use it must be acceptable in all of the
following categories in both Sections A and B. If you are at all unsure about any
of the PODs you are not under any obligation to sign that they are satisfactory, if
you are unsure about any item obtain a new supply from a community pharmacy
using the ward FP10. There may be circumstances where a POD is used but
does not completely meet the criteria below. This should be at the nurse’s
discretion and in agreement with the patient and also recorded into the patient’s
records.
Ensure patients are asked about the following:
• Have they brought all of their currently prescribed medication with
them?
• Do they take the medication as prescribed? If not, how do they take
it? (Concordance/Adherence)
• Do they take any prn medication?
• Other types of medication including:
o Inhalers
o Eye drops
o Topical preparations
o Once weekly medication e.g. methotrexate
o Injections such as depot antipsychotics or vitamins
o Oral contraceptives
o Hormone replacement therapy
o Nebules
o Home oxygen
o Insulin
o Over the counter medication
o Herbal preparations
o Other non-prescribed medication
Page 15 of 23

Section A. Checking the PODs Appendix B.
CRITERIA USE IF MEDICATION IS: AVOID IF MEDICATION IS:
Type of Product Oral, both solid or liquid
Opened eye or ear preparations
Topical, inhaled, or injected
(unless it can be confirmed as
Dressings, test strips, or ostomy
opened less than one month ago)
Suppository or pessary
Over the counter medication (unless
Unopened eye or ear preparations
this has been prescribed)
Presentation In a recognised medicine container
Unrecognised contents or container
Clean and dry
Broken or damaged
No signs of deterioration
Dirty or damp packaging
Liquids in original container
Poor storage conditions or any signs
of deterioration
Any signs of contamination
Age - Loose Dispensed within the last 3 months
Dispensed more than 3 months ago
tablets in bottles Clearly identifiable
Unidentifiable
Age - Blister
packed tablets
including
Inhalers,
creams &
suppositories
etc.
The date is within the POD printed expiry
date
If no expiry date, then dispensed within the
last 3 months
Care with items requiring special storage
conditions e.g. Insulin
Care with items with a shortened expiry
once opened e.g. GTN tablets
Page 16 of 23
POD is past it’s expiry date
If no expiry date, dispensed more
than 3 months ago or unclear when
dispensed
Unconfirmed or inappropriate
storage conditions
Unclear opening date of products
with shortened expiry once opened

Section A. Checking the PODs Appendix B.
CRITERIA
Age – Monitored
dosage systems
(MDS)
Age – liquids
USE IF MEDICATION IS: AVOID IF MEDICATION IS:
Sealed and filled by a pharmacy
If weekly box – filled within last month
If monthly box – filled within last 2 months
Unchanged since last filled
Page 17 of 23
Not sealed or not filled by a
pharmacy
Filled longer than 1 month for
weekly boxes or 2 months for
monthly boxes
No indication of when it was filled
Any changes to medications since
last filled
Dispensed within last 3 months Dispensed more than 3 months ago
Label The POD has the correct patient name on
the label
The POD has the correct drug name, form
and strength on the label
There are instructions on how to take the
POD which match the prescriber’s
prescription
For MDS – must be satisfied that the filled
tablets match the doses and frequencies on
the accompanying sheet or labels
Identity The name of the drug, form and strength
matches that of the blister strip or
packaging
The POD has any other patients
name on the label
The POD does not have the correct
drug name, form or strength on the
label
The POD has unacceptable hand
written annotations on the label or
instructions do not match the
prescriber’s prescription
The suppliers name & address
cannot be identified
Not possible to identify the product
by it’s packaging
Boxes containing mixed contents or
quantities greater than originally
dispensed

Appendix B.
Section B. Checking the PODs against the Drug Chart
Before the PODs are used they should be checked against the drug chart. To do this, have each item present and check the drug name,
form, strength and dose frequency against the prescription. If there are any discrepancies check with the prescriber and if necessary get
a new supply of the medication(s) via a ward FP10 from a community pharmacy.
The prescriber producing the drug chart should check that the medicines prescribed on admission correspond to those taken prior to
admission.
If there are any discrepancies check with the patient’s discharging hospital or the patient’s own GP.
Page 18 of 23

Medication name,
strength and form
Appendix C.
PODs Medication Checklist
Enter the name of the medication, strength, form, and quantity and expiry date.
Place a √ or a X in the appropriate categories.
A box is provided for any other comments.
Attach addressograph or
Name
Address
Date of Birth
Quantity Expiry
date
Good
Condition?
Page 19 of 23
Correct
Instructions?
Suitable
for use?
Assessed by …………………………………………………………….. Date……………………
Other comments

Appendix D.
Medication name,
strength and form
PODs Medication destruction form
Attach addressograph or
Name
Address
Date of Birth
Quantity Reason for
destruction
Page 20 of 23
Comments Destroyed
by:
signature
and date
NOTE: PODs controlled drugs will be destroyed by an authorised person and also recorded
in the patients’ own controlled drug register.
Witnessed
by:
signature
and date

Appendix E.
The community ward gave you at least 14 days supply of your current
medications. Further supplies need to be ordered from your own doctor.
The hospital will send your doctor a list of your current medicines.
Any unwanted medications should be returned to your community pharmacist
for safe disposal.
If you have any questions about your medications ask your doctor or
pharmacist.
Page 21 of 23

Patients Name………………………………………………………………….. Date ………………..
Doctor/Surgery…………………………………………………………………
NAME &
STRENGTH
OF
MEDICINE
BREAKFAST
NUMBER OF TABLETS TO TAKE
LUNCH
TEA
Page 22 of 23
BEDTIME
USE AND ACTION

Appendix F.
Title of Guideline:
EMPLOYEE RECORD OF HAVING READ THE GUIDANCE
Community Wards Guideline for the use of patients’ own drugs (PODs)
I have read and understand the procedures contained in the named Guideline.
PRINT FULL NAME
SIGNATURE
DATE
Page 23 of 23