Medicines Management Policy - Dudley Primary Care Trust

Medicines Management Policy
Document Description
Document Type Policy
Service Application
Version 3.0
Ratification date October 2009
Review date October 2011
All Dudley PCT employees and contractors involved in the
prescribing, supply and administration of medicines
Lead Author(s)
Name
Position within the Organisation
Specialist in Pharmaceutical Public Health
Presented for discussion, approval and ratification to
Core Policies and Procedures Group 29 October 2009
Change History
Version Date Comments
1.0 11/04 Ratified
2.1 02/07 First consultation and revision
2.2 11/07 Second consultation and revision
2.3 08/08 Third consultation and revision
2.4 12/08 Fourth consultation and revision
2.5 06/09 Fifth consultation and revision
2.6 10/09
3.0 11/10 Final Ratified Edition
Link with CQC Essential
Standards of Quality &
Safety
Regulation 10 Outcome 16 – Assessing and monitoring the quality
of service provision.
Regulation 13 Outcome 9 – Management of medicines.
Regulation 18 Outcome 2 – Consent to care and treatment.
Regulation 20 Outcome 21 – Records.
Regulation 23 Outcome 14 – Supporting workers.
Link with Trust Purpose
& Values Statements
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Summary
Medication is widely used in the health service to improve health, however there is a
significant amount of legislation concerning its use while professional bodies have also
issued good practice guidance on systems and processes. This policy describes the
procedures and good practice that should be used when providing medication to a
patient whether by prescribing, supplying or administering a product. It covers the
legal and professional standards that are expected of different staff groups and the
personal responsibility involved. It covers all aspects of the process from accurate
prescription writing to safe administration of products. It been developed with the
assistance of other partners including Dudley Metropolitan Borough Council and
Dudley Group of Hospitals Foundation Trust to ensure that it is consistent with local
arrangements where possible.
This Policy should be read in conjunction with:
1. The sections on 'Guidance on Prescribing' and 'Prescription writing' in the BNF
(most recent edition)
2. The Nursing and Midwifery Council Guidance for the administration of
medicines (February 2008).
3. The Nursing and Midwifery Council Code of professional conduct (April 2008)
4. The Nursing and Midwifery Council Standards of proficiency for nurse and
midwife prescribers (April 2006)
5. Medicines, Ethics and Practice: a guide for pharmacists (most recent edition)
6. Local policies and formularies as detailed in the document (These can be found
in the Policies and Procedures section of the intranet)
NB: This is a general policy covering any member of staff in PCT dealing with
medicines. Individuals have a level of personal responsibility to read and
understand this policy. Non-compliance with this policy may lead to
performance management and disciplinary consequences. In very serious
matters professional, civil and criminal legal consequences may occur also.
Some areas are covered by more detailed local policies. It is the responsibility
of managers and staff to ensure they follow the more detailed policies where
they are applicable.
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CONTENTS
Section
Page
1. Introduction 5
2. Prescribing of medicines 7
3. Supply of prescription Pads 15
4. Security and Safe Handling of Prescriptions 17
5. Obtaining medicines 18
6. Transport of Medicines 19
7. Storage and Security of Medicines 20
8. Responsibilities of the Person administering
the Medication 23
9. Administration 24
10. Controlled drugs 28
11. Management of errors or incidents associated
with medicines 35
12. Verbal orders for the Administration of Medication 37
13. Disposal of Medicines when off site 38
14. Alcohol 39
15. Illegal substances 40
16. Theft 42
17. General notes for the handling of medicines 43
18. Patients at risk from Self-Poisoning 44
19. Compliance aids 45
20. Vaccines 46
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21. Syringe drivers 47
22. Cytotoxic medicines 48
23. Prescribing of oxygen 49
24. Monitoring the Policy 50
Supporting Documents 52
Glossary 52
Useful telephone numbers 52
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1. Introduction
This policy deals with all aspects of the management and administration of
medicines for patients/clients cared for by the Primary Care Trust. All Trust staff
working within these areas are required to adhere to the procedures described
within it. The policy has been compiled by a multi-disciplinary team and is
intended to be used by all individuals, employed or contracted by the Trust, who
deal with medicines within the Trust (including all locum and agency staff). It
replaces all previous Medicines Management Policies.
1.1 Overall Responsibility
The following individuals are responsible for guidelines or training and
information on all aspects of the safe and secure handling of medicines within
the whole organisation and report directly to the Chief Executive for this
purpose.
Dudley Primary Care Trust
Dudley Provider Services
All controlled drug issues
Medical Director
Managing Director of Dudley Community
Services
Accountable Officer
1.2 Application and personal responsibility.
This Policy, which contains the standards and procedures associated with the
prescribing, administration, requisitioning and storage of medicinal products, is
mandatory for all staff employed by and/or working within Dudley Primary Care
Trust, including those working on a sessional basis. Staff seconded to other
organisations must abide by the standards of that organisation.
It is the professional responsibility of each member of staff to update himself or
herself on this Policy on at least an annual basis.
Managers are responsible for ensuring that copies of this Policy are available to
all their clinical staff and to ensure that they are fully aware of their
responsibilities, competencies and procedures. It is good practice to include an
update as part of each individual annual healthcare-staff appraisal. The Policy
is part of new healthcare staff induction and staff will have to sign that they
have read and understood the policy. A recognition that staff have updated their
knowledge of the policy will be included as part of annual appraisals.
Consultants and clinical leads are responsible for ensuring that all medical
officers in their team are fully aware of the key points in the Policy and are
trained to be competent in all aspects of prescribing of medicines, as specified
in the Policy.
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General Practitioners are responsible for ensuring that their practice operates a
clear medicines management policy that covers all aspects of the use of
medicines within their practice.
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2. Prescribing of medicines
2.1 Introduction
There are increasing numbers of types of prescribers and methods by which
medicines can be authorised for administration to a patient/client. Medicines,
which have not been authorised by a registered prescriber, must not be
administered to patients/clients. This authorisation must be in writing, in the
form of a prescription or Patient Group Direction (PGD), in advance of the
administration of the medicine.
2.2 Independent Prescribing
All prescribers are expected to adhere to the Dudley Joint Formulary, wound
care formulary and local prescribing guidelines.
Definition of Independent Prescribing
The Department of Health’s working definition of independent prescribing is
prescribing by a practitioner (e.g. doctor, dentist, nurse, and pharmacist)
responsible and accountable for the assessment of patients with undiagnosed
or diagnosed conditions and for decisions about the clinical management
required, including prescribing
2.3 Non Dudley employed clinicians prescribing for inpatients on PCT sites.
Where medical staff from Dudley Group of Hospitals, have been asked to
assess a patient and wish to make a recommendation concerning medication,
they should not write on the prescription sheet. Recommendations should be
written in the patient records for addition to the prescription sheet by the
patient’s own clinical team.
2.4 Non-Medical Prescribers
The introduction of prescribing by healthcare professionals other than doctors
and dentists involves them working outside traditional boundaries. This policy
aims to set out the administrative and procedural steps required by each
healthcare profession now eligible to prescribe. It contains advice on good
practice to ensure non-medical prescribers are practicing legally and safely
within a supportive environment.
It is necessary to develop non-medical prescribing guidelines within a Clinical
Governance Framework to encompass quality, education and training, records,
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and clinical audit, in order to minimize risk and ensure that patients/clients
receive the best quality care.
All NMP must be approved and deemed competent by Dudley PCT before
prescribing for a patient as part of their PCT employment.
Registered prescribers now include:
• Nurses who have undertaken the supplementary and/or the independent
prescribers course and are registered as such with the Nursing and
Midwifery Council.
• All Registered Pharmacists who have undertaken the independent
prescribers course and are registered as such with the Royal
Pharmaceutical Society of Great Britain (RPSGB) and approved by the
PCT.
• Supplementary prescribers are health professionals who have undertaken a
further qualification and are registered as such with their professional body.
These prescribers can prescribe within a clinical management plan for
individual patients, in conjunction with an independent prescriber (currently
only applies to medical practitioner/dentist) and the patient. These
professionals can be 1 st level nurses, pharmacist, chiropodists/podiatrists,
physiotherapists and radiographers (Allied Health Professionals - AHP). All
prescribers must comply with current legislation for prescribing and be
accountable for that practice.
Exceptions to this are as follows:
• In areas where there are no resident prescribers and in cases of
exceptional clinical urgency a verbal instruction is acceptable. (See section
12)
• Certain medicines may be administered following Patient Group Directions
approved by the PCT Prescribing Sub Committees. Criteria for supply and
administration under a PGD will be defined within the respective PGD.
• State registered chiropodists may supply or administer medicines specified
in the Medicines Act 1968, and in orders made under the Act, providing they
also hold a certificate of competence in the use of the medicines, issued by
or with the approval of the Chiropodist Board. The supply or administration
shall be only in the course of their professional practice.
Medical Students or Clinical Attachments are not permitted to
prescribe medicines.
2.4.1 What a Nurse or Pharmacist independent prescriber can prescribe
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Nurse and Pharmacist Independent Prescriber may prescribe any licensed
medicine for any medical condition that the nurse or pharmacist is competent to
treat. This allows access to virtually the whole of the British National Formulary
with the exception of Controlled Drugs and unlicensed medicines.
Current legislation allows nurses to prescribe some controlled drugs (see
section 10) but at present this does not apply to pharmacists.
2.4.2 What a Community Practitioner Prescriber can prescribe
The items that may be prescribed are listed in the British National Formulary
(BNF) or Drug Tariff.
2.4.3 Supplementary Prescribing by Nurses, Pharmacists,
Chiropodists/Podiatrists, Physiotherapists and Radiographers.
Definition of Supplementary Prescribing
Supplementary prescribing is a voluntary prescribing partnership between the
independent prescriber (doctor or dentist) and supplementary prescriber to
implement an agreed patient-specific clinical management plan (CMP), with the
patient’s agreement.
2.4.4 What a Supplementary Prescriber can prescribe
Following agreement of the CMP, the supplementary prescriber may prescribe
any medicine for the patient that is referred to in the plan, until the next review
by the independent prescriber. There is no formulary for supplementary
prescribing, and no restrictions on the medical conditions that can be managed
under these arrangements.
This mechanism of prescribing will be helpful for nurse and pharmacist
prescribers when they are newly qualified. It will also be appropriate in specific
situations, for instance
- When working within a team where a doctor is accessible
- For specific long-term conditions
- For situations involving Controlled Drugs.
Supplementary Prescribers can prescribe Controlled Drugs and unlicensed
medicines in partnership with a doctor, where the doctor agrees within a
patient’s CMP. From July 2006 chiropodists/podiatrists physiotherapists and
radiographers are also able to prescribe Controlled Drugs as supplementary
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prescribers, but only where there is a patient need and the doctor has agreed in
a patient’s CMP.
More detailed information on supplementary prescribing can be found on the
Department’s web site: www.dh.gov.uk/supplementaryprescribing.
2.5 Patient Group Directions
A Patient Group Direction (PGD) is defined as a written instruction for the
supply or administration of medicines to a group of patients who may not be
individually identified before presentation for treatment. It is not a form of
prescribing.
Further guidance on the use of PGDs can be found in the Trust Policy
document ‘Patient Group Directions General Policy for the Supply and
Administration of Medicinal Products by Approved Practitioners (Non- Medical)’.
2.6 Clinical Awareness and Competence of person writing prescription
2.6.1 The healthcare professional must be aware of, and able to demonstrate
knowledge of, the action of the prescribed item, the usual dosage, the common
side effects, interactions, local prescribing guidelines, current evidence and how
these relate to the treatment of the individual patient/client overall. They should
be familiar with sources of information about medication such as the BNF.
Whenever possible, prescribers should have access to the patient’s current
medical record.
2.6.2 As part of their continuing professional development standard as laid down by
their professional body. The healthcare professional must make every
reasonable effort to maintain and develop knowledge of the common
medications used in his/her area of practice. This knowledge should include
awareness of;
a) The signs of adverse drug reactions (ADR) to medication and the actions
to be taken should this occur.
b) Reactions that may occur when different medicines are combined.
c) Contra-indications
2.7 Writing Prescriptions
Prescriptions written by doctors or other authorised prescribers employed by
Dudley Primary Care Trust must conform to the following guidelines.
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2.7.1 Clarity
The prescription form or medication record card must clearly state the required
patient/client’s details i.e.
Name
Age & Date of birth (N.B. legal requirement for Prescription Only
Medicine (POM) if under 12)
Address
NHS number
Each item must be clearly written in blue or black indelible ink, preferably using
block capitals. Prescriptions must be computer generated where possible.
2.7.2 Generic Prescribing
Medicines should be prescribed using approved (generic) name where
possible. Where bioavailability is important the patient/client should continue to
receive the same brand: in such cases, the manufacturer’s brand name should
be stated. Examples are listed in the BNF e.g. anticonvulsants, lithium,
theophyllines.
2.7.3 Requirements for Prescription Pricing Division (PPD) prescriptions e.g.
FP10
Each item must include the following;
• name of drug (approved name)
• metric dosage
• frequency
• form and strength
• route to be used
• clear directions as to any site of application of treatment must be present.
• be signed and dated by the prescriber – NB name of prescriber should be
printed beside signature.
• PCT and practice code
• PCT practice address
• contact telephone number
• prescriber code for non-medical prescriber
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2.7.4 Requirements for in-patient treatment cards
• name of drug (approved name)
• metric dosage
• frequency
• form and strength
• route to be used
• clear directions as to any site of application of treatment must be present.
• be signed and dated by the prescriber
• time of administration (in 24 hour clock)
• PCT Unit (e.g. ward, house etc)
• unit number
• consultant
• drug sensitivities (including writing ‘none’ if none known)
2.7.5 Documentation of Allergies/Hypersensitivities
All treatment cards must specify whether or not the patient has any drug
allergies/hypersensitivities. It is the responsibility of the admitting medical/dental
officer to record these on the prescription sheet as well as in the medical notes.
Medical officers, pharmacists and nurses may also document any that become
apparent during the in-patient stay.
2.7.6 Errors
When an error is made in writing a prescription, the incorrect information must
be struck out with a single line, signed by the prescriber and the correct
information written in a new section.
2.7.7 The following points should be noted when prescribing strengths and
quantities
i) unnecessary use of decimal points should be avoided, e.g. 3mg, not 3.0mg
ii) quantities less than 1 gram should be written in milligrams, e.g.500mg, not
0.5g
iii) quantities less than 1mg should be written in micrograms,
e.g.100micrograms, not 0.1mg.
iv) a zero should be written in front of a decimal point where there is no other
figure, e.g. 0.5ml, not .5ml
v) 'micrograms', 'nanograms' and 'units' should not be abbreviated
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2.7.8 Recognised abbreviations
Only the following abbreviations are recognised within the health economy. All
other regimens must be written out in full or followed according to an agreed
protocol.
Dose
OD Once daily
OM Each morning
ON Each night
BD Twice daily
TDS Three times daily
QDS Four times daily
Mane Morning
Nocte At night
For patient records
Route
Ext
IM
Inh
IV
O
PO
NG
Neb
PR
PV
SC
S/L
Top
PEG
External use
Intramuscular
Inhalation
Intravenous
By mouth
By mouth
Nasogastric tube
Nebulisation
Per rectum
Per vagina
Subcutaneous
Sublingual
Topical
PEG feed
Depot injections should be prescribed with the interval expressed using the
term “every” (e.g. ‘every 3 weeks’ rather than ‘3 weekly’, which can be
misinterpreted. This can be abbreviated as every 3/52)
In the case of “when required medicines” the prescription should state the
circumstances when it is to be used/taken, the maximum number of doses to be
given and specify a time interval e.g. 4 hourly and where appropriate the
maximum dose in 24 hours. The criteria where a doctor must be contacted
should also be noted if appropriate.
Errors have occurred in both the dispensing and administration of
unclear prescriptions and for that reason the use of abbreviations such as
mdu and prn must not be used and clear directions written as above.
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2.8 Prescribing Controlled Drugs- see section 10.
2.9 How to report a suspected ADR i.e. use of the yellow card system.
If a patient suffers a suspected adverse reaction to a prescribed, over-thecounter
(General Sales List) or herbal medicine, the adverse reaction should be
reported via the Yellow Card Scheme.
The Yellow Card Scheme is a voluntary scheme through which healthcare
professionals notify the Medicines Control Agency (MCA)/Committee on the
Safety of Medicines (CSM) of suspected adverse drug reactions (ADR’s). The
MCA/CSM encourage the reporting of ADR’s to newly licensed medicines that
are under intensive monitoring (identified by a ▼ symbol both on the product
information for the drug and in the BNF and MIMS) and all serious or
unexpected suspected ADRs to all other established drugs.
Serious reactions include those that are fatal, life-threatening, disabling,
incapacitating or which result in prolonged hospitalisation and/or are medically
significant e.g. teratogenicity. The new electronic Yellow Card provides a simple
and fast way to report suspected ADRs. The electronic Yellow Card, together
with instructions on how to use it, is available on the MCA website
(www.mca.gov.uk).
Health professionals are encouraged to report all suspected ADRs using this
method, although hard copy Yellow Cards are also acceptable (and can be
found bound to the back of the BNF and Drug Tariff. All ADRs must be
recorded in the patients Medical Records. The supplementary prescriber should
also inform the independent prescriber of any reported ADRs.
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3. Supply of prescription Pads
N.B. The prescription pad and forms are the property of the Primary Care Trust.
Prescriptions must only be issued to patients for whom Dudley PCT holds
responsibility. It is the responsibility of the prescriber to ensure the security of
the pad/form at all times. (For further information see section 4)
Please also refer to section 7 and appendix 5 in the Facilities Management
Centre (FMC) Procurement and Facilities Department, “Controlled Stationery
Procedures Manual.”
3.1 For Non Medical Prescribers employed by Dudley PCT
3.1.1 The NMP is responsible for supplying details of registration status to their line
manager.
3.1.2 Prior to commencing prescribing, the line manager or designated member of
staff will ensure that the member of staff has access to NMP resource pack
http://joint.dudley.nhs.uk/cmsextra/Pharmacy-Prescribing-
Medicines/index.aspid=7286 and the NMP lead has been informed so as to
update the NMP prescribing database.
3.1.3 The line manager is responsible for ensuring the PPD is notified by completing
an Annex Form 1 (version 3) for the notification of newly qualified Non medical
Prescribers/Change in circumstances. This can be done by the FMC. For NMPs
employed within General Practice, this will be done through the GP system via
the Warehouse Manager at the FMC, Pensnett Trading Estate by completing
Annex Form 2 (version 3). For details on nurse prescribing forms please see
www.ppa.org.uk/ppa/Pct/nurses/pctNurse.htm
3.1.4 Once the NMP is registered with the PPD the line manager will order
prescription pads, firstly via telephone to the supplier and confirming this on the
proforma for ordering FP10 secure prescription pads. See Appendix 1 to
Medicines Management Policy 2.4 dec 08 doc.xls
3.1.5 When the prescription pads arrive the line manager will give out a maximum of
2 pads to each NMP (for nurses employed by General Practitioners, pads will
be forwarded to the appropriate surgery via the GP courier system). The line
manager will record the first and last serial number of each pad and also the
signature of the person issuing and receiving the pad. The Practice Manager
will record appropriate details on attached paperwork that should be returned
within 72hrs of receipt. A copy must be maintained by the Warehouse Manager
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& Practice Manager on a file. Note: For security reasons pads can only be
collected in person by the NMP.
3.1.6 Any un-issued prescription pads must be kept in a locked cupboard and treated
as controlled stationery.
.
3.1.7 Prescription forms will be supplied in pads of 50 forms from an approved
supplier. The pads will be ready personalised, with the nurse prescribers
details.
3.1.8 Any NMP who is employed by more than one PCT or GP Practice must have
separate prescription pads for each organisation. It is the prescriber’s
responsibility to ensure that all prescriptions are endorsed with the correct
practice code.
3.1.9 All NMPs will be reviewed regularly using the NMP prescribing competency
framework to ensure competency.
3.2 Medical Prescribers employed by Dudley PCT
Medical prescribers must order prescription pads for the service they are
prescribing for via the line manager in charge of the service. The line manager
will record the first and last serial number of each pad and also the signature of
the person issuing and receiving the pad. The line manager will record
appropriate details on attached paperwork that should be returned within 72hrs
of receipt. A copy must be maintained by the Warehouse Manager & line
manager on a file. Note: For security reasons pads can only be collected in
person by the prescriber.
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4.0 Security and Safe Handling of Prescriptions
Thefts and losses over recent years of prescription forms in general have
dramatically increased and the security of prescription forms are the
responsibility of the prescriber. Stock levels of the forms held should be kept to a
minimum.
4.1 General security
The prescription form must only be produced when needed and never left
unattended. When not in use they must be placed in a locked drawer/secure
stationery cupboard. When on patient visits the prescriber must keep the
prescription pad on their person. Prescription forms should never be left in a car.
If prescription pads are taken off PCT premises, they must be kept safe and
secure from other family members and visitors. Under no circumstances
should blank prescription forms be pre-signed before use.
4.2 In the event of loss or suspected theft.
All prescribers should follow the procedures below:
• The prescriber should immediately contact their line manager. For community
nurses this will be their line manager and for practice nurses, their practice
manager.
• The manager will then inform the Personal Assistant to Specialists in
Pharmaceutical Public Health, (SiPPH) Dudley Primary Care Trust
Direct Line: 01384 366589, Fax: 01384 241115
• The Personal Assistant will then inform the Head of Security, the Counter Fraud
Specialist and activate the cascade system by notifying the local community
pharmacists through the “Early Warning System”.
• A Senior Pharmacist will review the circumstances and decide upon any
necessary additional action.
• Prescribers will be asked to temporarily write/sign prescriptions in red or green
coloured ink.
• The incident must be logged on Sentinel.
• The police should also be informed by the manager as soon as possible after
the loss/theft is confirmed, giving details of the approximate number of
prescriptions stolen, their identification numbers, and where and when they
were stolen.
• A crime reference or loss reference number should be recorded against each
incident.
4.3 Recording of prescription numbers
It is good practice at regular intervals to note the prescription number issued to
a patient in the patient’s notes so that should prescription pad or individual
prescription be stolen the prescriber is able to indicate how many forms have
been taken.
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5. Obtaining Medicines
Medicines may be obtained from the Hospital Pharmacy Service or a
Community Pharmacy depending on the system in place for each Community
Service.
5.1 Obtaining medicines via the Hospital Pharmacy Service.
Medicines may be obtained from the Hospital Pharmacy via Pharmacy top-up
system or presentation of a signed written order. A signed written order may
either be a prescription signed by a doctor or other authorised prescriber, or a
stock requisition signed by the nurse in charge. Any signature must have the
name of person printed beside it. Staff collecting medicines must present ID
badges.
5.1.1 All order books and blank order forms must be stored in a secure place to
prevent unauthorised access. Only one stock and one Controlled Drug book
may be in use and held by each clinical area at any one time.
5.1.2 All drug requisitions must travel to and from the pharmacy department in sealed
tamper evident containers or by a person authorised by the registered nurse in
charge.
5.1.3 When requisitioning an order all remaining blank lines must be cancelled out
before signature. Completed requisition forms and requisition books must be
retained in the requesting department for two years from the date of order or
date of last entry.
5.2 Obtaining Medicines from a Community Pharmacy
Some services have Service Level Agreements for the supply of medicines
from other suppliers. All ordering must be done as specified under the SLA with
authorised signatures and a robust monitoring arrangement.
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6. Transport of Medicines
6.1 All medicines will be transported in such a manner as to prevent loss or improper
use.
6.2 If a messenger service (e.g. porter, driver) is used the medicines will be
contained in a sealed tamper evident satchel or other sealed container and kept
in charge of the messenger until handed to the individual in charge.
6.3 When items requiring refrigeration are transported, care must be taken to
maintain the cold chain.
6.4 If medicines are being transported by non-clinical members of PCT staff or Social
Services staff they must have received training in the safe transport of medicines
and follow the guidance in section 7.6 below.
6.5 Community Nurses may act as the patient/client’s representative in collecting
prescription medicines from a Pharmacy. This should only be done in
circumstances where it is essential for the patient/client’s immediate treatment.
A Community Pharmacy delivery service must be used, where available, when
the patient/client has difficulty collecting their medication or returning items no
longer required.
6.6 Members of staff transporting medicines, including dressings, should:
i) Carry the absolute minimum stock required.
ii) Carry the medicines in such a manner as not to be obvious.
iii) Whenever possible, travel direct to the place where the medicines are to
be administered but in any case within that span of duty N.B. CDs
(controlled drugs) must be delivered immediately once collected.
Avoid leaving medicines unattended in a vehicle unless in very
exceptional circumstances. Where it is necessary to leave medicines in
a vehicle they must always be stored out of sight and the vehicle locked.
iv) Return directly back to the site of storage with any unused medicines.
Medicines or products prescribed for an individual patient on a PPD
(Prescription Pricing Authority e.g. FP(10)) prescription form must be left
with the patient since it is their property.
v) Record when and where medicines have been transported.
6.7 Used syringes, needles and any part used injections must be discarded into a
suitable sharps container prior to transporting back to base. Please refer to
PCT Sharps Policy.
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7. Storage and Security of Medicines
(See also PCT security policy)
http://joint.dudley.nhs.uk/cmsextra/documents/cms/489-2008-8-5-3796510.pdf)
7.1 For each area of PCT managed service, the manager responsible for the
service is responsible for the safe storage, custody and administration of all
medicines used within her/his area, in accordance with this policy.
7.2 All medication on Trust property must be stored in a locked cupboard, drug
trolley or refrigerator designated for the sole purpose of storing medication. In
exceptional circumstances and where there are no other facilities, small
quantities of a patient’s own medication may be stored in a locked drawer as a
temporary measure. These storage facilities must be kept locked at all times.
7.3 There should be a single key for each lockable storage facility with a duplicate
key stored in a designated safe area or with a senior manager. Loss of keys
must be reported to the line manager on duty who will arrange an investigation
and change of locks or authorise temporary use of a second set of keys. When
drug cupboards and/or their locks are replaced or new keys cut for drug
cupboards this must be done only following verbal authorisation from the senior
manager responsible for the service and the incident must be logged on
Sentinel. The senior manager must inform the Pharmaceutical Advisor and
Trust Security Officer at the earliest opportunity. Any new key must be
managed as in 7.3.
7.4 The safe keeping and whereabouts of the drug cupboard keys is the
responsibility of the most senior person on duty. Wherever possible the drug
cupboard keys should be held personally by the senior officer in charge. If this
is impractical the drug cupboard keys must be stored in a designated place of
safekeeping and be managed in such a way (i.e. record signatures as key is
issued and returned) to prevent unauthorised access. Duplicate keys must be
stored in a similar manner, preferably in a different designated place of
safekeeping.
7.5 Preventing unauthorised access to keys is of paramount importance and the
location of key storage (including the duplicate key) should be approved and
documented by the manager responsible for the service.
7.6 When a unit where medicines are stored is temporarily not involved in the
active treatment of patients/clients or closed e.g. overnight or weekend, the
drug cupboard keys must be returned to their designated place of safe keeping
and secured in such a manner to prevent unauthorised access. Where the
duration of closure is longer than overnight or a weekend the advice of the
manager responsible must be sought.
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7.7 All medicines shall be returned to lockable medicine cupboards when not in use
except for emergency drug kits e.g. Cardiac Arrest Boxes, which shall be stored
in a manner not obvious to the general public.
7.8 Stocks must be checked on a monthly basis for out of date items. Except for
controlled drugs, all out of date medicines generated by healthcare
professionals, must be disposed of in the waste container and transported back
to the base/clinic for collection via the waste collection service for surgeries and
clinics.
For disposal of Controlled drugs see section 10 and Disposal of a
patient/client’s own medication see section 13
7.8 Where an area is covered by the Service Level Agreement with Dudley Group
of Hospitals (DGoH) Pharmacy department, the PCT staff and the Hospital
Pharmacy staff are responsible for ensuring that the stock is appropriate to the
field of practice and that the stock remains in date. The healthcare professional
is responsible for ensuring that systems are followed the stock is kept tidy and
clean and is stored in a way that facilitates ease of use. Where an area is not
covered by the SLA, then the Head of Medicines management and healthcare
professional staff are responsible
7.9 It is the healthcare professional’s responsibility to ensure that any medications
administered by them appear to be of suitable quality for use and have been
stored according to manufacturer’s guidance. If a defect is suspected the
guidance in section 5.4 must be followed.
7.10 If items are required to be refrigerated then a lockable medicines fridge must be
used for drug storage only. The temperature should be recorded regularly (daily
or each time the area is used if less frequently than daily) with a
maximum/minimum thermometer on an audit sheet.
7.11 Storage in a drug trolley
Drug trolleys must be secured to the wall when not in use. When unlocked they
must be supervised by a member of staff at all times (preferably two, in case
one gets called away). The members of staff are responsible for ensuring that
the trolley is always supervised and must lock the trolley if the contents are not
under direct observation. When a drug round is in progress the drug trolley lid
must be closed if the contents are not in direct sight i.e. turning away to give an
item to a patient. In an emergency the trolley may be left locked but not secured
to a wall, however reasonable steps should be taken to prevent this happening.
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7.12 Storage in the patient/client’s home.
Healthcare professionals are responsible for advising patients/clients and/or
their relatives or carers on security and safe storage of medicines to be
administered at home. Where possible patients/clients and carers should be
encouraged to store medicines in a locked cupboard, out of reach of children.
Medicines should not be stored in a kitchen or bathroom area.
For syringe driver boxes kept at patient/clients home please refer to the
Dudley PCT Policy for the Use of Syringe Drivers in the Community (Palliative
Care). Syringe driver policy
7.13 Storage in the GP surgery
Medicines for use in the GP surgery should be stored in a locked cupboard or
locked medicine refrigerator kept solely for this purpose. General Practitioners
are personally responsible for ensuring the safe keeping of all medicines within
the surgery.
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8. Responsibilities of the person administering the medication
8.1 The healthcare professional must be aware of the action of the prescribed item,
the usual dosage, the common side effects, interactions and how these relate
to the treatment of the individual patient/client overall. They should be familiar
with sources of information about medication such as the BNF.
8.2 The healthcare professional must make every reasonable effort to maintain and
develop knowledge of the common medications used in his/her area of practice.
This knowledge should include awareness of:
i. The signs of adverse reactions (ADR) to medication and the actions to
be taken should this occur.
ii Reactions that may occur when different medicines are combined.
iii Contra indications
iv How to report a suspected ADR i.e. use of the yellow card system.
8.3 Where a healthcare professional has concerns about the clarity of the
prescriber’s instruction or the appropriateness of a drug treatment then it should
be raised with the prescriber or a pharmacist.
8.4 Concerns about defective products should be raised with the supplying
pharmacy as soon as possible. The pharmacy should advise on the action
required concerning the medicine, and the necessity of obtaining an alternative
supply. The product must be quarantined immediately. The incident must be
logged on Sentinel which will be passed to the prescribing team. The person
discovering the defect must inform the prescriber if the patient has received the
product.
8.5 The healthcare professional is responsible for teaching
• The patient/client about medication in a manner commensurate with the
individual’s ability to comprehend. This teaching should include the names
and purpose of the medication, the dose and timing and the common
potential side effects.
• Student nurses about issues related to the prescribing and administration of
medicines as outlined above.
8.6 Where supervising a student health professional, the qualified professional
must clearly countersign the signature of the student.
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9. Administration
Registered healthcare professionals will normally undertake the administration
of medicines. Exceptions are Community Health Care Staff and Social
Services staff that have been trained in, and assessed as competent in, the
administration of medication (with the exception of CDs which are not to be
personally administered by these staff). Documentation of training should be
maintained by the Team Leader/Coordinator who has responsibility for ensuring
such training is completed. A record of this training should be held in the staff
member’s personnel file.
Only medicines that have been authorised by a medical or dental practitioner,
or other authorised prescriber or a healthcare professional authorised via a
Patient Group Direction must be administered to patients/clients. This
authorisation must be in writing, in the form of a prescription, in advance of the
administration of the medicine, (see section 2, Prescribing of medicines).
In areas where there are no resident prescribers and in cases of clinical
urgency a verbal instruction is acceptable (see section 12), except for schedule
2 and 3 controlled drugs, other than Phenobarbital for epilepsy.
See section 10 for further guidance on the administration of controlled drugs
.
9.1 Administration must be carried out in accordance with the patient/client’s
prescription. This can be ascertained by having present at the time of
administration one of the following:
a) A clear written direction from an independent prescriber or a PGD.
b) A duplicate copy of the discharge medication.
c) Verbal prescription in extreme circumstances only. (Section 12)
If there is any uncertainty regarding the prescriber’s intention this must be
clarified prior to administration, e.g. clarification of abbreviations not included in
2.7.6
9.2 The healthcare professional responsible for the drug administration must
ensure the following elements of the procedure are achieved: -
i) The patient/client is correctly identified and informed consent gained
before taking their medication or there is authorisation of administration.
ii) The patient/client is assessed to ensure they are able to receive the
medication and that it is safe to administer it.
iii) The correct drug and formulation is selected.
iv) The correct dose (i.e. strength or quantity) is selected.
v) The correct route is used to administer the drug.
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vi)
vii)
viii)
ix)
The drug is being given at the correct time and on the correct date.
The drug has been prescribed by an authorised prescriber or is
administered in accordance with an approved PGD.
The drug has not passed its expiry date.
Administration is completed to the correct patient/client*
*Generally, completion means that the patient/client has swallowed the
medication or received an injection or suppository. There are a
few exceptions, e.g. sub-lingual tablets, syringe drivers.
9.3 Orally administered medicines must be offered to the patient/client
accompanied by a drink (excluding sub-lingual administration), if
appropriate.
9.4 Medicines must not be crushed, broken or mixed with food or liquid unless
specified by the prescriber, as per manufacturers’ instructions or in consultation
with a pharmacist or speech and language therapist. This changes the
pharmaceutical qualities of the medication and may be construed as covert
administration. This includes administering medicines via PEG feeds.
As a general principle, by disguising medication in food or drink, the client or
patient is being led to believe that they are not receiving medication, when in
fact they are. The health professional will need to be sure that what they are
doing is in the client’s best interests and be accountable for that decision. .See
NMC documents on covert administration:-
http://www.nmc-uk.org/aDisplayDocument.aspxDocumentID=3602 and
http://www.nmc-uk.org/aDisplayDocument.aspxdocumentID=3954
9.5 Medicines should not be administered to or taken by any member of staff
unless purchased for personal use, prescribed by occupational health or
prescribed by a practitioner with whom that person is registered.
9.6 Only those medicines supplied by a pharmacy or assessed as suitable by
pharmacy shall be administered to patients/clients. All samples/clinical trial
medicines must be supplied only via a pharmacy.
9.7 Once a drug has been given the person administering the drug must make a
record. This record should be made at the time of administration and be in the
patient/client’s records or on an appropriate Medication Record Card which
must be filed in the patient/client’s records once complete. Home Care Staff
must sign a Medication Administration Record (MAR) sheet to confirm
administration. The record must include:
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i) Drug administered
ii) Dose
iii) Route
iv) Site, if appropriate e.g. depot injections
v) Date of administration, and time if appropriate
vi) Signature and designation of the person administering the drug.
vii) Batch number and expiry date of injection (if applicable)
viii) Patient consent according to PCT consent policy (if applicable)
9.9 Non-administration of a drug may be due to patient/client nonattendance/refusal,
adverse drug reaction or non-availability of a drug. In all
instances of non-administration of a drug all relevant details must be recorded
in the patient/client’s records and the patient/client’s doctor or consultant
contacted for advice.
Some clinical areas use a reference code to be entered on the treatment sheet
explaining non-administration. Staff must be made aware if such reference
codes are used. Codes must be clear and will be consistent across the PCT
and hospital.
9.10 In cases of non-attendance active effort must be made to trace the patient/client
and administer the drug within a reasonable length of time. When the drug can
be administered with a delay that does not pose a problem clinical judgement
can be used with regards as to whether the patient/client’s doctor should be
contacted.
9.11 In cases of non-availability of a drug every effort must be made to obtain the
drug within a reasonable period of time. The reason for non-availability must be
recorded in the patient/client’s records and the doctor or consultant contacted
regarding alternative treatment or the possibility of delaying administration until
the drug is available.
9.12 In cases of adverse drug reaction or patient/client refusal the patient/client’s
doctor or consultant must be contacted immediately and advice sought. For a
suspected ADR, a ‘yellow card’ should be completed according to the
guidelines from the Committee on Safety of Medicines (see section 2.9)
9.13 Community Nurses may only apply non-medicated inert dressings until
prescribed treatment is available.
9.14 Medicines must not be prepared in advance of administration except for
• Those done by pharmacy staff
• Antibiotic syrups
• The filling of concordance aids
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• Insulin injections by District Nurses for patients for self administration at
home
9.15 Protocols for specialist procedures such as non-clinical staff giving insulin or
social services staff undertaking administration of medicines are being
developed and will be circulated as appendices when approved. It is the
responsibility of the member of staff to check if there is a relevant protocol.
9.16 If it is suspected that the patient/client, their carer or representative are giving
higher doses than prescribed then the RMO/GP must be informed to discuss
review of medication with the patient/client their carer or representative.
27

10. Controlled Drugs (CDs)
NB
Accountability for the use of controlled drugs rests with the Accountable
Officer for the PCT (currently the Specialist in Pharmaceutical Public
Health)
10.1 Who can prescribe controlled drugs
All medical prescribers can prescribe schedule 2, 3, 4 and 5 CDs.
Following agreement by the Home Office’s Advisory Council on the Misuse of
Drugs (ACMD), changes to regulations on 1 May 2006 enable nurse
independent prescribing of some CDs. Nurse Independent Prescribers can
prescribe some CDs independently, but only for specific conditions. These
include diamorphine and morphine for palliative care and post-operative pain
relief. A list of these CDs and medical conditions is contained in the Drug Tariff
(see part XVIIbii) and also in the BNF. For further information visit www.ppa.org
and www.bnf.org.uk .
Nurse Independent Prescribers are also able to prescribe lower strength
Pharmacy (P) and General Sales List (GSL) medicines containing codeine
phosphate and dihydrocodeine tartrate.
Community Practitioners and Pharmacist Independent Prescribers cannot at
present prescribe CDs independently.
All supplementary prescribers are able to prescribe any CD provided it is listed
in the clinical management plan.
Controlled drug schedules are as follows:
Schedule 1 (CD licence)
• Have no recognised medicinal use and include hallucinogenic drugs.
• Examples include coca leaf, LSD and mescaline.
• Production, possession and supply of these drugs are limited to research or
other special purposes.
• Practitioners and pharmacists may not lawfully possess Schedule 1 drugs
except under licence.
Schedule 2 (CD)
• Includes the opiates, secobarbital, amphetamine and cocaine.
28

• Are subject to safe custody requirements and so must be stored in a locked
receptacle, usually in an appropriate CD cabinet or approved safe, which can
only be opened by the person in lawful possession of the CD or a person
authorised by that person.
• A licence is required to import or export drugs in Schedule 2.
• The drug may be administered to a patient by a doctor or dentist, or by any
person acting in accordance with the directions of a doctor or dentist.
• A register must be kept for Schedule 2 CDs and this register must comply with
the relevant regulations.
• The destruction of CDs in Schedule 2 must be appropriately authorised and the
person witnessing the destruction must be authorised to do so.
• Are subject to handwriting requirements as in 10.3.1
Schedule 3 (CD No Register)
• Includes a small number of minor stimulant drugs and other drugs which are
less likely to be misused than the drugs in Schedule 2.
• Are exempt from safe custody requirements and can be stored on the open
dispensary shelf except for temazepam, buprenorphine and diethylpropion,
which must be stored in a locked CD receptacle.
• Are subject to the same special handwriting requirements as Schedule 2 CDs,
except for temazepam and phenobarbital. Phenobarbital and temazepam can
be dispensed in response to a computer-generated prescription but the
prescriber's signature must be added by hand.
• There is no legal requirement to record transactions in a CD register.
• The requirements relating to destruction do not apply unless the CDs are
manufactured by the individual.
• Invoices must be retained for a minimum of two years.
Schedule 4 (CD Benzodiazepines and CD Anabolic steroids)
• Are exempt from safe custody requirements, with destruction requirements only
applying to importers, exporters and manufacturers.
• Specific CD prescription-writing requirements do not apply.
• CD registers do not need to be kept, although records should be kept if such
CDs are produced, or if a licensed person imports or exports such drugs.
o
Part 1 (CD Benzodiazepines):
29

• Includes most of the benzodiazepines, plus eight other
substances including fencamfamin and mesocarb.
• Possession of is an offence without an appropriate prescription.
Possession by practitioners and pharmacists acting in their
professional capacities is authorised.
• Are subject to full import and export control.
o
Part 2 (CD Anabolic steroids):
• Includes most of the anabolic and androgenic steroids such as
testosterone, together with clenbuterol (adrenoreceptor stimulant)
and growth hormones.
• There is no restriction on the possession when it is part of a
medicinal product.
• A Home Office licence is required for the importation and
exportation of substances unless the substance is in the form of a
medicinal product and is for self-administration by a person.
Schedule 5 (CD Invoice)
• Includes preparations of certain CDs (e.g. codeine, pholcodine, morphine)
which are exempt from full control when present in medicinal products of low
strengths as their risk of misuse is reduced.
• No restriction on the import, export, possession, administration or destruction of
these preparations and safe custody regulations do not apply.
• A practitioner, pharmacist or a person holding an appropriate licence may
manufacture or compound any CD in Schedule 5.
• Invoices must be kept for a minimum of two years.
10.2 Situation for supply and administration
Nurses can supply and administer some CDs under the terms of a Patient
Group Direction (PGD). PGDs can be used for the supply and administration of
Schedule 4 and 5 controlled drugs-with the exception of anabolic steroids.
Paramedics, chiropodists/podiatrists, orthoptists, physiotherapists and
radiographers can supply and administer schedule 4 and 5 CDs under the terms
of a PGD, with the exception of anabolic steroids. Occupational therapists and
prosthetists and orthotists were added to the list of those who can supply and
administer schedule 4 and 5 CDs under a PGD from July 2006.
30

10.3 Prescribing Controlled Drugs
10.3.1 Legal Prescription requirements
Prescriptions written for Schedule 2 and 3 controlled drugs and marked as CD
in the BNF, with the exception of temazepam and Phenobarbital are subject to
the following strict legal requirements (see relevant BNF section):
a) Be printed or written in ink, or other indelible substance
b) Specify the dose, dosage form (e.g. tablets) and where appropriate the
strength of the preparation.
c) State in words and figures the total quantity of the drug or total
number of dose units that are to be supplied or given.
d) Bear the patient/client's name, address and registration number.
e) Be dated
f) Be signed (not just initialled) by the prescriber.
g) Supply should be no more than 30 days supply (except in exceptional
clinical circumstances). N.B. On FP10MDA forms only 14 days supply
is permitted.
N.B.
* All CD prescriptions are valid for 28 days from date on prescription for
S2, 3 and 4 CDs (does not apply to S5).
* Dental prescriptions must have written the words “for dental
treatment only”.
10.3.2 Safety issues
(see NPSA alert 2008/RRR05 Reducing Dosing Errors with Opioid Medicines
http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/reducing-dosingerrors-with-opioid-medicines/
)
When opioid medicines are prescribed, dispensed or administered, in anything
other than acute emergencies, the healthcare practitioner concerned, or their
clinical supervisor, should:
• Confirm any recent opioid dose, formulation, frequency of administration and
any other analgesic medicines prescribed for the patient. This may be done for
example through discussion with the patient or their representative (although
not in the case of treatment for addiction), the prescriber or through medication
records.
• Ensure where a dose increase is intended, that the calculated dose is safe for
the patient (e.g. for oral morphine or oxycodone in adult patients, not normally
more than 50% higher than the previous dose).
31

• Ensure they are familiar with the following characteristics of that medicine and
formulation: usual starting dose, frequency of administration, standard dosing
increments, symptoms of overdose, common side effects.
10.4 Transport
PCT staff should not carry controlled drugs unless in exceptional
circumstances or to deliver services to patients such as:
• Terminal patients receiving drugs via syringe drivers.
• Patients undergoing detoxification regimens
• If a nurse is asked by a GP or the GP out-of-hours (OOH) deputising
service, when on the premises, to take out a controlled drug from the
surgery and administer to a patient. It is also the nurse’s responsibility to
ensure this is recorded in the surgery controlled drugs register.
Community Pharmacy delivery services should be used wherever possible
when the patient/client has difficulty collecting their medication.
On occasion it may be necessary for a nurse to collect an urgent prescription
from the pharmacy. The medication must have been prescribed for a specific
patient and the member of staff is collecting them under the direction of the
patient for administration immediately. The nurse should go straight to the
patient’s home and must not leave the prescription in the vehicle unattended at
any point.
When medicines are supplied out of hours, the OOH procedure should be
followed. See - http://joint.dudley.nhs.uk/cmsextra/documents/cms/222-2008-4-
29-4062085.pdf
10.5 Records
Controlled drugs should be documented as follows.
10.5.1 Patient/Client held stock
A running balance should be kept in the patient/client’s records to account for
this stock. If a discrepancy arises then efforts should be made to account for
this. If no reason can be found then the incident should be reported to the team
co-ordinator who is responsible for deciding on what further action should be
taken. The incident reporting procedure must be followed.
32

10.5.2 Stock held at PCT premises or other healthcare settings.
Records must be kept for schedule 2 controlled drugs by all persons authorised
to possess them.
The following particulars are to be recorded for CDs received:
a) Date on which received;
b) Name and address of person or firm from who received;
c) Amount received;
d) form in which received.
For CDs supplied/administered the following must be recorded:
a) Date on which the supply/administration was undertaken;
b) Name and address of person to who supplied/administered;
c) Particulars as to the licence or authority of the person
Supplied/administered to be in possession of CDs;
d) Amount supplied;
e) Form in which supplied.
The above particulars are the minimum fields of information that must be
recorded in the CD register
A running balance should be kept in an official controlled drug register with
entries of both obtained and supplied controlled drugs. (Further detailed
information is available in the Medicines Ethics and Practice booklet (RPSGB)
or visit www.rpsgb.org)
10.6 Destruction
10.6.1 Controlled Drugs no longer required by the patient/client.
Schedule 2 injectable CDs should be destroyed by the healthcare professional
at the patient/client’s home, and witnessed by the patient/client, their carer or
representative or another member of staff. A CD destruction/denaturing kit
must be used for all liquid schedule 2 CDs. Once denatured, drugs may be
disposed of in clinical waste containers. A note should be made in the
patient/client’s records that must be signed by both parties. For all other CDs
the patient/client, their carer or representative should be advised to return it to
their community pharmacy.
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10.6.2 In the event of a patient dying at home
In the event of a patient dying the above would also apply, as under the Misuse
of Drugs Act possession of CDs cannot pass to another person therefore all
must be destroyed. The nurse present should record all CD drugs not used
(recording form, strength and quantity) sign and date the record and, if possible,
ask a witness to sign that the record is true. A copy of the record should be
kept with the drugs for transfer to the community pharmacy for destruction and
a copy kept with the patient’s notes. If there is no carer/relative to return drugs
to a community pharmacy, all drugs should be destroyed as soon as possible.
10.7 Breakages and Damages
If any healthcare professional finds or accidentally causes a supply to be
damaged or broken (e.g. ampoules/bottle) this incident shall be reported
promptly to the nurse manager. An entry on such incidents will need to be
made directly in the patient records detailing the date, time, quantity of stock
damaged or broken, the signature of the member of staff who found this and
the signature of the member of staff or other person present who witnessed the
incident. The staff involved may wish to add additional information if thought
necessary. If damaged or broken supply is discovered by a patient or carer then
the same procedure should be followed noting who made the discovery.
10.8 Storage
All controlled drugs should be stored in a locked cupboard specifically for that
purpose, separate to other drugs. CD cupboards must have a daily stock check.
Please refer to the Medicines Ethics and Practice booklet (RPSGB) or visit
www.rpsgb.org for details.
For checking CD stocks held on PCT premises serviced by the Pharmacy
Department, Dudley Group of Hospitals please refer to DGoH Medicines
Management Policy. It is an audit requirement that there is a pharmacy check
once every six months.
For further information on CDs legislation and best practice please contact the
Medicines Management Team at the PCT or see the controlled drug section on
the PCT website.
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11. Management of errors or incidents associated with medicines.
It is recognised that despite careful checking mistakes do happen. Errors in
administration can include for example selecting the wrong medication,
administering an incorrect dose, using the wrong route, giving the medication to
the wrong patient/client, failing to ensure that the patient/client has received it or
may involve a dispensing error from the pharmacy.
Any error/incident must be reported via the PCT Sentinel reporting
systems.
Errors or incidents concerning the administration of medicines require
investigation under the Serious Untoward Incident Investigation Policy. This
does NOT mean that disciplinary action will automatically follow. Each incident
will be considered in its particular context.
11.1 Clinical Errors by Staff involving Medicines
Dudley PCT operates a ‘fair blame’ policy which to encourage all errors to be
reported and investigated as to the cause. Local training course are available in
investigation of incidents.
Whenever errors in the administration of medicines are found then the
healthcare professional administering will:-
i) Contact the appropriate prescriber for the patient/client so that if
necessary remedial action can be taken to ensure the safety of the
patient/client. If the prescriber is not the patient’s GP then they must be
informed as to the nature of the error and the steps taken.
ii)
iii)
Report the incident to the senior manager in charge who has the
responsibility of investigating the incident.
The healthcare professional must also ensure
a) The patient/client’s blood pressure and pulse is taken and recorded, if
possible, and observe for any signs of shock.
b) Follow the incident reporting procedure and inform Clinical
Governance. Clinical Governance will inform the Medicines
Management Team.
c) Enter details of the event in the patient/client’s records including
details of any remedial action taken and the individuals informed.
It is the responsibility of the nurse in charge to ensure that the patient (and/or
relatives, dependent on circumstances) is advised at an early stage. How this
35

occurs, and by whom, will need to take account of the nature of the error and
any adverse consequences suffered by the patient. Any discussions should be
documented in the patient's case notes.
11.2 Consequences of an error
Actions following an error may range from a review of processes, assessment
of individual accountability and training needs to a report to the National Patient
Safety Agency on the circumstances. Professionals may be referred to their
professional body. Repeated errors may lead to performance management
processes being activated.
11.3 Errors by Medical staff
The Medical Director will have responsibility for investigating the incident and
reporting the incident following the Incident Procedure.
11.4 Dispensing errors
In the case of a suspected dispensing error the medicines must be quarantined
immediately. The Pharmacist in Charge of either the hospital or community
pharmacy, from where the drug was dispensed, must be contacted for advice
on the action required concerning the drug and obtaining a replacement. If the
drug has been administered then the action laid out in 11.1 must be followed.
If the drug has not been administered the Medicines Management Team must
be contacted for advice, as above. The incident should be reported via sentinel
and documented in the patient/client’s records. The Clinical Governance Team
will advise on any risk management issues arising from an incident.
If the dispensing pharmacy is closed then the error must be reported the next
working day.
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12. Verbal orders for the Administration of Medication
It is recognised that in extreme circumstances it may be necessary to accept
verbal instructions about medication.
12.1 Verbal Prescriptions via Telephone
12.1.1 Verbal instructions from a doctor to adjust the dose of a medicine may be
accepted by a Registered Nurse in exceptional circumstances. In very rare
circumstances a verbal instruction may be accepted to initiate a medicine. If
possible a fax or email should be used to confirm the prescription.
A verbal message cannot be accepted to initiate a Controlled Drug; however a
request to increase the dose may be acceptable in exceptional circumstances.
For increasing the dose of a syringe driver see section 21.
12.1.2 The nurse must record on the patient/client’s records
i) the name of the prescriber
ii) the details of the instruction
iii) the date and time of the order
iv) an indication that it is a verbal instruction
This record must be annotated "TELEPHONE ORDER" and signed by the
nurse. It is good practice for a second member of staff to listen to the doctor
repeating the instructions.
12.1.3 The instructions should be read back to the Doctor, in the presence of a second
registered nurse or other healthcare professional if possible, confirming the
patient/client's name and registration number and the name and dosage of the
medicine.
The details of the verbal order must be entered in the patient/client’s records
and signed by the nurse receiving the verbal order and the second nurse if one
is involved.
12.1.4 The nurse receiving the verbal order must administer the medicine in
accordance with the procedures for drug administration.
12.1.5 It is the prescriber’s responsibility to provide written confirmation of the verbal
request as soon as practicable but within 24 hours in all circumstances.
12.1.6 Only one dose of any drug can be given - subsequent doses should not be
given without a written prescription from a doctor.
37

13. Disposal of Medicines when off site.
Please refer to PCT Waste Policy for extra information. waste policy
13.1 Medicines once dispensed to a patient/client are their property. They should
not be removed for disposal without the patient/client’s consent. If any
medication is not current therapy the patient/client or their
relative/representative/carer should be encouraged to give their consent to the
disposal of such medication by a pharmacy. Patients/clients, their relatives,
representatives or carers should be advised to take the medication to a
community pharmacy. If a patient is utilising a community pharmacy delivery
service then unused medication may be returned to the driver when they next
make a delivery.
13.2 If it is felt unsafe to leave non-required medication in the possession of a
patient/client, but the patient/client is unwilling to give consent for disposal, the
registered nurse should contact the doctor in charge or patient/client’s doctor to
advise them of concerns. This action must be fully documented in the
patient/client’s record along with the name of the doctor contacted.
13.3 When Controlled Drugs are no longer required they must be destroyed as
specified in section 10.6
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14 Alcohol
14.1 Patient/client under the influence of alcohol.
In the circumstance where the patient/client is thought to be under the influence
of alcohol or illicit drugs the community nurse should not administer the
prescribed treatment (unless it is life saving) but make alternative arrangements
to administer required doses at a later time. The patient/client’s Registered
Medical Officer (RMO) or GP should be informed immediately and the guidance
on non-administration of a drug (section 9.9) must be followed.
14.2 Possession of alcohol on trust premises
All patients should be informed of the general policy of no alcohol on Trust
premises. If a patient is found in possession of alcohol, it must be stored in an
appropriate place until the patient is to be discharged or removed from the ward
by a family member with the patient’s permission. If the patient has been
informed about Trust policy, staff can remove the alcohol from the patient on
best interests ground.
Some clients in long-term care may be allowed small amounts of alcohol, which
are purchased by PCT staff and consumed under supervision. NB: the effect of
alcohol on any medication must be checked with a pharmacist.
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15. Illegal Substances
.
15.1 Patient/clients found in possession of illegal controlled drugs.
Each professional worker must be aware of the procedures appertaining to
safety, risk assessment and risk management and adhere to these procedures
at all times.
15.1.1 On Trust premises.
If a patient/client is found in possession of illegal drugs or a substance thought
to be illegal, then he or she should be advised that the possession of the item is
unlawful. The Trust Head of Security should be contacted for advice on further
action. The medical staff and police must be informed and the incident logged
on Sentinel.
If a member of staff suspects a visitor to be dealing in drugs they must inform
the Trust Head of Security immediately.
If a suspicious substance is discovered, not in the possession of an individual,
the police must be informed. The supervisor or second member of staff must be
notified and the incident logged on sentinel. The substance must be locked
away and the senior manager in charge holds the key until the police arrive.
15.1.2 On Social Services Premises
The community nurse must inform the manager of the establishment who will
follow their own policy and procedures in dealing with the situation.
15.1.3 In the patient/client’s home
PCT staff must use their professional judgement in dealing with each situation.
Where concern exists that the patient/client is using or is in possession of illicit
substances the situation must be discussed with the patient/client’s RMO and
documented in the patient/client’s record.
PCT staff must not receive illegal substances but encourage the client to
dispose of them. Staff should be aware of personal safety issues at all time.
http://joint.dudley.nhs.uk/cmsextra/documents/cms/489-2008-8-14-3025847.pdf
15.2 Suspicion of dealing
In general the patient/client’s right to confidentiality must be preserved and a
member of staff must not divulge the identity of the patient/client to the police.
However this would not be the case when the quantity of substance involved
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may imply dealing, as breach of confidentiality would be justified because of the
wider public implications. In such an event the PCT staff must seek guidance
from the Trust Head of Security.
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16. Theft
16.1 If medicines under the care of a member of staff are lost or stolen then the
member of staff must take action immediately to inform their line manager, the
police and the Trust Head of Security. The Serious Untoward Incident
Investigation Policy must be followed.
16.2 If theft of medicines by a member of staff is suspected the matter should be
reported to the line manager and Trust Head of Security. The Trust Head of
Security is responsible for deciding on what further action should be taken.
http://joint.dudley.nhs.uk/cmsextra/documents/cms/489-2008-8-5-3796510.pdf
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17. General Notes on the Handling of Medicines
17.1 The contents of one container must never be transferred to another container
without pharmaceutical advice as the stability and product liability of the product
may be affected. Part empty containers must either be disposed of or the drug
should continue to be used until the container is empty.
No drug should be removed from its container/packaging except for immediate
administration or for counting purposes, when only one container may be
removed at a time.
17.2 With the exception of pharmacists, under no circumstances may members of
staff alter labels. Clarification of the prescriber’s intentions is permissible
providing this does not obscure or change the original instructions.
17.3 Due attention should be paid to additional information e.g. hazard-warning
labels on drug containers.
17.4 If drug labels are unclear or dirty, the container must be returned to the
supplying Pharmacy.
17.5 Under no circumstances should samples of medicines, dressings, topical
products, nutritional products or medical devices be accepted from members of
the Pharmaceutical Industry for use on patients/clients.
17.6 Under no circumstances should medication returned from patients’ own homes
be used on another patient, it must be disposed of as waste.
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18. Patients at Risk from Self-Poisoning
If a Healthcare Professional on a Community visit considers that a patient
is at risk and capable of planned or accidental self-poisoning with their
prescribed medication they should:-
• Remove the medicines from the home with the patient’s or relative’s
permission, and store in a locked cupboard at team base. The medicines
removed must be recorded in the patient’s records.
• Document reasons for decision and notify Psychiatrist and/or GP.
• Enter details of visit, reason for removal, medicine, strength and quantity in
the patient’s nursing record.
• If there are mental health capacity issues then the prescriber must be
contacted for further discussion
If the situation does not warrant immediate removal but the healthcare
professional has a concern these must be documented and shared with the rest
of the team and prescriber.
If a patient being discharged or given leave from hospital is similarly at risk,
they should only be provided with a small amount of medicine, exact quantities
can be discussed with the prescriber.
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19. Compliance aids
All compliance aids should be filled by Dudley Group of Hospitals Pharmacy
Department or by a community pharmacist after prior agreement with the
supplier. Medicines quality and effectiveness can be affected by decanting into
these aids and pharmaceutical advice is essential before one can be supplied.
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20. Vaccines
Vaccines are usually fridge items and handling of the products must be
undertaken in line with the PCT cold chain guidelines. See:-
http://pctnet.dudley.nhs.uk/cmsintra/Immunisation/index.aspid=566&doc=show
Please refer to the Dudley PCT Immunisation Website for details on individual
vaccines and immunisation schedules.
http://www.dudley.nhs.uk/sites/immunisations/index.aspid=3195
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21. Syringe Drivers
Please refer to the current ‘Policy for the use of Graseby MS26 Syringe Drivers
in Palliative Care’ compiled by Dudley Macmillan Community Palliative Care
Team. (http://joint.dudley.nhs.uk/cmsextra/documents/cms/191-2008-1-21-
5949772.pdf)
Patients/clients may receive subcutaneous infusions of medicines such as
morphine, diamorphine, heparin and insulin via an electronically powered
syringe driver. Macmillan Nurses and District Nurses may operate syringe
drivers provided that they have received training and are competent as laid
down in the current syringe driver policy.
21.1 Administration must be carried out in accordance with guidance in section 9 of
the MMP.
21.2 When a dose increase is required outside of the patient/client’s drug
regimen/ceiling dose, the doctor/competent independent prescriber is expected
to attend and re-assess the patient/client and give written instructions on dose
adjustments. In exceptional circumstances a verbal instruction to adjust a dose
can be accepted and the procedure in section 12 followed.
In very exceptional circumstances it is permissible for a verbal instruction to be
taken to increase the dose of a syringe driver containing a controlled drug
providing that it is at the direction of the patient/client’s doctor/competent
independent prescriber and it is in the patient/client’s best interest to do so. A
community nurse acting on such a verbal instruction should be aware of
possible consequences resulting from such action and the importance of fully
documenting the incident as described in section 10. The doctor/competent
independent prescriber must provide written confirmation of the dosage
alteration as soon as practicable but within 24 hours in all circumstances.
An additive label must be completed and attached to the syringe ensuring that
graduation markings are obscured, in order to ensure that the dose is
measured in mm not ml as per ‘West Midlands Palliative Care Guidelines.’
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22. Cytotoxic Medicines
22.1 Intravenous administration
Patients requiring cytotoxic medicines to be administered by the intravenous
route should be referred to the Georgina Unit, Russells Hall Hospital.
22.2 Subcutaneous administration of cytotoxic drugs
This must only be undertaken after specific training.
22.3 Oral administration of cytotoxic drugs
A minimal touch technique should be used and hands washed immediately
before and after administration. Tablets must NOT be crushed. In cases of
swallowing difficulty a suspension may be available from the supplying
pharmacy.
22.4 Disposal of cytotoxic waste
The nurse administering the treatment must ensure that appropriate waste
receptacles and collection arrangements are followed as laid down in the Joint
Trust Waste Management Policy.
http://pctnet.dudley.nhs.uk/documents/cms/149-2007-1-9-5025008.pdf
48

23. Prescribing of Oxygen
Please refer to the Home Oxygen section of the Dudley PCT website for details
on home ordering of oxygen on the ‘Home Oxygen Service’ page. See:-
http://pctnet.dudley.nhs.uk/cmsintra/general-Practice/index.aspid=4840
For further assistance please contact the Dudley Respiratory Support Service
at Dudley Group of Hospitals on 01384 244383
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24. Monitoring the policy
If you have any questions regarding this policy or about medicines please
contact Medicines Management Team at the PCT.
A Pharmacist shall inspect all areas where medicines are stored at regular
intervals. A report of each unit will be made in writing to the unit manager
responsible for drug storage, which will be copied to the Pharmaceutical
Advisor and General Manager, should there be any indication that the
procedure detailed above is not being followed.
Knowledge and implementation of the Policy will be discussed and documented
as part of annual Personal Development Plans
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This policy was produced by Specialist in Pharmaceutical Public Health and
Pharmacist, Dudley PCT.
The policy was circulated amongst managers and local clinical networks for comment
at various stages of development. Other areas such as chiropody, dentistry,
Community nursing teams, local authority staff, general practice, clinical governance
and training and development were consulted.
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Supporting Documents:
Duthie Report "Department of Health Guidelines for the Safe and Secure
Handling of Medicines" 1988
Controls Assurance Standards Medicines Management.
Dudley PCT Waste Management Policy and Procedures (2009)
Dudley PCT Policy for the use of Graseby MS26 Syringe Drivers in the
community in palliative care (2007)
Dudley PCT Non Medical Prescribing Policy (2004)
Dudley PCT Patient Group Direction Information Pack (2007)
Dudley PCT Serious Untoward Incident Investigation Policy (2008)
Dudley Group of Hospitals Medicines Management Policy (2009)
Dudley PCT Security Policy (2008)
Dudley PCT Protocol for supply of Palliative Care Medicines Out of Hours
(2007)
Dudley PCT Sharps Policy (2009)
Abbreviations
ADR
AHP
BNF
CD
CMP
DGoH
FMC
NMC
NMP
PCT
PGD
POM
PPD
RPSGB
SiPPH
SLA
Adverse Drug Reaction
Allied Health Professional
British National Formulary
Controlled drug
Clinical Management Plan
Dudley Group of Hospitals
Facilities Management Centre
Nursing and midwifery Council
Non Medical Prescriber
Primary Care Trust
Patient Group Direction
Prescription Only Medicines
Prescription Pricing Division
Royal Pharmaceutical Society of Great Britain
Specialist in Pharmaceutical Public Health
Service Level Agreement
Contact telephone numbers:
Medicines Management Team/NMP lead: 01384 366589
Nurse Prescribing Lead:
Dudley Group of Hospitals Medicines Information Department: 01384 244088
PCT Head of Security: 01384 366470; mobile 07825681857
Police: 0845 113500
52