Introduction

The purpose of this policy is to define the standards for Clinicians and Non-Clinicians working in BrisDoc services in the prescribing, administering, dispensing, ordering, and storage of medicines to ensure compliance with best practice and legal requirements.

The aim of a standardised approach is to eliminate error, the risk of harm to patients, and protect staff.

Definitions

Medicine

Any substance or combination of substances presented for treating or preventing disease whose primary mode of action is pharmacological, metabolic, or immunological. Any substance or combination of substances which may be administered with a view to making a medical diagnosis or restoring, correcting, or modifying physiological or psychological functions.

Controlled Drug (CD)

A Controlled Drug (CD) is a drug identified by the Misuse of Drugs Act 1971 and related Regulations as having potential for diversion and misuse.  The Regulations divide the CDs into five Schedules with differing levels of control, depending on therapeutic benefit balanced against harm when misused.  BrisDoc do not differentiate the level of control in each schedule of controlled drug, all controlled drugs are managed with schedule two requirements.

Prescribe

To authorise in writing the supply and/or administration of a medicine.

Medical Prescriber

A registered doctor who may prescribe any licensed medicine for any medical condition according to the authorised formulary for their profession, including Controlled Drugs.

Independent Prescribers

Nurse and AHP Independent Prescribers are registered clinicians who are entered on the relevant parts of their professional Register and may prescribe any licensed medicine for any medical condition according to the authorised formulary for their profession, including Controlled Drugs.

An Independent Prescriber must work within their own level of professional competence and expertise.

Supplementary Prescribing

Supplementary Prescribing is defined as a voluntary partnership between an independent prescriber (doctor or dentist) and a supplementary prescriber to implement and agreed patient-specific Clinical Management Plan with the agreement of the patient. The key principles of supplementary prescribing emphasise the importance of communication between the prescribing partners (the patient is treated as a partner in their care) and the need for access to shared patient records.

Pharmacist

A pharmacist is currently trained to dispense medication but they can also with further qualifications, prescribe medication.

Prescription Form

Prescription Forms (NHS England) FP10 are secure prescription forms, serially numbered with anti-counterfeiting and anti-forgery features. Prescriptions are controlled stationery therefore must be stored securely, fully accounted for and reported if missing. Prescriptions are ordered via a secure ordering system and distributed free. The range of forms is listed on the Department of Health (DH) and NHS Business Services Authority (NHSBSA) websites. Please note there are no prescription forms currently held for home visiting/outreach at the homeless health service (HHS) as it is deemed too high risk with this patient population.

Administer

To give a medicine by introduction into the body (e.g., orally, rectally, by inhalation or by injection) or by external application (e.g., a cream, ointment, patch).

Supply

To provide a clinically appropriate medicine for a patient for self-administration or administration by another person.

Patient Group Direction (PGD)

A specific written instruction for the supply or administration of named medicines in an identified clinical situation in the absence of a written prescription.

Responsibilities

Medical Director

Responsible for the safe and secure handling of medicines and Accountable Officer for controlled drugs. This is delegated to the Deputy Medical Director for the respective service line in their absence.

Lead Clinicians (GP, Nurse, Allied Health Professionals [AHPs] and Pharmacists)

Lead clinicians (medical and non-medical), including the Clinical Guardian team, in each service are responsible for prescribing practice and supervision of all prescribers.  They will ensure robust prescribing policy and procedure is followed and developed in their service as team leaders.  There is a governance structure through which all leads will be accountable for the appropriate ordering, storing and stock management of medicines held in BrisDoc premises.  Nominated representatives from this group will attend and liaise with the respective medicines Management Groups as required.

Facilities Manager and Practice Managers

Practice Managers, in practices and the Facilities Team oversees the management of medicines, stock control and prescriptions pads. They will action appropriate drug alerts, received by the Governance team from the MHRA, arranging for stock to be checked, withdrawn, and replaced as appropriate across services.

Lead Pharmacist and Pharmacy Support

The Lead Pharmacist will provide support for audit, advice on best practice, monitoring prescriptions, provision of reports on medicines used and their cost, medicines supplier and PGD sign off.

Additional Pharmacist support with regards to Medicines management and prescribing data is provided by NHS Bristol, North Somerset, South Gloucestershire (BNSSG) Integrated Care Board (ICB).

Facilities Team

The facilities team is responsible for checking, monitoring, and replenishing medicines stocks in all IUC Treatment Centres and cars.

Specific tasks include:

• Assessing medicines stock against minimum levels, determine what replacements are required
• Check expiry dates, rotate stock, tidy medicines stocks
• Collect medicines (which will always be delivered to Osprey Court) from Osprey and store at relevant Treatment Centre
• Maintain records of stock levels
• Reconcile prescriptions for medicines supplied by clinicians against stock lists
• Submit records to the Facilities Team for review and action
• Log a learning event if stocks do not reconcile and escalate to line management
• Managing the withdrawal and replenishment of stock recalled through a drug alert

Any discrepancies will be alerted to the Facilities Team with regards to any potential over usage of a medicine for review and investigation. All drug orders will be kept for a period of 2 years to ensure any trend analysis can be noted.

Please refer to Facilities Team Weekly Medication Processes SOP.

Practice Services

Delegated authority will be given by the Lead GP to the lead nurse in each service who will be responsible for the monitoring, ordering and storage of medication. They will be supported by other members of their team together with the lead Pharmacist. Any concerns will be reported via the learning event process and relevant data/reports will be reviewed at the medicines management committee meetings. Practice services do not accept any patient return of medications.

Medicines Management Group

Please see Medicines Management Group Terms of Reference.

All Clinicians

All clinicians, whether prescribers or not, must comply with legislation, their professional body requirements, and guidelines, and BrisDoc medicines policies and procedures. Clinicians are responsible for their own prescribing practice and accountable for their actions.

Prescriptions will only ever be in accordance with the clinician’s license to prescribe, and will be within BNF and local formulary guidelines, or the departure therefrom will be clearly documented.

Independent Prescribers

Purpose

This section applies to all qualified independent prescribers employed or contracted by BrisDoc and covers registration, practice, and clinical governance of independent and supplementary prescribing. This includes.

• Nurse, AHP and Pharmacist Independent Prescriber
• Supplementary Prescribing

who are eligible via profession registration and qualification standards.

Registration with Professional Body

Any independent prescriber must register as such with the appropriate regulatory body before commencing their prescribing role.

Training Requirements

All independent prescribers must undertake training as determined by their professional body and maintain ongoing competence through continuing professional development. The Scope of Practice Statement outlines the areas that the practitioner will be prescribing in and their methods of achieving competence in that area. An individual competence and professional development will be monitored and supported by their Line Manager.

Accountability

Prescribers must act in accordance with the standards set by their registering body for prescribing. Practitioners must act within their own professional competence and expertise when prescribing, seeking advice where they require it and adhere to local prescribing policies.

BrisDoc Contracts

The prescriber and line manager must ensure the individual’s job description and contract is updated to reflect their new prescribing responsibilities before prescribing is undertaken. The Lead Clinician responsible for their practice is responsible for ensuring all prescribers are registered with the relevant authorities. For self-employed clinicians’ relevant checks of registration and performers lists are conducted prior to working in the service.

Indemnity and Legal Liability

All primary clinical care (delivered under an NHS contract for primary medical services) is covered by NHS Resolution’s Clinical Negligence Scheme for GPs (CNSGP). Additionally, BrisDoc provides medical negligence indemnity cover for employed Practitioners for issues not covered by CNSGP. This does not remove a Practitioner’s responsibility and accountability for their own prescribing actions, nor does this include professional indemnity provided by a registration authority.

Self-employed clinicians will provide their own medical defence organisation indemnity cover for non-CNSGP covered issues.

Prescribing

All independent prescribers hold individual clinical responsibility for undertaking an appropriate assessment, or critical review of assessment, for all patients for whom they prescribe.

The prescriber must prescribe only for the specific patient. Prescription items are not transferrable.

Controlled drugs must only be prescribed in accordance with the current legislation and best practice where there is a clinical need.

Single Prescribing Competency Framework

To support all independent prescribers in prescribing safely and effectively, a single prescribing competency framework can be found at:

https://www.rpharms.com/resources/frameworks/prescribing-competency-framework/competency-framework

Medicines Management Overarching Principles

This section details the principles by which BrisDoc clinicians will manage the administration and supply of medicines in respective services.

Regular medicines management meetings are held to address and monitor matters of medicines e.g.  alerts, learnings, prescribing and other medicines management issues. These meetings have minutes recorded and have associated terms of reference.

This policy is intended to protect all BrisDoc staff, patients and the wider public from any harm associated with the use or misuse of medicines, and to enable prompt access to prescribed medicines, especially out of hours.

A suite of SOPs are available to support the principles described in this policy for the management of medicines within the appendices.

Ordering Medicines

The governance process for the documentation of medicines orders and receipt, and their reconciliation is essential to secure intelligence and assurance with respect to the probity and accuracy of the ordering process, particularly regarding controlled drugs. Email orders will be sent on a secure network, records kept of orders against stock lists and receipt of medicines delivered will be maintained and saved on the respective medicine’s portal or the BrisDoc shared drive. The process will be kept under review by the Facilities Manager and Lead Nurses and is scrutinised by the Medicines Management Group.

Prescriptions

Prescriptions are generated by Adastra/EMIS via Electronic Prescribing Service (EPS) and digitally transferred directly to the relevant pharmacy. Hand-written and printed prescriptions in Treatment Centres are provided by exception if the IT system fails or there is another reason preventing the use of EPS.

EPS is not possible in the IUC visiting cars. Hand-written prescriptions can be generated at home visits and where necessary will be written legibly, clearly, in indelible ink and include full patient details and the date. The issue of a prescription will be documented in the prescription log in the car. Where a hand written script is issued an electronic version must be created on Adastra and ‘stored for later’. The visiting clinician may task the Clinical Assessment Service (CAS) to generate an EPS script to go to the patient’s chosen pharmacy for collection by a family member/carer.

Prescriptions for end-of-life care can be used for home visits. These prescriptions will need to be completed with appropriate doses by the visiting clinician and signed for the community pharmacy to dispense the medication appropriately.

Prescriptions are no longer sent to pharmacies via fax.  They are either sent electronically or in rare exceptions hand written.

Ordering and Monitoring Prescription Pads

Integrated Urgent Care

The ordering of printer and prescription pads for IUC is managed by the Facilities Team.

Printable prescriptions

Upon receipt of printable prescriptions, the serial number of each box of prescriptions is recorded, along with the number of the first and last prescription in each box.  A central log is maintained of where each box of printable prescriptions is issued to.

Handwritten prescriptions

For hand-written prescription pads the serial number of each prescription is recorded and a central log is maintained of where each pad is issued to.

A batch of individual prescriptions will be issued to a car and replenished when used and as required. A log of issued prescription form serial numbers and their use will be maintained by the driver and scrutinised by the Facilities Manager.

At the start of each shift the Host/Driver will load the IUC Treatment Centre prescription printers with prescription forms. A log of prescription serial numbers and their use is maintained in each Treatment Centre. When business continuity requires the use of hand-written prescriptions, a log of the prescription number and Adastra case record number will be maintained by each clinician on duty. The Host is responsible for issuing and retrieving the logs and reconciling them with the remaining handwritten prescriptions. These logs are returned to the Facilities Team for audit and re-ordering.

All prescription forms (including those from a car) will be securely locked away in the Treatment Centre by the Host at the end of each shift.

See SOP Writing a Prescription – IUC.

Practice Services and HHS

In practices prescriptions are ordered by the Practice Manager from NHS England (NHSE). Upon receipt a record is kept of the prescription numbers. Prescriptions issued to clinicians will be tracked by prescription number.

‘No fixed abode’ is acceptable as an address for homeless individuals.

Security and Safe Handling of Prescriptions

It is the responsibility of all to always ensure the security of prescriptions and prescription pads. In the event of loss or theft the following procedure should be followed:

• Report any loss immediately, with details of approximate number of prescriptions lost and serial numbers if known, to the Shift manager or senior clinician on duty and report as a learning event
• The senior clinician or investigating manager will inform Police, NHSE, NHS Business Services Authority and ICB Head of Pharmacy and manage the incident in accordance with the Learning Event management policy

Repeat Prescriptions

IUC

BrisDoc recognises that there are occasions when a patient will run out of their medicine or may be visiting the local area and have forgotten/lost their medicine. A request for a repeat prescription will therefore be considered on an individual patient basis.

In cases where an IUC clinician recognises that to go without a regular medicine may be to the detriment of symptom control and good health, a clinician may provide a repeat prescription for the relevant medicine for a short duration that gives the patient time to arrange with their own GP to provide their usual repeat prescription and to be reviewed for their long-term condition. EMIS access should be sought to provide confirmation of repeat medicines and when they were last prescribed. Other resources such as summary care record, Connecting Care and the NHS prescription tracker can be used to obtain further information regarding acute/repeat prescriptions.

Prescribing repeat medication will be in line with local formulary and guidance

As a rule, no more than three days’ supply should be prescribed (longer supplies may be given during bank holiday periods). Prior to prescribing EMIS and Adastra should be checked for other occurrences of repeat prescription requests from the patient to determine if there were a pattern that would affect a decision to prescribe and inform the content of the Post Event Message to the patient’s own GP.

IUC does not issue repeat prescriptions for patients who are under the care of a private service or provider.

For patients visiting from abroad who have run out of their usual medication, IUC can issue a repeat prescription for the shortest period (e.g., until they can temporally register with a local GP). The prescriber must ensure they have proof of the medication(s) and a correct up to date list. The prescriber can refuse to prescribe any medication they deem unsuitable/unsafe/inappropriate.

See SOP Transporting and Dispensing Medication from IUC Car.

See SOP Prescribing and Dispensing Medication from IUC Treatment Centre Stock.

See SOP Remote Prescribing and Dispensing Medication from IUC Treatment Centre Stock.

Practices

See SOP – Repeat Prescribing in Practice Services.

Homeless Health Service (HHS)

The overriding principle of prescribing at the homeless health service is managing risk. This includes mitigating risks against overdose, patients selling their medication and/or losing their medication. Prescribing small amounts of medication at one time helps reduce these risks. Risk needs to be assessed holistically for patients depending on their individual vulnerabilities. If there is reasonable evidence of script diversion, then prescribing for that patient will immediately stop.

• For uncontrolled substances and medication/products at low risk of diversion this will usually be supplies for one or two weeks only
• Pharmacy notes for “Supervised consumption on pharmacy premises” can be used for any drug and can improve compliance as well as mitigate risks
• Use of EPS whenever possible for audit purposes and to reduce the number of scripts lost

As many patients accessing the HHS only hold temporary registration it is essential to use all data-sharing available including EMIS, SCR, Connecting Care, BSDAS, Theseus and others to access accurate and real-time information. This avoids any possibility of duplicate prescribing or other prescribing errors. Patients who do not consent to data sharing cannot receive treatment from HHS and should be directed back to the GP where they hold full registration.

PGD Use

Non-prescribing clinicians will be able to issue emergency medication via the use of a PGD. The PGDs are produced by BrisDoc’s Medicines Management Group.

• PGD users will have training prior to being able to issue drugs
• PGD users will be assessed as competent by a Prescriber prior to issuing drugs under PGD
• PGD users will sign to indicate they are able to undertake usage of PGDs
• The Clinician will record the drug given and identify that it was given under PGD in the patient notes

• Clinical Guardian will be used to audit the clinical consultations, therefore any use of a PGD drug and its appropriateness will be conducted as part of this review
• All PGDs must be signed off by the ICB and regularly reviewed

Unlicensed Medicines and Uses

Examples of unlicensed drugs are those made by Specials Manufacturers. Some medicines may be used in ways that lie outside their marketing authorisations (formerly product licences). This is particularly so for medicines which are used in palliative care.

Patients should usually be informed if a medicine supplied to them is unlicensed or used in an unlicensed way, and any implications, e.g., that the medicine may not have been assessed by the licensing authority against the criteria of safety, quality, and efficacy. It is the professional responsibility of the prescriber to decide whether it is appropriate for a patient to be supplied with a medicine for an indication outside its marketing authorisation.

In addition, sometimes a medicine may be used outside its licensed route. The prescriber must carefully weigh the likely benefits against the anticipated risks and wherever possible discuss these with the patient before agreeing the most appropriate treatment.

Prescribers and pharmacists should work together to ensure that unlicensed medicines are only supplied when the patient has a special clinical need that cannot be met by an available licensed medicine. This special clinical need does not include reasons of cost, convenience, or operational need. Every reasonable effort should be made by prescribers (with support from pharmacists) to identify a UK licensed medicine, or a licensed medicine in a similar class, that meets the patient’s special clinical needs.

Where medicines are prescribed for unlicensed indications, it must be recorded on the patient’s consultation notes.

Further guidance is available as below:

https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Support/toolkit/professional-standards—prescribing-specials.pdf

Amber and Red Drugs

Prescriptions will not be issued for any “RED” drugs. “AMBER” drugs will seldom be issued other than following senior clinician consultation.  Please see guidance from BNSSG regarding the traffic light system and classification of medicines.

Administration of Medicines

IUC

The occasions when an IUC clinician may be required to administer a medicine will be by exception and typically in an urgent situation or medical emergency. These will be stat doses in the following circumstances:

• the immediate control and management of symptoms
• resuscitation where the clinician makes a judgement that immediate intervention is needed
• providing a window of watchful waiting that then allows for more considered advice and/or treatment from the clinician.

The medicine, dose and route, batch number and expiry date will be documented in the patient consultation notes. Issue of the medication should be recorded as per this policy.

The clinician administering a medicine in the Treatment Centre or at a patient’s home is responsible for undertaking any monitoring required to assess the effect of the medicine or any adverse reactions and recording the effects in the patient consultation notes.

See the Prescribing and Dispensing Medication for IUC Treatment Centre Stock SOP.

Practice Services

In practice services, medicines are not routinely stocked (except vaccines, implants and emergency medicines) and any available will be part of the practice’s resuscitation equipment and the GP visiting bag (refer to Resuscitation policy for medicines contents by practice). Practices will also stock emergency drugs as per CQC requirements. Any drug(s) that are administered will be documented in the patient’s EMIS record and relevant patient consultation notes.  Drug stock is checked regularly, and records are kept reflecting each time the stock is checked and the stocks administrator must sign and date that they have rotated the stock.

Where a medicine that is not held in stock is to be administered in a surgery the patient will be issued a prescription for that medicine and will be asked to bring it to their appointment for administration. Appropriate records will also be recorded in the patients EMIS notes.

HHS

In addition to the above, Homeless Health will assess on an individual basis as to whether a patient could be reasonably expected to collect and bring their medications. Considering the patients mental health, vulnerabilities, organisational skills, drug taking history and the nature of the drug for administration. Patients who cannot be reasonably expected to collect their medications will have their medication collected for them from the pharmacy and stored on site in a secure locked cabinet. This will be recorded in the ‘patient’s own’ chapter of the drug record book and signed out for administration.

Supplying Medicines

Supplying a medicine from stock should be by exception in IUC. Medicines may be supplied by a clinician from stock held at a Treatment Centre or in a car when it is not appropriate to provide a prescription e.g., when there is no open Pharmacy, or it is unrealistic to expect the patient to travel to the nearest open Pharmacy.

In instances where a medicine is supplied the clinician should clearly document the medicine and administration instructions in the case record including batch number and expiry date. An entry in the ‘Medication Issued from Stock Form’ will be generated for the medicine supplied and available in the Treatment Centre so the Facilities Team can reconcile supply against stock levels and re-order stock. A medicine administered from car stock will be recorded in the Car Medication Form.

The clinician and host will retrieve the medicine from the storeroom and check the medicine against the case record and issue it to the patient with administration instructions and safety netting advice. The clinician must label the medication box(es) with the patient’s name and dosing instructions and make up suspension by adding required volume of water.

When supplying medicines from IUC stock only a complete box of medication should be issued for the patient to take away. The medication should be in its original packaging with the Patient Information Leaflet.

Please refer to the controlled drug section for supplying controlled drugs from stock.

See Prescribing and Dispensing Medication from IUC Treatment Centre Stock SOP.

See Transporting and Dispensing Medication from the IUC Car and Remotely Prescribing and Dispensing medication in IUC Treatment Centre SOPs.

Spoons and oral syringes

For liquid medicines and especially medicines for children, the supplier should provide a 5ml, 10ml, 50mls spoon, or an oral syringe. Both should comply with BS3321: Part 7 1995. An oral syringe should be supplied when an oral liquid medicine is prescribed in a dose other than 5ml or multiples of 5ml, 10ml, 50mls. The syringe is marked in 0.5-ml divisions from 1 to 5ml to measure doses of less than 5ml and is provided with an adaptor and an instruction leaflet for the patient or carer on its use.

Shelf-life

Medicines for supply must have a sufficient shelf life to cover the intended period of treatment for the patient to whom it is supplied. Some medicines needing reconstitution prior to supply (e.g., oral antibiotic suspensions) have a limited shelf life once reconstituted. Anyone supplying a medicine of this type must ensure that supplied quantities allow for this. Patients requiring treatment courses which exceed the shelf-life of the reconstituted medicine will need appropriate arrangements put in place for further supplies. Whichever arrangement is put in place, the procedure for the supply of completed courses should be discussed and agreed with the patient or their carer.

Returned Medicines

BrisDoc does not accept returned medicines (the only exception to this is at HHS). Patients or a family member should be instructed to return un-used, out of date, or no longer required medicines to their local pharmacy.

The HHS may accept illicit and prescribed medications from their service users or found by staff on site where their continued circulation may cause harm and where the service user cannot reasonably be expected to return it to a pharmacy. These substances should be immediately disposed of in a Controlled Drugs denaturing kit.

Please refer to the controlled drugs section.

Handling Adverse Drug Reactions, Clinical Incidents and Recalls

All adverse drug reactions (ADR) should be reported in accordance with Medicines Healthcare Regulatory Authority (MHRA) Yellow Card system (available in BNF or reporting online at www.mhra.gov.uk) as well as through BrisDoc’s learning event reporting portal. All ADRs should be recorded in the patient clinical record.

Any notification comes through the Brisdoc Governance email address, and the relevant clinical lead and Facilities Manager will review the detail and action if necessary.

Audit

Practitioners should audit their own practice as part of their ongoing review of CPD needs.

Prescribing by all clinicians is monitored by the Medicines Management Group at the ICB, Clinical Guardian audit, peer review, individual clinician review by line managers and audit.

Documentation and Record Keeping

All prescribers are required to keep contemporaneous records which are accurate, unambiguous, and legible in line with requirements of the registering body’s standards for record keeping. Records must comply with organisational policies for Records Management and Data Protection, Confidentiality and Disclosure.

Prescriptions may be hand-written, or computer generated and must be signed and dated by the prescriber. Electronic Prescribing Service must be the preferred method of issuing a prescription.

Controlled Drugs

BrisDoc has adopted the BNSSG ICB Guidance for Controlled Drugs (CDs) and works in accordance with NICE guidelines (2016), NHS England South West, the Misuse of Drugs Regulations (2001), and Controlled Drugs (Supervision of Management and Use) Regulations (2013).  The policy also follows Care Quality Commission guidance on Controlled Drugs (2024).

CDs are only held in stock by IUC.

Any application for a CD licence or actions related to ongoing management of CD licencing must be raised to the Director of Nursing, AHPs and Governance.

Please see the Applying for a Controlled Drug License SOP.

Principles

The key principles of this policy are that:

• CDs will be managed and used safely and effectively
• Patients should have timely access to the CDs prescribed for them
• Opportunities for CDs to be abused or diverted are minimised/prevented
• Good practice will be shared, and concerns identified promptly and rectified as soon as practical

Responsibilities

BrisDoc staff will comply with appropriate legislation relating to the prescribing, supply, documentation, safe custody, and administration of CDs. This involves not holding Controlled Drugs at any premises until the Home Office have granted a CD Licence.

BrisDoc’s Controlled Drugs Accountable Officer (CDAO) is responsible for the safe and effective use and management of CDs within the organisation. They must ensure monitoring and auditing of the management and use of CDs, record and investigate concerns, ensure adequate procedures are in place and ensure relevant individuals receive appropriate information, education and training. There is a requirement that the CDAO shares concerns and information with police, counter fraud, security, regulators and ICB applicable.

The Medicines Management Committee is the official forum for all medication including CD management, but CD management oversight will be handled by the clinical team.  All changes to operations regarding CDs will be made in writing to all required teams, contemporaneous record is evident for good governance.

Registered Clinicians must:

• act within the legislation and professional responsibilities relating to controlled drugs
• ensure they consider themselves competent to act in accordance with the medicines management policy
• be familiar with, and always follow, their own professional code of practice in relation to medicines
• use tools that support safe and appropriate prescribing of CDs
• document via indelible route, primarily EPS or written prescription and give information to the person taking the CD or the carer administering it including for example:
  • The patient’s full name, NHS number, address, and date of birth, age if appropriate
  • Document the name and form of the drug, even if only one form exists and the strength of the preparation, where appropriate (if more than one form exists)
  • Know how to use sustained and immediate-release formulations when prescribed together,
  • State dose, frequency, and duration,
  • Document the total quantity to be supplied in words and figures
  • Understand side effects and efficacy
  • State what the CD has been prescribed for,
  • Understand how to safely dispose of unused, unwanted CDs,
  • Understand that the CD is for use only by the person it has been prescribed for.
  • Understand the prescription must be signed by the prescriber with his/her usual signature and dated by him/her (a date stamp can be used)
  • Document any remaining space crossed through to reduce opportunity for fraud

The failure of staff to comply with this policy may result in disciplinary action.

It is imperative that all new colleagues that will handle and be involved in the record keeping of controlled drugs are trained in the following information and are aware of regulations and the protocol around controlled drugs.

Ordering Controlled Drugs

Requisitions

One of the designated clinicians must produce a written requisition to obtain Schedule 2 CDs from North Bristol Trust.  Schedules 3 to 5 are obtained from Arcadia or Kents suppliers via Facilities Team.

North Bristol Trust pharmacies hold a list of approved clinicians able to order CDs required for SevernSide use.

A designated Clinician will liaise with IUC Head of Nursing & AHPs to order CDs for SevernSide.  The CD requisition form (FP10CDF) will be sent to North Bristol Trust Pharmacy by Facilities.  Ordered CDs will be collected from North Bristol Trust Pharmacy by authorised clinicians who will receive a signed requisition from North Bristol Trust Pharmacy with the number of drugs ordered and a date and time stamp which is to be given to Facilities.

A member of the Facilities team and the authorised clinician will then collect the controlled drugs from North Bristol Trust and are responsible for their safe transportation to the Treatment Centre.  This must be undertaken in a BrisDoc vehicle with a CD safe and the CD Register must be updated in accordance with audit procedure.

Practice Services do not currently order any control drugs.

See SOP Ordering, Collecting and Dispersing Schedule 2 Controlled Drugs and Ordering and Storing IUC Schedule 3 to 5 Controlled Drugs

Retention of signed orders, requisitions, and invoices

The Facilities team will keep all signed orders and requisitions for CDs for 2 years and invoices for 7 years.

Storage of Controlled Drugs

CD Cupboards

In accordance with good practice guidelines (Misuse of Drugs (Safe Custody) Regulations 1973), CDs will be stored in accordance with the following criteria:

• Kept in a locked, secure metal safe within a locked drug store cupboard which is fixed securely to a wall – the hinges must be protected and the safe is of suitable thickness for purpose.
• The room containing the CD cupboard is lockable. This cupboard and keys are not open to public access.
• All combination codes to locks must be changed every 6 months.
• The room containing the CD cupboard is tidy around the cupboard to avoid drugs being misplaced.
• Nothing is displayed outside to indicate that CDs are kept within the cupboard.
• The number of sets of keys to the locked CD cupboard, and who holds them is always known.
• One designated person (host) within the premises takes overall responsibility for the keys. The cupboard will only be opened by the designated person concerned, or person authorized by them to do so. The keys / access codes will be stored securely.
• The CD storage cabinet must be locked after each entry into the cupboard.
• Stock is kept to a minimum, governed by clinical need.
• Items other than CDs, such as money and paperwork, will not be stored in the CD cupboard.
• The CD register is stored safely outside the CD cupboard in an appropriate location within the drug store cupboard.

Medication	Class	Schedule
Codeine	B	5
Diazepam	C	4
Lorazepam	C	4
Midazolam	C	3
Oral morphine 10mg / 5ml	A	5
Morphine	A	2
Oxycodone	A	2

Recording of CDs kept as stock

Records for all CDs must be kept in a CD register.  There are two CD registers, one for schedule two drugs and one for schedules three, four and five drugs.

All schedules of CDs are treated in the same way and in accordance with this policy.

Format of CD register

To comply with legislation all CD registers are:

• bound (not loose leaved)
• Contain individual sections for each strength and form of a drug
• Have the name, strength and form of the drug specified at the top of each page
• Have the entries in chronological order and made on the day of the transaction or the next day
• If an entry is contained within more than one line – each line needs to be signed and dated
• Have the entries made in black ink or otherwise indelible form
• Not have cancellations, obliterations, or alterations
• Have corrections made by a signed and dated entry in the margin or at the bottom of the page and a learning event submitted.
• Be kept at each location to which it relates and be available for inspection at any time.
• Be kept for a minimum of two years after the date of the last entry, once completed
• Not used for any other purpose

Administration for CDs received into stock, the following details will be recorded in the CD register:

• Date on which CD was received
• Order Requisition number
• Name and address of supplier (e.g., pharmacy)
• Quantity received
• Name, form, and strength in which the drug was received
• Signed as correct by two persons, one of which must be a clinician
• Osprey Court moves large volumes of CDs frequently to bases – a clear reconciliation of movement of CDs to each base for each medication must be documented in the CD register.

Administration for CDs supplied to patients via prescriptions, the following details will be recorded in the CD register:

• Date on which supply was made
• Name and case number of patient
• The authority of person who prescribed CD
• Quantity supplied
• Form and strength in which drug supplied
• Signed as correct by two persons, one of which must be a clinician
• The register will be completed only after the CD has been collected by the patient representative or healthcare professional
• The medicine will only be dispensed once the patient is present at the base

See the Dispensing Medication for IUC Treatment Centre Stock SOP.

Maintaining CDs at Treatment Centres & Cars

In accordance with good practice guidelines, identified members of staff have responsibility for carrying out daily stock checks of CD balances. These checks will be made by a clinician at the commencement of the start of the shift on weekdays and the commencement of the start of the early shift on weekends. The Host is responsible to ensure clinicians in each Treatment Centre complete this task.

Reconciliation of CDs

The role of operational co-owners is to ensure safe keeping of the keys and keycodes.  All controlled drug checks, dispensing controlled drugs or transporting controlled drugs must be done together with a clinician.  It is the clinician that handles controls drugs and are ultimately responsible for all CDs under all circumstances.  Operational co-owners are witnesses, and counter-signatories in daily stock checks and dispensing all CDs.

The Process for Daily Checks of the CDs at bases

See SOP Daily CD Checks in IUC Treatment Centre and Cars

Transportation of Schedule 2 drugs in the Car

Schedule 2 CDs are not stored in the cars, however on occasions they may need to be taken on a home visit or transported between bases.

See SOP Transporting and Dispensing Medication from the IUC Car.

The Process for Daily Checks of the CDs in the cars

These drugs, schedule 3,4 and 5 CDs are stored in the car medication boxes.  There is a CD register for each car – these stays inside the car.

See SOP Daily CD Checks in IUC Treatment Centre and Cars

The accountability for maintaining the correct stock levels of CDs lies with the Medicines lead for each service.

Role & Name	Service
Lead Clinical Practitioner – Medicines*	IUC SevernSide
Lead Nurse	Homeless Health
Lead Nurse	Broad Mead
Lead Nurse	Charlotte Keel

* In SevernSide liaison from the host goes via the shift manager reports

Oramorph Reconciliation

The entire Oramorph stock will be measured in millilitres.  Any open bottles will be visually checked for volumes each day.  If there is any discrepancy outside of 10ml measurements this will be reported as a learning event and investigated. Brisdoc only stock morphine sulphate oral solution of strength 10mg/5ml.

Monthly stock check of CDs

See SOP Facilities Monthly Stock Check of Controlled Drugs

Transportation of CDs

All health care professionals in legal possession of a CD have a professional duty of care to take all reasonable steps to always maintain safe custody of that CD.

The following section articulates how the transportation of CDs occur.

Checking In and Out of CDs to Cars

Refer to the following SOP’s –

Prescribing and Dispensing medication from the IUC Car

Daily CD Checks in IUC Cars

Transporting CDs from base to base for stock adjustment

Please refer to the following SOPs

Prescribing and Dispensing medication from the IUC Car

Car Safes

At no time will Schedule 2 CDs be left in a car that is unattended during the day or overnight or left for a long period of time.

Prescribing Controlled Drugs

CD Prescribing Points

• CD prescriptions for Schedule 2 and 3 drugs are currently valid for 28 days
• It is good practice to prescribe no more than three days’ supply for CDs schedule 2, 3 and 4 in the IUC setting, excluding over bank holidays where longer periods are absolutely necessary.
• If more is prescribed, the clinical reason for a greater supply should be documented in the patient’s electronic notes.
• When supplying long term pain relief on repeat prescription the prescriber will check EMIS first, supply no more than the minimum required amount and ensure that patients are not over-ordering their medicines by advising the patient’s GP to highlight areas of concern.
• It is good practice to generate all CD prescriptions via computer electronic records where possible to enable a clear audit trail. If handwriting the prescription is unavoidable, make a record of the medicines prescribed in the patient’s electronic records and record the prescription number in the IUC prescription record log and on the patient record.
• Good practice requirements and professional codes of ethics make it clear that it is inappropriate for a prescriber to prescribe or administer CDs for personal use, or for family members, at any time.
• Lost or stolen controlled drug prescriptions will not be replaced except under exceptional circumstances with a police crime number at the prescribers’ discretion. If medications are claimed to have been lost the greatest care must be taken to verify this. This includes looking on Connecting Care to see where the script has been issued and phoning that pharmacy. Medicines that have been lost should not necessarily be replaced if the clinician is not confident that it is safe to do so.

Requests for repeat prescriptions of drugs of dependence must be treated with caution. If a patient is on a weekly/daily script, the clinician can refuse to issue further medication if it is deemed unsafe or inappropriate. In such cases all resources must be checked/validated e.g., EMIS/summary care record/ connecting care/community pharmacy/NHS spine and further discussion with CC or pharmacist is strongly recommended. Consideration for a special patient note should be given.

Homeless Health Service

At the HHS, particular care should be taken if starting a Pregabalin or Diazepam script. Initiating pregabalin or diazepam is a major event and should almost never occur.  The decision needs to be very clearly documented in the notes and where possible should be discussed at the weekly Multidisciplinary Team meeting with the Addictions consultant. Blue prescriptions should be used for diazepam.

Diazepam must not be stored at the HHS as stock or as patients own supply under any circumstances.

CD prescriptions are issued as blue paper scripts at HHS. This allows prescribers and pharmacists to monitor missed doses of OST more accurately for patients who are on daily supervised consumption. This is essential for managing risk of accidental overdose.

Blue Scripts – Process

Blue FP10 prescriptions will be ordered from PCSE by Medicines lead in each service. On receipt the serial numbers will be checked and recorded it in Blue Script Spreadsheet or log book.

Blue FP10 prescriptions should be stored in a secure place at all times and access to them is only for relevant staff members that require access to blue FP10 scripts.

The spreadsheet record should include:

On Receipt

• date received
• name of person who received the order
• FP10SS (issued in batches of 50) first and last number of batches

On Issue

• date of issue
• which Blue FP10s have been issued (quantity and serial numbers)
• name of person who taken the Blue FP10s
• serial numbers of any unused Blue FP10s returned
• details of Blue FP10s that have been destroyed, including who destroyed them and how they were destroyed (these records should be retained for at least 18 months).
• All destruction of Blue FP10s must be conducted by two people.

HHS Specific Information on Blue Scripts

Recording every blue script issued in the prescriber’s page of the Excel Spreadsheet “Blue Scripts” (shortcut on prescriber’s Windows desktop)

A clinician can take a small number of scripts to be held in a locked location in their consulting room. These scripts must be recorded on the “Blue Script Register” tab of the Blue Script spreadsheet (a shared file on the T drive, with shortcut on each clinician’s desktop).  It is necessary to record the clinician’s name, number of the top script and number of the bottom script. The scripts should be returned at the end of the session to the safe in the SMART Team’s cupboard. The relevant numbers of returned scripts should again be recorded in the spreadsheet. Each prescriber is responsible for the security of the prescriptions they have taken.

Whenever a blue script is issued the clinician must fill in the spreadsheet in their own page of the spreadsheet.

• Date of issue
• Patient’s NHS number
• Unique Prescription number
• Click on the save button

The prescriber must make a note in the patients record that a prescription has been issued and whether it has been given to the patient, stored to give to the patient later, hand delivered and by whom, or posted to a pharmacy. If it is to be given later, instructions should be given as to who may do this.

Practice Services & HHS specific information

Patients, temporary staff, and visitors should not be left alone with Blue FP10s or allowed into secure areas where forms are stored.

The forms must be removed from the printer and secured to the secure location at the end of a clinic as these forms are acceptable in handwritten form. Patients must never be left unaccompanied by staff in areas where printers contain FP10 SS forms.

If it is necessary to post a completed Blue FP10 to the patient or to a community pharmacy, then this must be recorded in the patient’s electronic record including the serial number of the form.

Under no circumstances should prescription forms be pre-signed before use.

Emergency and Out of Hours Supplies of CDs

Under no circumstances may an emergency supply of a Schedule 2 or 3 CD be made to a patient without a valid prescription.

A basic stock of palliative care drugs that might be needed urgently in the IUC setting is available in the Treatment Centres. There are several pharmacies participating in a Palliative Care Local Enhanced Service open for extended hours, where a range of palliative care medicines is kept in stock in sufficient quantities.  There is an up-to-date list of participating pharmacies available on Remedy, and via the clinical toolkit.

When supplying CDs to a patient representative or community healthcare professional, steps to confirm their identity must be taken before providing the CD.

Methadone Prescribing in IUC

BrisDoc does not issue prescriptions for methadone and Subutex unless by exception when the criteria set out in the position statement below are fully met.

Position Statement

Substitute prescribing for patients with substance misuse e.g., Methadone and Buprenorphine (Subutex) is offered by General Practice and the Drugs Services, often under shared care arrangements. This can lead to an expectation that the IUC Service will similarly offer this service. However, there are increased risks in issuing such prescriptions via IUC when the patient is not known to IUC, and such prescribing could be subject to potential abuse. As such the IUC Service will only prescribe if it can be confirmed with the patient’s normal pharmacy (i.e., they are still open) that there has been a problem originating from the patient’s own GP or the pharmacy which means that medications that have been prescribed by the patient’s own GP cannot be safely dispensed. As such the request should preferably come directly from the pharmacy (via the Professional Line) rather than via NHS 111.

A situation in which a patient has, for whatever reason, missed their pick-up will not be managed by IUC.

If a prescription is requested for any other reason the IUC Service will not prescribe and has no responsibility to do so. Patients should be referred to dedicated substance misuse services that are provided to respond to such circumstances. Specifically, IUC will not initiate such medicines.

Any patients requesting a methadone/buprenorphine prescription who are transferred to IUC via NHS 111 should be consulted by the Clinical Coordinator for advice and management, or the IUC pharmacist (if available).

If a prescription is issued, then this should be sent electronically to a pharmacy and ideally prescribed as a daily supervised dose.  The pharmacy should be contacted directly before sending a prescription to ensure they have appropriate stock and are willing to issue the Methadone/Buprenorphine with a new prescription.

Destruction of Controlled Drugs

It should be noted that IUC must not accept waste medicines, including CDs.

In accordance with legal requirements, all obsolete Schedule 2 CDs must only be destroyed in the presence of an authorised witnesses.

There are two pathways to destroy Schedule 2 controlled drugs.

The first pathway is for a named clinician on the Home Office Authorised Witness list to lead the destruction of drugs with a witness following process outlined.

The second pathway is for a lead clinician to arrange for the appropriate, safe destruction of any CDs held at any of the Treatment Centres. The lead clinician will contact the controlled drugs team at NHS England and NHS improvement (Southwest) to arrange destruction of CD The application will be reviewed by the NHS England CD Southwest team and a designated person (the lead clinician) will be allocated for the purposes of witnessing the destruction of the controlled drugs.  The second person stated on the authorisation form will destroy the controlled drugs in the presence of the witness specified.

 

The authorisation timeframe will be a short window and limited to the premises to which the application is related.

For further information or clarification, email:  southwestcontrolleddrugs@nhs.net

The website www.cdreporting.co.uk has all the resources required on-line.

All the CDs held at any of the IUC Treatment Centres will be disposed of in accordance with NHS England CD guidelines – this includes expired drugs and accidental breakages and spillages.

Each Treatment Centre where control drugs are stored and therefore destroyed requires a T28.  This is a Waste exemption certificate that allows bases to denature controlled drugs and complies with the Misuse of Drugs Regulations 2001.

T28 waste exemption: sort and denature controlled drugs for disposal – GOV.UK (www.gov.uk)

Details of the stock CD that is being destroyed must be documented and accounted for in the base CD register.

All CDs requiring destruction need to be destroyed so that the active ingredient is irretrievable. IUC will use commercially available CD denaturing kits to denature Controlled Drugs. There are 100mls kits available at base and larger kits available from Facilities if required to denature a larger batch.

Please see SOP – Destroying and Recording Controlled Drugs in IUC

Once the CDs have been destroyed, the resultant mixture should be added to the general pharmaceutical waste in a clinical waste bin, or equivalent. Good practice, to ensure the active ingredients are denatured would be to keep the container in the Drugs cupboard until fully deactivated in 24 hours.  This is the responsibility of the Lead clinician and Facilities.

 

Expired stock of controlled drugs

Expired CD stock should be stored in the CD cupboard until destruction and placed in the ‘Expired / broken CD ’ plastic sealed box to prevent it from being issued in error

This will be registered in the CD Register as expired and form part of the daily CD Register count.

Schedule 2 only

The lead clinician will report expired drugs on the NHS England CD website.

Home (cdreporting.co.uk)

Accidental breakages/Spillages of controlled drugs

Complete a learning event for the accidental breakages.  The Learning event should specify the medication details broken, details of the incident and details of all individuals witnessed the incident or affected by the incident as well as the date and time.

If the vial is intact and has active medication present inside the vial, carefully put the vial in the sealed plastic box in the safe marked ‘Broken / expired CD’.

If the active ingredient and the vial is irretrievably broken, use absorbent material (Cat litter) to mop up the active ingredient using PPE provided and dispose of in a sharps bin. Carefully, put the fragments of glass in a sharps bin and dispose of gloves in a sharps bin if necessary.  There will be a box of cat litter in each base for denaturing and mopping up spills for this purpose.

This will be registered in the CD Register as expired and form part of the daily CD Register count.

A Lead Clinician or Governance will complete a Controlled Drug Incident for the NHS England CD website

Home (cdreporting.co.uk)

The broken vials will be denatured as described above.

Please see SOP Breakages of Controlled Drug Vials

Disposal of Waste / unused

Any medicine left over in a vial after administration is considered waste.  Medicine is also considered waste if it has been prepared for administration but not actually used.

Please follow the destruction of CDs above. Disposal of waste does not need to be formally reported. Denaturing kits should be used.

Significant Incidents Involving CDs

Significant incidents include:

• any incident where a patient is harmed, or the potential for harm or a ‘near miss’ has occurred.
• Patient or carer complaints involving the prescribing of CDs, including complaints of a failure to prescribe appropriate doses and/or appropriate medicines
• Concerns expressed by colleagues, police, drugs misuse services or others about unusual, excessive, or inappropriate prescribing of CDs
• discrepancies at the time of stock checks and transfer of CDs

Any significant incident involving CDs must be reported and managed in accordance with BrisDoc’s Learning Event Management Policy and reported to the through the NHS England CD website.

All CD’s that are unaccounted for thefts and losses must be reported to the Home Office, through on-line forms below, and the Police within 48 hours.  It may be necessary to report to the CQC and ICB following CD Accountable Officer advice.

Controlled drugs and precursor chemicals: thefts or losses – GOV.UK (www.gov.uk)

The Commissioner will monitor incidents involving CDs in conjunction with the NHS England Accountable Officer.

The Head of Nursing or Lead Pharmacist will attend the CD Local Information Network (LIN) meeting to share information and intelligence about the misuse and safe use of controlled drugs.

Dealing with CD Discrepancies

If a discrepancy is found during a routine stock check and the source CAN be identified, the clinician checking the stock should record the outcome and make any corrections to the CD register with a signed and dated entry in the margin or, at the bottom of the relevant page.

If the source of the discrepancy CANNOT be identified during the stock check, then the clinician checking the stock should immediately submit a learning event and inform the Shift Manager.  The Shift Manager, in conjunction with the senior clinician on duty will then co-ordinate a formal internal investigation and advise the NHS England CD Accountable Officer.  This will include completion of an external learning event.  It may be necessary to contact the Police, CQC and Brisdoc Insurers.  Consideration should be given to wider communications and senior leads meeting should be convened to disseminate learning.

The clinician should record the discrepancy on a Learning Event Form. This will include:

• date and time of discovery of discrepancy
• drug, form, and strength
• the nature of discrepancy
• the names of the members of staff who discovered the discrepancy.
• any other relevant information

This discrepancy will then be investigated at the earliest opportunity by:

• examining current stock in CD cupboard
• examining current and previous entries in CD register
• checking the calculation of the running balance
• any other relevant investigation
• review of available CCTV
• all details of the discrepancy MUST be reported to the NHSE CD Accountable Officer within 24 hours of its discovery*
• An incident panel will be established to investigate if considered necessary

*Reporting will be completed at the earliest opportunity as the medicines lead may not be available during the OOH period.

Monitoring CD Use

This will be undertaken through monitoring ordering trends and from Prescription Prescribing Authority (PPA) information provided by the ICB Head of Pharmacy. The Head of Nursing and AHPs will maintain appropriate links with the NHSE CD Accountable Officer and Local Intelligence Networks.

It is also an annual requirement that the Home Office CD division is sent an annual drug return to confirm that we have not supplied to CD’s to any other organisations.  There is no requirement for detail of end-to-end use but a confirmation email stating of “Nil return”.  The email address for this is annualdrugreturns@homeoffice.gov.uk.

CD auditing

This will be a regular, monthly task undertaken by a clinical practitioner and a facilities team member. The number of CDs within each base will be recorded alongside the medication expiry date. Out-of-date medication will be denatured as per the policy, and if usage is low, an order will be placed as per the policy.

Closing a CD Register

In the rare event of closing a Treatment Centre, the principle is that the CD Register is accountable for CDs in that base only.  The CD Register does not follow the CD drugs.  When the CDs are moved, the CD Register records the drugs remaining in the base.  In the event of a closure of a base – there will be ‘zero balance’ recorded as the drugs will be removed from the base.  The CD Register is then ‘closed’ and stored accordingly.  No further entries are recorded, and the CDs that are removed are recorded in a new or existing CD register in another base.

Medicines and Stores Management

This section details processes for monitoring, storage and return of all medicines

Temperature Management

Please refer to Specialist Pharmacy Service (SPS) guidance on temperature management for medicines.

Guidance – SPS – Specialist Pharmacy Service – The first stop for professional medicines advice

Where temperature monitoring is in place, daily checks must be carried out and recorded on the relevant log. Where daily checks are not possible, for example over a weekend, checks must be performed as regularly as practicable during service operating hours.

These logs, along with thermometer calibration certificates, should be sent to the governance team for keeping when a new log is started.

See Appendix – Temperature Record Log

Temperature Excursions

1. If the alarms go off, action must be taken to try to ensure that the room or fridge remains within the desired range – open / close windows, install portable fan / heater to cool / heat the room, close fridge door, or contact engineer to service fridge
2. Once these measures have been taken, ensure that the temperature record has been recorded, then reset the thermometer to silence the alarm
3. If the temperature has varied outside of the required range, inform the lead clinician on duty. They will need to know the temperature reached, an estimate of how long the temperature has been out of range and the details of any medication stored there
4. Log a learning event in accordance with the learning event policy and fill in the excursion checklist (See Appendix).

Broad Guidance:

• If fridge outside of temp range for <20mins and reason known, then reset fridge temp only. No further action needed.
• If unknown how long outside of temperature range, quarantine vaccines (clearly label not for use and put in alternate fridge that is in recommended temperature range)
• If temp is out of range for more than 20 minutes but it was during a restock, then note min/max and current temps after 1hr of finishing stock check, reset temps and log on the recording chart the reason for the excursion.
• In cases where the fridge was out of temperature range for more than 20mins contact the Screening and Immunisations team for advice, email query to swscreeningandimms@nhs.net or call 01138 249540 Monday to Friday (9-5). Outside these hours you can contact the health protection team on 03003038162 and press option 1.
• Do not contact the manufacturer until the above has been done. Support from the Screening and Imms team will then be available to investigate and assess the risk. The Screening and Imms team will contact the vaccines manufacturers. For vaccines no from Immform (travel vaccines etc), the practice will need to contact the manufacturers for advice if the vaccines can still be used on or off label.

Palliative Care Patients

IUC recognises the importance of Clinicians being good partners in supporting patients to follow their end-of-life wishes. Where these exist IUC will respect those wishes and the treatment plan agreed with the patient’s usual clinicians.

To this end IUC clinicians will support the prescribing, administration, and supply of end-of-life care medicines in accordance with the BNSSG anticipatory prescribing guidelines and the use of “Just in Case” boxes and medicines.

Palliative Care advice, guidelines and documentation is included in the Palliative Care Pack in each car and with the Clinical Coordinator and on the clinical toolkit.

Packing Down

Medicines

Part packs of medicines MUST NOT be supplied to a patient from stock.

If there are concerns about giving a patient a full pack e.g., opiate-based analgesia, a prescription must be issued. If prompt pain control is required when there is no pharmacy open analgesia may be administered as a stat dose at the treatment centre or during the home visit. The patient must source their ongoing analgesia when a pharmacy next opens.

Diazepam

IUC recognises that there will be rare occasions when diazepam must be supplied to a patient. To respect individual patient management plans the patient’s own GP may have in place, and to reduce the risk of dependency, IUC clinicians will supply a maximum of 14 x 2mg tablets of diazepam on one occasion only.

Oxygen

Oxygen is supplied by BOC Medical. HX cylinders hold 2,300 litres of oxygen and CD cylinders hold 460 litres.

HX Cylinders should be re-ordered when the dial indicates a quarter full to ensure that a replacement is in place when needed.

CD Cylinders will be returned to base as soon as the dial shows empty (each vehicle carries 2 cylinders, and the empty cylinder will be replaced from stock).

Safe Storage of Oxygen

Oxygen cylinders are stored in a locked storage room. The room has hazard warnings on the door. The cylinders are stored in trolleys whilst in use and in an appropriate static and fixed unit when not in use.

Supply

To supply a patient at home with Oxygen, please refer to the clinical toolkit.

Re-ordering Arrangements

Cylinders can be ordered by contacting BOC on 0800 111 333 and ordered using the account name of Broadmead Medical Centre, Homeless Health Service, or Charlotte Keel Medical Practice. In IUC, cylinders can be ordered by contacting the Shift Manager who will highlight on the shift report and will liaise with the Facilities Manager to replace stock.

Delivery can take 24-48 hours.

Safety

All locations where oxygen is stored must have gas cylinder signs displayed. Cylinders must be in a safe and secure environment.

Oxygen cylinders must be included in COSHH and fire risk assessments.

All spare and in-use cylinders should be adequately restrained on a trolley or suitable racking and should not be left free standing. If necessary additional trolleys/racking can be purchased from BOC.

Where more than one cylinder is available, they should be clearly identified with appropriate labels: FULL, IN-USE or EMPTY. Staff should ensure cylinders are used in strict rotation, so that cylinders on trolleys and with the earliest filling date are used first.

All medical gas cylinders must be kept clean, dry, and stored away from any sources of heat or ignition. Cylinders should be handled with care, never knocked violently, or allowed to fall over. Never roll cylinders along the ground. Additional cylinders or empty cylinders should be restrained to a wall by a safety chain or on an oxygen trolley/racking when not in use.

When using medical gas cylinders, it is important that no part of the cylinder valve or equipment is either lubricated or contaminated with oil or grease. Special care is also needed with the use of oil or petroleum-based hand creams as these could provide sufficient contamination to the medical cylinder valve surface when handling the cylinder to cause an ignition when the valve is turned on.

The application of paraffin-based skin products to patients e.g., diprobase ointment, emulsifying ointment, white soft paraffin causes an additional fire hazard when administering oxygen to them.

On no account must staff transport oxygen in their own motor vehicles.

Storage

Broadmead Medical Centre

Cylinders are stored in room 1 downstairs and the store room upstairs. Each room has a fire door for safety. Cylinders should be transported to the Boots basement using the transportation trolleys or a Boots cage. Empty cylinders should be taken to the basement for collection as soon as they are empty.

Homeless Health Service

An HX oxygen cylinder in kept in the nurses’ clinic room and the grab bag, kept in the same room, includes a CD cylinder. Empty cylinders are kept in the administration office until they are collected.

Charlotte Keel Medical Practice

HX cylinder of oxygen is kept in treatment room one on a portable oxygen trolley, two spare HX cylinders are kept in the treatment room sluice. A CD oxygen cylinder is kept in a green bag for emergencies next to the resuscitation kit in the central area of the treatment room.  A spare CD cylinder is kept next to the resuscitation bag.

Integrated Urgent Care

Treatment Centre Storage Locations

Marksbury Road

• CD and HX cylinders are stored in the understairs cupboard (larger stock as this is the main exchange base). The HX cylinder in use is stored on a trolley, and empty cylinders are within the racking.
• Car stock 2 X CD held in separate oxygen bags.

Cossham 

• CD and HX cylinders stored in Hospital Gas storage room, HX delivered to our operation area at the beginning of our shifts on a trolley. 2 X spare CD always kept in storage room.
• Car stock 2 X CD held in separate oxygen bags.

168 Medical Centre

• HX cylinder always stored on trolley in consulting room
• 1 X CD stored in cupboard as spare.
• Car stock 2 X CD held in separate oxygen bags.

Clevedon

• HX cylinder always stored on trolley in consulting room
• 1 X CD stored in Resus bag in our cupboard

Greenway

• HX cylinder always stored on trolley in consulting room
• 1 X CD stored in Resus bag in our cupboard.

Oxygen Administration

Oxygen is a medical gas which is a licensed medicine and as such is subject to the Medicines Act and must be treated in the same way as any other medicine.

The National Patient Safety Agency (2009) reports the potential for serious harm if oxygen is not administered or handled properly. The main safety concerns relate to underuse and overuse of oxygen:

• Underuse of oxygen is extremely dangerous as it exposes critically ill patients to the risk of hypoxic organ damage.
• Overuse of oxygen can also be harmful, especially for patients with chronic obstructive pulmonary disease (COPD).

The concentration of oxygen required depends on the condition being treated. The administration of an inappropriate concentration of oxygen constitutes a drug error which must be reported in accordance with the Learning Event Management Policy.

Current prescribing guidelines on oxygen therapy can be accessed via the current edition of the British National Formulary. The administration of oxygen must be recorded in the case record.

Oxygen is only used as an emergency medicine and should only be administered by a clinical member of staff.

Face Masks

Simple oxygen face masks are supplied for single patient use. The oxygen mask is placed over the patient’s nose and mouth with the elastic strap over the ears and to the back of the head. Adjust the length of the strap to ensure the mask fits securely.

Monitoring

Pulse Oximeters should be available on each resuscitation trolley and every vehicle. The oxygen saturation levels of all patients receiving oxygen should be checked and documented in the case record.

Audit

Oxygen cylinders are checked daily by a nominated individual to ensure there is sufficient supply. These logs will be checked regularly to ensure that the process is being carried out routinely before the logs are filed.  Compliance audits are undertaken.

Oxygen cylinders will be included in the audit of resuscitation equipment.

In The Event of Fire

• Operate the fire drill
• Notify the fire services, warning them of the presence of medical gas cylinders
• Evacuate the immediate area
• Once the immediate actions have been taken – and provided it is safe to do so:
• Move the cylinders – close the cylinder valve to stop flow of product and move away from source of heat.

Unless staff are trained in the use of either fire extinguishers or fire hoses do not attempt to fight a fire in which cylinders are directly involved.

After The Fire

Cylinders which have been involved in a fire should be identified and segregated from all other cylinders. Under no circumstances should their contents be used. Immediately inform BOC Healthcare that the cylinders have been involved in a fire.

The cylinder(s) will be collected as quickly as possible and returned for examination.

Change Register

Date	Version	Author	Change Details
1st January 2014	1.0	CLN	New Policy
14th October 2016	2.0	CLN	Update CD schedules, inclusion of Pharmacists in BrisDoc skill mix, removal of reference to Senior Clinical Operations Lead, update role responsibilities, inclusion of practice prescription processes. Ensure CD standards comply with NG46. – routine policy review
6th October 2016	2.1	CLN	General edits including rationalising section on managing cases of measles out of hours. Following review by Medical Director and ensure applicability to HHS.
1st March 2019	2.2	FB	Reviewed prior to IUC Service commencement
26th October 2020	2.3	CLN, FB	Update language and roles to IUC, change PGD development to IUC responsibility, remove prescription pad location at Charlton Form Hospice, removal of processes related to paracetamol and ibuprofen suspensions. Routine review.
1st August 2022	2.4	RH, FB, TA, RC	Full policy review and update. Routine review.
17th October 2022	2.5	Sabrina Flew	Minor correction to Clevedon equipment.
16th December 2022	2.6	NR, RS	Updates to CD transportation, Medication issued from stock, destruction of schedule 2 drugs
19th January 2023	2.7	RS, SF, NB	Updates to CD’s in terms of destroying, managing and collecting CDs to ensure within NHS England procedure, Oramorph monitoring
25th January 2023	2.8	RS	Update to CD destruction and CD process following compliance visits from Home Office
13th February 2023	2.9	RS	Theft or loss reporting, code changes on all locks and CD licence management updates
3rd April 2023	3.0	RL	SOP for applying for CD Licence
16th May 2023	3.1	RL	Update to CD responsibilities
29th November 2023	3.2	RS	Update on transportation of CDs following a LE
3rd January 2023	3.4	NB	Update of medication pack down (diazepam)
3rd January 2023	3.4	NB	Dispensing medication from stock update
3rd January 2023	3.4	NB	Update on facilities responsibilities
11th March 2024	3.4	NB	Update on t28 denaturing for schedule 3 and 4
11th March 2024	3.4	NB	Update SOP Operational Management of CDs and ensuring consistency, Update on spoon and oral syringe sizes, Update on daily reconciliation of CDs Update on accidental breakages of vial stock of schedule 2 CDs, Update disposal of waste/schedule 2,3,4, Update SOP ordering and receiving CDs, Update on the process for daily check of CDs in the cars
XX XX XXX	3.5	Meds Management Group	Update on CD registers in cars, closing CD register, clarity recording CD register. Full internal review, ICB review, Update of Temperature section

SOPs

SOP – Daily CD Stock Checks in IUC Treatment Centre and Cars

SOP – Using EPS to generate an Electronic Prescription – IUC

SOP – Writing a Prescription – IUC

SOP – Prescribing and Dispensing Medication from IUC Treatment Centre Stock

SOP – Remotely Prescribing & Dispensing Medication in IUC Treatment Centre

SOP – Transporting and Dispensing Medication from the IUC Car

SOP – Breakages of Controlled Drugs Vials

SOP – Facilities Monthly Stock Check of Controlled Drugs

SOP – Ordering, Collecting and Dispersing IUC Schedule 2 Controlled Drugs

SOP – Ordering and storing IUC Schedule 3 to 5 Controlled Drugs

SOP – Destroying and Recording the Controlled Drugs in IUC

SOP – Repeat Prescribing in Practice Services

This can seem a daunting task, but there a few basic principles, which will ensure safe prescribing. Repeat prescriptions will come electronically through workflow.

Straight signing vs reauthorisation

All drugs on repeat prescription will have several authorisations, usually set at 3-6. This means that if a patient is receiving a medication every two months, the prescribing clerk can issue the prescription for signing six times, which will last a year. Once the authorisations have finished, the prescribing clerk will need a reauthorisation from the prescriber before any further prescriptions are issued.

Do I need to check every prescription for straight signing?

It is important to scan the prescription for obvious issues (e.g. – benzodiazepines on repeat prescription or incorrect drug dosages). Workflow of repeat prescriptions make this task much easier.

Shared Care Protocol and Traffic Light Status (TLS)

The traffic light status within the BNSSG formulary, tells us the circumstances in which we are allowed to prescribe a drug.

https://remedy.bnssgccg.nhs.uk/

• Red drugs can ONLY be initiated and maintained by specialists and there is no involvement with either GP prescribing or monitoring.
• Amber drugs are initiated by specialists who will ensure dose stability before handing over to the GP for ongoing maintenance of a drug. This handover must be accompanied by a shared care protocol.
• Green drugs can be initiated and maintained in general practice. Care should be taken to use formulary items over non-formulary items.
• Blue drugs can be used in primary or secondary care but are considered second-line drugs.

Although we should not be prescribing hospital only red drugs in primary care, it is important to document them in the medication screen to highlight potential drug interactions. This can be done as follows:

• Add the drug as a repeat medication with a re-authorisation of only 1/1
• In the dosage instructions, free text “Red drug, hospital only to dispense”
• Issue a quantity of only 0
• Proceed as if to issue the medication but use the change all drop down box to convert to hospital print.

Reauthorisation of amber drugs

Many of the amber drugs need ongoing monitoring as part of the shared care protocol. Examples would be methotrexate, sulfasalazine, and azathioprine. Although warfarin is green in the traffic light status, this is also treated as an amber drug because of its requirement for frequent monitoring. Any medication requiring ongoing monitoring will have an active problem code of “Near Patient Testing – enhanced services admin” and will have the frequency and type of monitoring free texted next to it.

All these drugs will have a reauthorisation of only 1/1. This means that the prescribing clerk is unable to issue these prescriptions and they are passed to a prescriber each time.

How do I re-authorise an amber drug?

It is essential to check the shared care protocol for each drug within the BNSSG formulary. This will inform you of the frequency of monitoring and actions to take if there are any abnormalities.

What if there has been no recent monitoring as per guideline?

Then you must issue only TWO WEEKS of the medication and communicate with the patient/pharmacy (see below) Please check ICE when looking for results.

Checks for reauthorisation of medication for long term conditions

Most repeat prescriptions will be for long term conditions such as Hypertension, Depression and Asthma.  The important checks for these groups of patients are as follows:

• When was their last chronic disease review? Is it due? Look in diary but also consider any backlogs associated with the Covid-19 pandemic
• Have they had relevant blood tests in the last year?

(More frequent if CKD 3 or more)

• Are they on the correct doses of medication? (e.g.: secondary prevention statin doses, reduced doses DOACS with reduced GFR)
• Do they still need it? (e.g.: ticagrelor normally for a year, nutriprem for 6 months adjusted age)
• Do they need additional investigations? (e.g.: long term steroids)
• Is there a potential for dependence? (Opiates, benzodiazepines)
• Is the patient on the Palliative Care Register? If not, should they be Can drugs be rationalised? See validated tools such as STOPP/START criteria and the BNSSG Medication Review Tool for the elderly
• Are medications synchronised?
• How is compliance with medication? It is important to check for both under and over-use.
• Is the choice of medication in line with local and national policies?
• Has the patient recently been discharged from hospital/OOH? If so, look through discharge summary for any medication changes

Prescription Refusal

Prescription refusal (as opposed to issuing smaller quantities and asking for review) should only happen if:

• You feel the medication is inappropriate
• You feel there may be safety issues if you prescribe
• (e.g. – multiple diuretics with no renal function for over 18 months, over-use of prescription drugs of dependence)
• Prescription refusal if no other medication being issued

If you are refusing all the medication requested, then text the patient via SMS text template (if they have not opted out). If they have opted out, you must generate a “prescription refusal” letter within EMIS. This can be found as an EMIS template within letters. It is important to write the name of the pharmacy above the patient’s name. This letter can be sent electronically to the patient’s pharmacy, either by the practice pharmacist or the prescribing clerks.

• Prescription refusal if other medications being issued

It may be that you are happy for some medications to go through but not others. The best way to do this is via SMS text which leaves a consultation note in EMIS. If the patient has opted out of SMS text, you need to use the following method:

First, it is important to write a consultation note about why you are not prescribing a certain medication because there will need to be an audit trail of this. This consultation note can be copied and pasted as a message to the patient and pharmacy. An example of this could be:

“Sept 2016 – iron not issued, need repeat blood test to see if still needed”

If you are in EPS workflow, you need to “reject” the individual medication not being issued:

You then need to issue the medications which are allowed (either on paper or electronically) and copy and paste this message for the patient and pharmacy about the rejected medication. This is done at the point of issue when you can click on to the yellow message boxes as follows:

It is important to realise that there is no permanent record of a patient/pharmacy message when written like this, so the consultation note is crucial for the reception team.

Prescription issued but review required

This will be a more common scenario when no harm will come to a patient if a prescription is issued, but they are due a review or blood tests.

The easiest way of communicating that a review is due, is to text a patient as this message is stored in the consultation screen. The quantity may also need to be reduced (if it is a patient safety issue) as well as re-authorising only one issue. Please do not reduce quantities of medication for long term medication without first communicating with the nurse team.

If you are unable to text the patient, it is important to highlight the medication and edit it (which can be done in the medication and workflow screen). The quantity should be reduced to whatever is clinically appropriate, but be mindful of the availability of the next routine GP appointment (can be up to 3 weeks)

As well as reducing the quantity, and reauthorizing only one issue, you need to put a message in the pharmacy and patient information as follows:

You do not need to add the message to a consultation note because it will be visible in the medication screen, but it is important to delete the message once it has been actioned.

Repeat Dispensing

Repeat Medications for Nurse Chronic Disease Reviews

The nurse team will have a system for recall, and it is important to adopt the following principles for medications requiring nurse review:

1. No reduction of medications
2. Text patients to say review/bloods due and re-authorise 1/1
3. If still not seen, re-authorise 1/1 and task nurse team
4. If still not seen, decline meds only if considered a patient safety issue

SABA inhaler over-use

• Task practice nurse team to phone patient for review

Combined contraceptive pill review overdue

• Check if high or low risk patient (BP, BMI, age, risk factors)
• Offer 1-3 months treatment depending on risk status and task PN to invite for review
• Decline further treatment if not attended for review

 

Repeat Dispensing

If a patient is stable on medication, a batch of prescriptions can be printed out for the pharmacy to dispense at regular intervals. Examples would be a patient on a stable dose of thyroxine or those stable hypertensive patients. You can default to repeat dispensing in the Rx types:

Blister packs

Weekly blister packs can be made up by pharmacies for those patients who are fulfilling the criteria for eligibility. These include patients with sensory impairments, dexterity issues or cognitive impairment. If you think a patient may be eligible, it is important to liaise with their nominated pharmacy so they can complete an assessment form.

You do not need to issue weekly prescriptions for this to happen.

You can simply add a message that a drug is to be put in a blister pack using the patient information box.

Weekly prescribing

The only indications to be prescribing weekly are as follows:

• Dangers of intentional overdose
• Overuse of medication such as opiates
• Drug dependency

You do not need to be prescribing weekly for patients to receive a blister pack

Postdating prescriptions

You may wish to issue a delayed prescription for several reasons:

• Antibiotics in reserve
• Weekly prescribing of controlled drugs

 

You can postdate the prescription in this way:

 

SOP – Applying for a Controlled Drugs Licence

Controlled Drug Licences are obtained through the Home Office and are site-specific so any new/relocated sites will need a new licence. This responsibility sits with the Facilities team.

You can obtain a new licence through Controlled drugs licence application form (eforms.homeoffice.gov.uk). Governance Team have records of previous applications which can be used as an example.

The process of applying goes as follows:

• Submit application form
• Await to be assigned a Compliance Officer
• Compliance Officer will reach out and propose a date for a Compliance Visit. They will also ask for some further information, of which can be found below.
• Carry out the visit
• Action any improvements to process suggested in the visit.
• Await invoice for the CD Licence
• Pay invoice
• Receive CD Licence

This process can take between 2-3 months, including arranging and conducting the Compliance Visit. It’s important that Controlled Drugs are not stored at a site until the CD Licence has been obtained.

Given that BrisDoc transport CDs between bases, we require a ‘supply’ and ‘possess’ licence – it’s important to check that this is correct once the Licence has been received.

Authorised witnesses

When applying a CD Licence, you will need to appoint Authorised Witnesses for the destruction of drugs, enabling the destruction of CDs in the licenced persons’ presence. These colleagues need to not handle medication for clinical use day-to-day, and have a DBS by security watchdog. If colleagues experience a change in address, name etc, they will need to apply for a new licence through this link. Please note that this can take up to 3 months to process.

Compliance Visit

The visit:

The Compliance Officer will conduct a discussion around BrisDoc’s process of storing, auditing, transportation, prescription and destruction of CDs. Examples of questions they may ask are:

• Who is usually present at the base where CDs are stored? e.g. hosts etc
• How often are the key codes changed?
• How often are CD Register records kept for?

All relevant information is in the Medicines Management Policy but it is worth meeting with relevant staff ahead of the visit to ensure that everybody is clear on process.

Renewing a Licence

Licences will need to be renewed yearly – it’s worth beginning this application 2-3 months ahead of the previous licence’s expiry date. This allows time for any necessary processing and Compliance Visits. You can renew CD Licences through this link – Controlled drugs licence application form (eforms.homeoffice.gov.uk).

Frequency of Compliance Visits will depend on decisions made by the home office. This could be only three-yearly or as often as yearly. It’s important to look out for emails from the Home Office regarding CDs, and to forward these to the Director of Governance and other relevant colleagues.

Changing a Licence

You can make any changes to existing Licences, including:

• Change in authorised witness
• Requesting additional CD schedules
• Requesting a change of activity
• Change of name
• Change of registration details.

This would also be via this link Controlled drugs licence application form (eforms.homeoffice.gov.uk).

SOP – Facilities Team Medication Processes

Bases

Monday – Medication audit – 5 bases.

A medication audit is carried out every Monday to check usage & expiry dates of non-CD medication. Photos of the controlled drug audit books are taken and used to justify any usage. If there are any discrepancies in the CD audit books, a learning event is submitted.  Medication issued from stock forms and in-car medication forms are collected and brought back to Osprey and used to justify medication usage.

Any medication due to expire is removed from the bases, logged on the audit and taken back to Osprey for disposal.

Once the medication audit has been completed, it is uploaded to the AHS stock data.

Medication issued from stock forms and car medication forms are scanned on the s:drive and saved for auditing purposes

Tuesday – Medication justifications & medication ordering.

The uploaded medication audit is cross checked against the medication issued from stock forms, in-car medication forms and the CD audit books to ensure there are no discrepancies. Any discrepancies with CD medications are reported immediately and a learning event submitted.

The justification report is downloaded from Adastra to cross check any medication that cannot be justified by the medication forms.

After the medication has been justified, a medication order is placed in relation to usage.

Thursday – Medication distribution

Medication ordered on a Tuesday, arrives on a Thursday. Medication is cross checked with delivery notes and added to the AHS stock data.  A clinician will assist the facilities team by cross checking the CD medication with the delivery note, sign the delivery note and add the CD medications to the audit book.  The CD medication is then put into the medication cabinet.

Do not split pack’ and ‘sealed’ stickers are added to the boxes of medication, expiry dates are checked and arranged so shortest dates are supplied first, all medications are added to the medication cabinet.

Once medication has been packed away, the distribution is carried out. All medications are allocated to the correct base delivery box, ready for a Friday delivery to the bases.

Friday – Medication delivery to bases

The medication delivery boxes are picked up from Osprey. These boxes are transported in the boot of a Brisdoc car.  Once medication has been delivered to the bases, the medication is added to the medication cabinets.

At Osprey, a medication audit is carried out weekly and cross checked against the AHS stock data to ensure quantities are correct.

Weekly processes

Every week, 1 car is audited (every visiting car gets a full car audit once a month). A full car audit form is completed, replenishing any medication, used, open or out of date.

Non-CD medication

• A medication audit is carried out weekly, any medication expiring within the next 30 days is highlighted in red on the audit spreadsheet.
• The facilities team will order the medication that needs to be replaced.
• If medication goes OOD before the facilities team remove it, it is stored in OOD box in the medication cupboard at each base for facilities to collect.
• Once the medication has been delivered, it’s distributed accordingly.  Any OOD medication is then returned to Osprey for destruction, this is logged on the medication stock database.
• Destruction certificates are kept on the SDrive.

 

 

Monthly Check

CD medication

The above processed is followed, but with CD’s the stock level and earliest expiry date is logged on the Monthly CD Count spreadsheet.  This is checked by the facilities team and a member of the medicines management team once a month.  All expired CDs are denatured and kept in the OOD box in the medication cabinets at each base, once 24 hours have passed, the denatured CDs are put in the clinical waste bins.  All expired CDs must be documented in the CD audit books and the medication stock database.

 

Medication stock levels and the cost / usage of expired medication are checked monthly and discussed at the Medicines Management Group to ensure stock levels are adequate whilst ensuring OOD medication remains low.  Regular medication reviews are carried out by the facilities team and medicines management lead and stock levels are adjusted accordingly.

MONTHLY CONTROLLED DRUGS COUNT

Date: 

	COSSHAM	F6	MARKS BURY	K1	168 MEDICAL	W8	GREENWAY	CLEVEDON	K2	OSPREY
Number of Oxycodone (Sch 2)		NOT IN THE CARS		NOT IN THE CARS		NOT IN THE CARS	NOT IN THIS BASE	NOT IN THIS BASE	NOT IN THE CARS	NOT IN THIS BASE
Earliest expiry date:
How many expire on this date:
Number of Morphine Sulphate Inj (Sch 2)
Earliest expiry date:
How many expire on this date:
Number of Codeine
Earliest expiry date:
How many expire on this date:
Number of Diazepam
Earliest expiry date:
How many expire on this date:
	COSSHAM	F6	MARKS BURY	K1	168 MEDICAL	W8	GREENWAY	CLEVEDON	K2	OSPREY
Number of Morphine (Oral)
Earliest expiry date:
How many expire on this date:
Number of Midazolam (Inj)
Earliest expiry date:
How many expire on this date:
Midaz Buccal 2.5mg
Earliest expiry date:
How many expire on this date:
Midaz Buccal 5mg
Earliest expiry date:
How many expire on this date:
Midaz Buccal 10mg
Earliest expiry date:
How many expire on this date:

 

Quarterly processes

A full audit is carried out and expiry dates checked. A copy of this audit is set to the accounts department.

SOP – Completing CD drug Registers in Bases & Osprey

All additions to the CD Registers are to be completed in black ink

CD drug audit check

When carrying out the daily medication checks, the following columns must be completed:

 

• Column number 4 – Current Balance in Stock – This is the number of each drug the clinician counts in stock.  Please record count as follows:

o    Diazepam, Codeine and Lorazepam Tablets –  complete box = 1 (all boxes should be full and complete, we should not split packets)

o    Midazolam Ampoules – each ampule = 1

o    Buccalom/Midazolam oral Tubes – each tube = 1

o    Morphine Sulphate Solution – count in mls

• Column number 5 – Date Supplied or Disposed – Enter the date checked
• Column number 6 – Time– Enter the time of the drug check
• Column number 9 – Given / Disposed by (Signature)– The clinician conducting the check signature
• Column number 10 – Witnessed by (Signature) – The person witnessing the drug check signs here, i.e. the host/driver
• Column number 11 – Balance in Stock – This is the number the clinician has counted in stock as per guidelines set above

Issuing medication from Osprey Stock

When issuing medication to a base from Osprey stock, the following columns in the Osprey register must be completed:

 

• Column 3 Name and address from whom obtained (i.e. supplier) / CASE NUMBER – When issuing medication to a base, please state the base the stock is going.
• Column number 4 – Current Balance in Stock – This is the number of each drug the clinician counts in stock before issuing medication from stock.  Please record count as follows:

o    Diazepam, Codeine and Lorazepam Tablets – complete box = 1 (all boxes should be full and complete, we should not split packets)

o    Midazolam Ampoules – each ampule = 1

o    Buccalom/Midazolam oral Tubes – each tube = 1

o    Morphine Sulphate Solution – count in mls

• Column 5-  Date Supplied (to service user) or disposed –date the medication has been issued
• Column 6 Time – the medication has been issued
• Column 7 Quantity Supplied (to service user) – record the amount given in the units described above
• Column 9 – Given / Disposed by (Signature) – This must be the Clinician’s signature
• Column 10 – Witnessed by (Signature) – The Host or Driver witness signature
• Column 11- Balance Left in Stock – – This is the number the clinician has counted left in stock as per guidelines set above

 

Adding stock to base

When adding stock to the base, the following columns must be completed:

• Column 1 Quantity Obtained (from supplier) – Enter the quantity of medication added to the base stock.
• Column 2 Date Supply Obtained – Enter the date you restocked the base stock.
• Column 3 Name and address from whom obtained (i.e. supplier) – When restocking the base, the supplier will always be Osprey Court
• Column number 4 – Current Balance in Stock – This is the number of each drug the clinician counts in stock including the stock that has just been added.  Please record count as follows:

o    Diazepam, Codeine and Lorazepam Tablets –  complete box = 1 (all boxes should be full and complete, we should not split packets)

o    Midazolam Ampoules – each ampule = 1

o    Buccalom/Midazolam oral Tubes – each tube = 1

o    Morphine Sulphate Solution – count in mls

• Column number 6 – Time – Enter the time
• Column number 9 – Given / Disposed by (Signature) – The clinician conducting the restock signature
• Column number 10 – Witnessed by (Signature) – The person witnessing signs here
• Column number 11 – Balance in Stock – This is the number the clinician has counted in stock as per guidelines set above

All additions to the CD Registers are to be completed in black ink

 

Appendix – Temperate Excursion Checklist

Enquirer and background information
Name and job role
Email address
Telephone number
Date and time of incident
Date and time incident form completed
Medication information – Include manufacturer, brand name and strength and form
Manufacturer, Drug name, strength and presentation	Batch Number		Expiry date and time	Any other information
Please append additional pages or lines to this table if there are more medicines
Temperature excursion information
Where did the excursion occur
Temperature excursion START time – what was the date and time of last recorded storage within the designated temperature range?
Temperature excursion END time – when did vaccines return to correct storage temperature conditions?
TOTAL DURATION of temperature excursion (include hours/minutes) [If multiple excursions include details of duration for each one]
What were the minimum and maximum temperatures during this excursion?
Date and time temperature excursion was discovered by staff.
Rectifying steps taken
Have steps been taken to prevent the problem recurring?
Have you quarantined the medication?
Incident reported?

 

 

Appendix – Temperature Record Log