Procedure For The Decanting Of Topical Preparations In The ...

CLINICAL GUIDELINES FOR DECANTING OF TOPICAL
PREPARATIONS
1. Aim/Purpose of this Guideline
1.1. Procedural document for all practitioners who decant Topical Preparations
within the Dermatology Unit
2. The Guidance
2.1. Equipment
Prescribed topical preparations
Gloves & aprons
Flat wooden spatula
Foil bowl and / or galli pot
Labels
NB: Please wash your hands and wear gloves and an apron as necessary in order to
prevent cross contamination and contact with own skin.
2.2. Procedure
Action
1. In accordance with the
Medicines Management Policy check that the
information contained on the patients
prescription chart is complete, correct and
legible, and the prescribing doctor has signed it.
2. Check that the topical preparation is due and
has not been given already.
3. Take the prescription chart to the patient. In
accordance with the Medicines Management
Policy check the identity of the patient against
the prescription chart.
4. Assess the patient’s skin prior to applying the
prescribed treatment.
Rationale
To protect the patient from harm.
To avoid duplication.
To prevent error.
To ensure treatment is correct.
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Action
5. Discuss the treatment with the patient and
gain the consent to the application of the topical
treatment.
6. Take the prescription chart to the drug
preparation room. Select the required topical
preparations and check the expiry date.
7. Stick a label on the outside of a galli pot or foil
bowl that states the patients name, date of birth
and strength of the topical treatment.
8. Remove topical preparation from the main
container via a flat wooden spatula, pump
container or squeeze out of a tube. Decant the
appropriate amount into the foil bowl or galli pot.
9. Dispose of spatula.
10. Place the main container back in the
cupboard.
11. Repeat steps 6, 7, 8, 9 and 10 to decant
other prescribed topical preparation for the
same patient.
12. Take the decanted preparations and the
prescription chart to the patient.
13. Re-check the identity of the patient against
the prescription chart.
14. Discard foil bowl/ galli pot in clinical waste
bin after the patient has been treated.
Rationale
To establish the patient’s knowledge of
the treatment, gain valid consent and
co-operation.
Treatment with medication that is
outside the expiry date is dangerous.
Drugs deteriorate with storage. The
expiry date indicates when a particular
drug is no longer pharmacologically
efficacious.
To prevent error.
To prevent cross contamination.
To prevent reuse of single use item.
For appropriate storage.
To avoid error.
To prevent error.
To prevent error.
To prevent cross contamination.
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3. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Tool
Frequency
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
Nurse to complete treatment response checklist in patient pack.
Check patient records to ensure policy has been adhered to - staff
compliance audit.
Patient outcome/evidence of infection due to cross contamination.
Nurse carrying out the treatment.
Nurse lead – Lisa Pollard.
Completion of treatment response checklist.
Patient assessment/outcome.
Ongoing monitoring of compliance.
Training of new staff members.
Yearly audit.
Only report if there is a problem.
Report to lead nurse.
Lead nurse will take responsibility with support from the clinical
lead.
Required actions will be identified and discussed with care team.
All changes to be made accordingly and promptly.
Changes to practice to be identified and shared with all
practitioners during the unit meeting.
Required changes to practice will be actioned with the support of
the lead nurse.
The lead nurse to take each change forward where appropriate. .
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
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Appendix 1. Governance Information
Document Title
Date Issued/Approved: March 2012
Procedure for the Decanting of Topical
Preparations in the Dermatology Unit
Date Valid From: March 2012
Date Valid To: March 2015
Directorate / Department responsible
(author/owner):
SN Pollard/SN Collier
Contact details: 01872 253265
Brief summary of contents
Procedural document for all practitioners
who decant Topical Preparations within the
Dermatology Unit
Suggested Keywords:
Target Audience
Executive Director responsible for
Policy:
Date revised: February 2012
This document replaces (exact title of
previous version):
Approval route (names of
committees)/consultation:
Decanting
Topical Preparations
Dermatology
RCHT PCT CFT
Director of Nursing, Midwifery and Allied
Health Professions
Procedure For The Decanting Of Topical
Preparations In The Dermatology Unit
Divisional Manager/Speciality Lead
Kathryn Radcliffe
Divisional Manager confirming
approval processes
Name and Post Title of additional
signatories
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
Document Library Folder/Sub Folder
Links to key external standards
Related Documents:
Kathryn Radcliffe
Not Required
Internet & Intranet
Dermatology
None
None
Intranet Only
Procedure for the Decanting of Topical Preparations in the Dermatology Unit
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Training Need Identified?
No external training needed – in house
training only for all registered nurses.
Version Control Table
Date
Versio
n No
Summary of Changes
10 Jun 10 V1.0 Initial Issue
Changes Made by
(Name and Job Title)
SN Pollard
SN Collier
Dermatology
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Procedure for the Decanting of Topical Preparations in the Dermatology Unit
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Appendix 2.Initial Equality Impact Assessment Screening Form
Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: Procedure for the Decanting of Topical Preparations in the Dermatology Unit
Directorate and service area:
Is this a new or existing Procedure?
West of Cornwall and Speciality
Medicine/Dermatology
Existing
Name of individual completing
Telephone:
assessment:
SN Bonnie Collier/SN Lisa Pollard 01872 253265
1. Policy Aim* Standard procedure for the Decanting of Topical
Preparations in the Dermatology Unit.
2. Policy Objectives* Provision of clear guidelines to ensure continuity of best
practice.
3. Policy – intended
Outcomes*
5. How will you measure
the outcome?
5. Who is intended to
benefit from the Policy?
6a. Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around this
policy?
Standardised practice.
Staff assessment
Departmental Audit
Patient Outcome
Practitioners
Patients
No
b. If yes, have these
groups been consulted?
c. Please list any groups
who have been consulted
about this procedure.
*Please see Glossary
7. The Impact
Please complete the following table using ticks. You should refer to the EA guidance notes
for areas of possible impact and also the Glossary if needed.
Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
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Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Equality
Group
Age
Positive
Impact
x
Negative
Impact
No
Impact
Reasons for decision
Disability
x
Religion or
belief
x
Gender
x
Transgender
x
Pregnancy/
Maternity
Race
x
x
Sexual
Orientation
x
Marriage / Civil
Partnership
x
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
A negative impact and
No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that the policy
promotes equality, equal opportunities
or improved relations - could it be
adapted so that it does? How?
Full statement of commitment to policy of
equal opportunities is included in the policy
Please sign and date this form.
Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House,
Penventinnie Lane, Truro, Cornwall, TR1 3LJ
A summary of the results will be published on the Trust’s web site.
Signed ________________________________________
Date _________________________________________
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