NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST. Medicines Policy: Code of Practice GLOSSARY AND ABBREVIATIONS

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1 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Medicines Policy: Code of Practice GLOSSARY AND ABBREVIATIONS Reference CL/MM/002 Approving Body Directors Group Date Approved 28 October 2014 Implementation Date 28 October 2014 Version 4 Summary of Changes from Minor revisions Previous Version Supersedes CL/MM/002 version 3, approved October 2011 Consultation Undertaken Medicines Management Committee Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications Target Audience 1 st August st August st August 2014 N/A All staff who use the Medicines Policy, for supply, storage, prescribing, administration and destruction of medicines Review Date October 2017 Lead Executive Medical Director Author/Lead Manager Professor Malcolm Partridge Head of Pharmacy and Clinical Director for medicines management Further Guidance/Information Sonia Gilmore, pharmacist Medicines Management Committee CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

2 secretary Extension CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

3 CONTENTS Paragraph Title Page 1. Introduction 4 2. Executive Summary 4 3. Policy Statement 4 4. Definitions (including Glossary as needed) 4 5. Roles and Responsibilities 4 6. Policy and/or Procedural Requirements 5 7. Training, Implementation and Resources Impact Assessments Monitoring Matrix Relevant Legislation, National Guidance 15 and Associated NUH Documents Appendix 1 Equality Impact Assessment 16 Appendix 2 Environmental Impact Assessment 19 Appendix 3 Here For You Assessment 21 Appendix 4 Certification Of Employee Awareness 23 CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

4 1.0 Introduction 1.1 This policy provides a summary of all the terms and abbreviations used throughout the NUH Medicines Policy: Code of practice 2.0 Executive Summary 2.1 NUH staff prescribing on approved NUH prescription stationery must ensure they only use the abbreviations included within this policy. This is necessary to for other staff to avoid ambiguity and misinterpretation of prescriptions, which may lead to errors. 3.0 Policy Statement 3.1 All users of the NUH Medicines Policy: Code of practice should ensure that they also read this policy in conjunction with the other policy chapters. 4.0 Definitions 4.1 See section 6 of this policy 5.0 Roles and Responsibilities 5.1 Committees Medicines Management Committee- are responsible for producing and maintaining this policy 5.2 Individual Officers Individual practitioners are responsible for ensuring they are familiar with the contents of this policy and adhere to it when prescribing CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

5 6.0 Policy and/or Procedural Requirements Terminology used within the medicines policy: code of practice; currently policy numbers CL/MM/001 to CL/MM/ Terminology relating to staff Appointed practitioner in charge: A senior registered practitioner appointed in overall charge of a ward or department that in certain agreed circumstances may not be a nurse e.g. senior medical physicist. Assigned practitioner in charge: The senior registered practitioner on duty for the ward or department who has been rostered as the practitioner in charge for that shift. Clinical Director for Medicines Management: The officer who is responsible at the Trust wide organisation level for all policies and procedures relevant to medicines management. At the operational level they are responsible for assuring the Trust that systems are in place for the delivery of such policies and procedures. Clinical Lead / Head Nurse / Matron: The senior nurse who provides clinical, professional and managerial leadership direction to the nursing and directorate team. Clinical Observer: A person who may hold medical or nursing qualifications but who does not have a substantive contract with NUH Trust. These persons are not permitted to prescribe or administer medicines. Clinical/Ward Pharmacist: The individual pharmacist who is assigned to oversee the medicines management needs of the patients and staff on a ward or department. Designated Practitioner: A registered practitioner, identified by the appointed practitioner in charge as competent to perform a specific function and is appropriate to do so. Dietitian: A practitioner registered with the Health and Care Professions Council with expertise in the science of nutrition. CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

6 Doctor: A medical practitioner registered with the General Medical Council or a dentist registered with the General Dental Council. For the purpose of this Medicines policy, this term includes Foundation year 1 doctors but excludes medical or dental students. Head of Pharmacy: The pharmacist who has overall responsibility for the Pharmacy Department and its services. Medical Student: A student studying medicine at Nottingham University Medical School or a student from another medical school who is on a placement approved by the Dean of Nottingham University Medical School or one of his / her deputies. Non-registered nurse (also known as Health Care Assistant, Auxiliary Nurse, clinical support worker, care assistant and nursing assistant). A member of nursing staff who is not registered with the Nursing and Midwifery Council. The non-registered nurse provides direct patient care under the supervision of a Registered Nurse. The Registered Nurse delegates appropriate duties to the non-registered nurse. Training is usually locally agreed and provided, and may include training and competency assessment in more advanced clinical roles (for example cannulation and venepuncture). Nurse/midwife: A nurse or midwife registered with the Nursing and Midwifery Council (NMC). This Code will use the term nurse to include nurses and midwives registered with the NMC. Nurse in charge: The nurse in charge of a clinical area for a shift. Operating Department Practitioner: An Operating Department Practitioner (ODP) registered with the Health and Care Professions Council. Pharmacist: A professional who is registered as a pharmacist with the General Pharmaceutical Council. Pharmacy Assistant/Assistant Technical Officer (ATO): An individual who has achieved or is working towards NVQ 2 in pharmacy. Pharmacy technician: An individual who has achieved a BTEC/NVQ CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

7 3 qualification in pharmacy, and who is registered as a pharmacy technician with the General Pharmaceutical Council. Practitioner: a qualified healthcare professional registered with the appropriate statutory body. Practitioner in Training: A person who is undergoing training who is not yet registered with their professional body. Senior Pharmacist: The pharmacist in charge of a section or a department within the pharmacy, or a pharmacist who provides a specialist service, either clinical or non-clinical. Student Nurse/ midwife: A student studying for a recognised nursing or midwifery qualification at a University or College. Ward Manager: The individual with overall responsibility for the management of a particular ward, unit or department. Ward Pharmacy Technician: A qualified, competent pharmacy technician who regularly visits a ward or department to support the clinical pharmacist and medicines management processes. 6.2 Other terminology used Medicine: Medicines, whether for internal or external use, will be regarded for the purpose of this Medicines Policy as comprising the following categories: Medicinal preparations, including controlled drugs, prepared and intended for administration to patients, as defined under section 130 of the Medicines Act This includes topical lotions, applications, intravenous infusions, medical gases, parenteral and enteral nutrition and medicated dressings. Alternative or complementary medicinal products such as aromatherapy, herbal, homeopathic remedies. Other pharmaceutical preparations not directly used to treat patients, including disinfectants, reagents. Other biological agents used to treat patients, including larvae and CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

8 leeches. Radioactive agents and contrast media used in diagnosis and treatment. Controlled Drug (CD): A medicine that is controlled under the provisions of the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001, and the Health Act 2006, with legal requirements for supply, storage, administration, destruction and record keeping. Any infringement of this act may result in prosecution under criminal law. FP10NC: A prescription form that may be dispensed either in a hospital or community pharmacy. Hospital only medicine: A medicine that is only available from a hospital pharmacy dispensary and must be prescribed by, or under the supervision of, a hospital consultant only. Such medicines are red on the Nottingham Traffic Lights Prescribing System. Independent Prescriber: A doctor or non-medical prescriber who has completed the necessary training to be responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing medicines. They must be registered as an independent prescriber with their professional body. Local Agreements: Local agreements are written procedures which: allow practise of variation to this Medicines Code of Practice. They must be approved by the Medicines Management Committee or groups reporting to MMC. may permit some staff (whom are ineligible to work under a Patient Group Direction PGD) to supply or administer medicines. These may be approved by the Non-Medical Prescribing and Supply Committee (NMPAS). May be in place to allow nurse supply of pre-labelled medication to patients. Non-Medical Prescriber: A practitioner who is not a medical practitioner who has successfully completed a recognised non-medical CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

9 prescribing course and is registered as a non-medical prescriber with their professional body. This includes both independent and supplementary prescribers. Parenteral: A route of administration that incorporates all injectable routes of administration. This includes intravenous injections and infusions, subcutaneous injections and infusions, intramuscular injections, intrathecal injections and infusions, epidural injections and infusions, intradermal injections, intraocular injections, intravesical injections, intraarticular injections, intraarterial injections. This list is not exhaustive. Patient Group Direction (PGD): A written instruction for the supply and / or administration of named medicines in an identified clinical situation by a practitioner from an approved list. A medical practitioner and a pharmacist must sign the instruction. Individuals who are authorised to use PGDs must be individually named and must be able to demonstrate the required levels of competence. Pharmacist professional check or screen: The process that a pharmacist completes to ensure the prescription for an individual patient is legal, appropriate and safe for that patient. Prescriber: Any practitioner legally authorised to prescribe under the Medicines Act 1968 or subsequent amendments. This includes supplementary prescribers, extended formulary nurse prescribers and independent prescribers. Shared Care Protocol: A written prescribing and monitoring protocol that is in place for a medicine or group of medicines, allowing the prescribing and monitoring of these medicines to be shared between primary and secondary care. Such medicines are amber 1 on the Nottingham Traffic Lights Prescribing System. Supplementary Prescriber: A non-medical prescriber who has completed the necessary training to implement an agreed patient specific Clinical Management Plan in a voluntary partnership with a medical practitioner. They must be registered as a supplementary prescriber with their professional body. 6.3 Approved abbreviations for prescribing CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

10 Routes IM IV Inh Neb NG NJ PEG PEJ PO PR PV SC SL Top Intramuscular Intravenous Inhalation Nebulisation Naso-gastric Tube Naso-jejunal Tube Percutaneous Endoscopic Gastrostomy Percutaneous Endoscopic Jejunostomy By Mouth Per Rectum Per Vagina Subcutaneous Sublingual Topical Intraperitoneal and intrapleural should be written in full and not abbreviated. Times / frequency of administration BD Mane MDU Nocte OD OM ON PRN Protocol QDS TDS Units kg g mg ml L mmol Twice daily Morning As directed (outpatient prescriptions only) At bedtime/ night Once a day Each morning Each night As required As per protocol (protocol for use must be stated) Four times daily Three times daily kilogram gram milligram millilitre litre millimole CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

11 dose per kg mm min hr h dose per Kilogram millimetres minute hour hour There are no other approved abbreviations for prescribing units of measurement. In particular, micrograms, nanograms, units, mega units and international units must be written out in full. A small circle after a number must not be used to indicate hourly frequency Drug names for fluids only KCl Potassium Chloride NaCl Sodium Chloride 6.4 Approved abbreviations used throughout the medicines policy APC Area Prescribing Committee ATO Assistant Technical Officer BNF British National Formulary BTEC Business and Technology Education Council CCG Clinical Commissioning Group CD Controlled Drug Dr Doctor DTC Drug and Therapeutics Committee GSL General Sales List GP General Practitioner etto Discharge prescription (see TTO) prepared electronically on approved NUH electronic prescription system ID Identification LMWH Low molecular weight heparin MHRA Medicines and Healthcare products Regulatory Agency MMC Medicines Management Committee MSG Medicines Safety Group. NMC Nursing and Midwifery Council NMPAS Non-Medical Prescribing Administration and Supply CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

12 NVQ NUH ODP OTC P PCA PD PGD PIL POD POM PSD RGN RN RM rinn SOP TTO WIA Committee. National Vocational Qualification Nottingham University Hospitals NHS Trust Operating Department Practitioner Over the counter Pharmacy only medicine Patient controlled analgesia Peritoneal Dialysis Patient Group Direction Patient Information Leaflet Patient s Own Drugs Prescription Only Medicines Patient Specific Direction Registered General Nurse Registered Nurse Registered Midwife recommended International Non-proprietary Name Standard Operating Procedure Discharge prescription (To Take Out). Wound Infiltration Analgesia 7.0 Training and Implementation 7.1 Training Training will be undertaken by existing work programmes for junior doctors, nursing staff, and pharmacy staff. Relevant policy updates are made available to all staff by the Medicines Education Group. 7.2 Implementation As above, Resources CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

13 No additional resources are required. 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

14 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Prescribing audit Responsible individual/ group/ committee Individual Managers Process for monitoring e.g. audit Monitoring of Risk Register Frequency of monitoring Monthly rolling programme Responsible individual/ group/ committee for review of results MMC Responsible individual/ group/ committee for development of action plan Directorate Governance Forum Responsible individual/ group/ committee for monitoring of action plan Directorate Governance Forum / MMC CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

15 10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 Legislation and national guidance- see individual sections of the medicines policy for more information CL/MM/001- CL/MM/035 Also CL/CGP/016, CL/CGP/069 NUH Nursing and Midwifery abbreviations list CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

16 APPENDIX 1 Insert templates of relevant impact assessments (page break after each) Equality Impact Assessment (EQIA) Form (Please complete all sections) Q1. Date of Assessment: Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening Race and N/A N/A N/A Ethnicity Gender N/A N/A N/A Age N/A N/A N/A Religion N/A N/A N/A Disability N/A N/A N/A Sexuality N/A N/A N/A c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

17 Pregnancy and N/A N/A N/A Maternity Gender N/A N/A N/A Reassignment Marriage and N/A N/A N/A Civil Partnership Socio-Economic N/A N/A N/A Factors (i.e. living in a poorer neighbour hood / social deprivation) Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? N/A Q4. What data or information did you use in support of this EQIA? Nil Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups- None needed What By Whom By When Resources required CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

18 Q7. Review date October 2017 CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

19 Environmental Impact Assessment- APPENDIX 2 The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Waste and materials Soil/Land Water Air Environmental Risk/Impacts to consider Is the policy encouraging using more materials/supplies? Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (e.g. use of a furnaces; combustion of fuels, emission or particles to the Action Taken (where necessary) No NA No No NA No No NA No CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

20 Energy Nuisances atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? NA NA No No CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

21 Appendix 3 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit APPENDIX 3 The We Are Here For You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 3 (1 being not at all, 2 being affected and 3 being very affected) Value Score (1-3) 1. Polite and Respectful 1 Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen 1 We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind 1 All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) 1 Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. 5. On Stage (patients feel safe) 1 CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

22 We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) 1 We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative 1 We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely 1 We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate 1 We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable 1 Take responsibility for our own actions and results 11. Best Use of Time and Resources 1 Simplify processes and eliminate waste, while improving quality 12. Improve 1 Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL 12 CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October

23 APPENDIX 4 CERTIFICATION OF EMPLOYEE AWARENESS Document Title Medicines Policy: Code of Practice Glossary and abbreviations CL/MM/002 Version (number) 4 Version (date) 28 October 2014 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - general manager Non clinical directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. CL/MM/002 version 4 Medicines Policy: Code of practice Glossary and abbreviations October