TheatrePracticeStandardsGeneric1

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Generic Theatre Standard No 25 - Controlled Drugs in the Operating Department Standard: All aspects of management of controlled drugs within operating department areas will be in concordance with Trust and National Policy. Please see: • A policy for the Rules relating to all Activities Involving Controlled Drugs • The Medicines Policy Chapter 3 - Ordering and Stock control • The Medicines Policy Chapter 4 – Standards of Practice – Custody and Storage • The Medicines policy Chapter 5 – Preparation and Administration Controlled drugs keys will held only by Registered Nurses and Registered ODP’s. Regular controlled drugs checks will be carried out and recorded in a daily logbook held in each controlled drug cupboard. Method: • Under the Misuse of Drugs Act (1971), the accountability for safe custody and issue of controlled drugs lies with the Registered Practitioner within the operating theatre. • Responsibility for the issue of controlled drugs and for holding the keys may be delegated by the Registered Nurse or Registered ODP within the theatre but they will retain accountability for the drug stock. • Agency nurses and ODPs whose registration has been confirmed with the N.M.C. may be delegated to hold the keys and issue controlled drugs. • Controlled drugs keys will be kept centrally in a locked cupboard until they are required. • Controlled drugs checks will be carried out prior to commencement of each days operating list and at each changeover of staff. The controlled drugs will again be checked at the end of the days operating session before the keys are returned to the central holding cupboard. • Two members of staff of which one must be a registered nurse / ODP must carry out each drug check. The other member of staff may be any member of the theatre team who has received the appropriate training and has been assessed as competent in this skill. • Each check must be recorded in the stock control logbook kept in each anaesthetic room. Both parties who carry out the drugs check must sign the logbook. • Controlled drugs must be issued in accordance with the Misuse of Drugs Act 1971. All drugs must be signed for in the controlled drug register by the person issuing or checking the drug and by the person administering the drug. • Ordering of controlled drugs may only be undertaken by registered nurses /ODPs, whose signature is held on file in the pharmacy department. • Controlled drugs must be received from pharmacy in a sealed transfer bag. These drugs must only be entered into the register and put into the controlled drug cupboard by a registered nurse / ODP. • If a controlled drug is found to be missing, all efforts must be made to locate it. If it is not possible to discover where the discrepancy has occurred, the Theatre Coordinator and pharmacy must be informed and a datix report completed. Compliance: 100% Exceptions: None References: Misuse of Drugs Act 1971 • RCHT Medicines Policy • RCHT A Policy for the rules relating to all activities involving controlled drugs 90
Generic Theatre Standard No 26 - Pharmacy delivery and stock rotation Standard Statement: All staff are responsible for putting Pharmacy items away and ensuring correct stock rotation. Please see: • The Medicines Policy Chapter 3 - Ordering and Stock control • The Medicines Policy Chapter 4 – Standards of Practice – Custody and Storage Method: • All staff will receive training on how to put Pharmacy away correctly, it is imperative that pharmacy items are stored correctly to maintain effectiveness and access in emergency situations • Staff must ensure that they are familiar with the location of all drugs in case of an emergency. • Every item of Pharmacy delivered to the departments, must be checked confirmed pn the order list provided and retained as proof of delivery. • All items must be stock rotated, i.e. new stock placed at the back and older stock brought forward to ensure items are used in date order, to prevent drugs passing their expiry date and wastage of resources. • Once emptied, the Pharmacy boxes should be returned to Theatre Reception. • General pharmacy requirements are fulfilled twice a week by pharmacy technicians on a top up basis. • Controlled Drugs are ordered by Registered Nurses / ODPs as required by each individual theatre. • Special one off items may be ordered as required using the request system to pharmacy, specific patient details may be required Compliance: 100% Exceptions: None 91
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New Bookmark Drugs Table of Content
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MEMBERSHIP OF THE WORKING PARTY Dr
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SECTION I - SUMMARY AND RECOMMENDAT
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SECTION III - INTRODUCTION Patients
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purchase these services. They must
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SECTION VI - PREPARATION FOR THE TR
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A patient who remains hypotensive d
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A patient who has been made physiol
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4. Other equipment • suction •
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important to involve those who take
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REFERENCES 1. Association of Anaest
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APPENDIX II TRANSFER CHECKLIST FOR
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21 Portland Place, London W1B 1PY T
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Storage of Drugs in Anaesthetic Roo
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Generic Theatre Standard No 08 - Ca
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6.2. Overall performance against th
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• Clean theatre clothing should b
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• Protective face shields must be
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Generic Theatre Standard No 02 - Op
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• Please read NJR Manual and Trai
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13. Positioning of the Patient •
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Generic Theatre Standard No 04 - In
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Example of Environmental Theatre Cl
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3. Between case cleaning procedures
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6.1. Floor scrubbing machines • C
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• Personnel participating within
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Generic Theatre Standard No 06 - Ma
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Generic Theatre Standard No 06A - M
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Generic Theatre Standard No 06B - M
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lood, CSF or brain tissue, should b
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Exceptions: None References: • Af
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• Environment/equipment cleaning
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Generic Theatre Standard No 06F - M
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Page 70 and 71: Generic Theatre Standard No 06H - M
Page 72 and 73: Generic Theatre Standard No 07 - De
Page 74 and 75: Generic Theatre Standard No 08 - Ca
Page 76 and 77: Generic Theatre Standard No 09 - Ca
Page 78 and 79: • The deceased patient should be
Page 80 and 81: 11 Leakages from the oral cavity, v
Page 82 and 83: • Mormonism o It is essential tha
Page 84 and 85: FAITH CONTACT ADDRESS TELEPHONE NO
Page 86 and 87: • The active electrode must alway
Page 88 and 89: Generic Theatre Standard No 11 - De
Page 90 and 91: Generic Theatre Standard No 13 - Ma
Page 92 and 93: • The labelled container must be
Page 94 and 95: • Staff Responsibility • All st
Page 96 and 97: • It is the responsibility of the
Page 98 and 99: 6. Induction of anaesthesia • See
Page 100 and 101: 4. Time Out - Before start of surgi
Page 102 and 103: • The registered anaesthetic prac
Page 104 and 105: • The Senior Surgeon/Operating Cl
Page 106 and 107: Generic Theatre Standard No 16 - St
Page 108 and 109: Generic Theatre Standard No 18 - Us
Page 114 and 115: 3. Planned over-running sessions
Page 116 and 117: Generic Theatre Standard No 23 - Bo
Page 120 and 121: Generic Theatre Standard No 27 - Ph
Page 122 and 123: Generic Theatre Standard No 29 - Vi
Page 124 and 125: Generic Theatre Standard No 31 - Th
Page 126 and 127: • Advice should be obtained from
Page 128 and 129: 8. Harassment and Bullying • Dign
Page 130 and 131: Appendix 1. Governance Information
Page 132 and 133: Appendix 2. Initial Equality Impact
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