2005 Edition Report on Drug Administration Procedure & Practices ...

REVISED GUIDELINES ON THE HANDLING OFDANGEROUS DRUGS IN HA HOSPITALSProcess Authorised Staff Particulars(1) Issuance of a signedorder for the procurement ofDD from pharmacy.Ward Manager (WM) i/c;Nurse Specialist (NS) i/c;Nursing Officer (NO) i/c;Registered Nurse (RN) i/c;Enrolled Nurse (EN) (If no registerednursing staff are on-duty)Each ward to supply a list of authorizednursing staff with specimen signatures topharmacy.For practical purpose, the list should bekept small and up-dated regularly.The nursing staff issuing the signed ordershould sign and indicate her title andname clearly for verification bypharmacy staff(2) Delivery of DD to/fromwardsAs advised by the Department of Heath,the pharmacist i/c or an authorizednursing staff can appoint a designatedhospital staff acting as his/her agent forthe collection, delivery andtransportation of DD to/from wardsLockable receptacles should be used inthe transportation of DD.(3) DD records and stocks inwardsA DD register will be kept in each wardto record DD transactions.Copies of the signed order issued shouldalso be kept for the statutory 2 years.Pharmacist should inspect the DDregister and stocks in the wards monthly.Any irregularity should be rectifiedimmediately. Any irregularity thatcannot be rectified have to be reported tothe Director of Health as required underthe Dangerous Drug Ordinance.(4) Disposal of DD records The expired register and the signedorders in the wards can be disposed ofonly with the approval of the pharmacisti/c in accordance with agreed procedureswith hospitals.For administrative convenience, thepharmacist i/c will be appointed as theperson approving of the disposal.Pharmacy would work out the agreedprocedure with the nursing staff.(5) Transfer of DD from 1ward to another foremergency use after officehours when pharmacy isclosed.The designated WM, NS, RN i/c of thehospital at after-office hours should beinformed and approved of such transfer.The ‘recipient’ ward should send aqualified nurse or a student nurse to the‘donor’ ward for the collection of the DDand the MAR of the patient should bepresented. The qualified nurse in the‘donor’ ward should record the patientparticulars in its DD register.The pharmacist should be informed ofthe incident and to review the optimalward stock level.It is not necessary for the ‘recipient’ward to record the quantity of DDreceived in its register becausetechnically, the DD is only administeredto its patient and not stocked.(6) Retrieval of DD fromlocked DD cupboard inwardsWM, NS, NO and designated RN andEN who are performing the duty of thesister i/c.Should exercise 3C 5R principle.Advisable to have a second person tocountercheck.(7) Administration of DD topatients in accordance todoctors’ prescriptions ordirections in the bed cards orcase sheets.Any qualified nurse which include:Registered Nurse (General);Registered Nurse (Psychiatric);Enrolled Nurse (General);Enrolled Nurse (Psychiatric);Registered Midwife;Nurse Learner under supervision.Should exercise 3C 5R principle.Advisable to have a second person tocountercheck.7ddguide5 HAHO 17 April 981