Medicines Policy. Signature: Date:

Transcription

1 Medicines Policy Recommending Committee: Approving Committee: Medicines Management Committee Clinical Performance Council Signature: Designation: Date: Chairman Version Number: 02 Date: February 2008 Review Date: January 2011 Responsible Officer: Head of Pharmacy

2 CONTENTS Introduction 4 Aims of the Policy 4 Responsibilities 5 1 Prescribing Of Medicines General Principles Prescribing Controlled Drugs Prescribing Cytotoxic Chemotherapy Prescribing for Inpatients Prescribing for Discharge (TTOs) Prescribing for Outpatients Patient Group Directions (PGDs) Non-medical Prescribing Transcribing Prescribing by Staff for Themselves, Their Families and Orders for Personal Supplies 16 2 Supply of Medicines The Formulary Purchasing Quality of Purchased Medicines Supply of Controlled Drugs Supply of Cytotoxic Chemotherapy Supply of Medicines for Inpatients Non-stock Medication One Stop Dispensing Ward/Dept Medicines Stocks Returning Medicines Supply of Medicines for Discharge (TTOs) Delivery of Drugs Supply of Medicines for Outpatients Prescriptions Containers Emergency Cardiac Arrest Boxes Medicines Required Urgently and in Emergencies Sale of Over the Counter Medicines 27 3 Storage Of Medicines Responsibility of Ward Managers Storage Facilities Main Cupboards Bedside Drug Boxes Medicines Trolley Medicines Refrigerator Disinfectant Cupboard Reagents Cupboard 29 Page 2 of 46 Page

3 3.2.7 Sterile Fluids for Infusion/Irrigation Controlled Drugs Cupboard Ward and Department Closures Temporary Ward Closure Long Term Ward Closure Temporary Unit Closure Within a Speciality Stock Balances, Losses and Discrepancies Drugs Other than Controlled Drugs Controlled Drugs 31 4 Administration of Medicines General Principles Administration of Medicines Against a Prescription Non Written Prescriptions Emergency Situations Verbal Prescriptions By Telephone Patient Group Directions (PGDs) Homely Remedies Use of Patients Own Medicines Self Administration of Medicines Use of Unlicensed Medicines and Use of Medicines for Unlicensed Indications Controlled Drugs Errors in Administration Administration of Intravenous Medicines Flushing of Intravenous Cannulae Disposal of Sharps Administration of Cytotoxic Chemotherapy Take Home Medications (TTOs) Miscellaneous Drug Incidents Drug Defect Reporting Procedure Adverse Drug Reaction Reporting Suspected Theft of Medicines Liquid nitrogen Disposal of unneeded and expired medicines and waste Leeches and maggots Medicines-related policies, procedures, protocols and guidelines43 6. Implementation of the Medicines Policy Education and Training Audit of Compliance with the Medicines Policy 44 Appendices Appendix 1: Training Needs Analysis Medicines Management 45 Page 3 of 46

4 INTRODUCTION All Trusts are required to have a Medicines Policy to ensure the safe and secure handling of medicines. The Policy should be read by all individuals who are involved with medicines within the Trust. The scope of the Policy is very broad, including most aspects of medicines handling eg. prescribing, ordering, supply, transport, storage, administration. The Policy may be used during the induction of new staff and also as a general reference source. It should be used in conjunction with other relevant Trust policies, procedures and guidance eg. Medicines Formulary, Emergency Prescribing Guide, Noddy s Guide, Antibiotics Policy, clinical policies, procedures, protocols and guidance. The Policy will be subject to review every three years. Modifications to the Policy should be referred the Medicines Management Committee via Pharmacy and approved by the Clinical Performance Council. Key Documents underpinning this Policy are: 1. The Medicines Act 1968 and subsequent amendments 2. The Misuse of Drugs Act 1971 and subsequent amendments 3. The Safe and Secure Handling of Medicines A Team Approach (RPSGB 2005) 4. NMC Code of Professional Conduct (NMC 2004) 5. Standards for Medicines Management (NMC 2007) 6. Standards for Better Health, Safety Signpost C4d (HCSU 2005) 7. Medicines, ethics and practice a guide for pharmacists (RPSGB 2007) 8. British National Formulary (RPSGB & BMA Sept 2007) 9. BNF for Children (RPSGB, BMA, RCPCH 2007) 10. The Best Medicine: The Management of Medicines in Acute and Specialist Trusts (HCC 2007) Standards for Medicines Management, published by the NMC provides a detailed framework of standards and guidance for nurses and midwives. It is recommended that this is read in conjunction with this Policy. AIMS OF THE POLICY The aims of the Medicines Policy are to: Define the Trust-approved practices relating to the safe and secure handling of medicines for all staff involved in the handling and use of medicines. Minimise and control the risks to patients, the staff and the organisation associated with medicines Provide an auditable standard for the safe and secure handling of medicines RESPONSIBILITIES Medical Director Executive director responsible for the management of the Chairman of the Medicines Management Committee, the Head of Pharmacy and Clinical Directors. Chair of the Clinical Performance Council which ratifies this Policy. Page 4 of 46

5 Chairman of the Medicines Management Committee To support the Trust in managing medicines in accordance with current standards and recommendations through the effective functioning of the Medicines Management Committee, which approves this Policy. Director of Nursing & Midwifery Responsibility to ensure that nursing and midwifery staff are aware of and comply with the Medicines Policy. Through delegation to the Assistant Director of Nursing, contribute to the production and modification of this Policy. Head of Pharmacy To organise, monitor and report on systems for the safe and secure handling of medicines within the Trust. To produce and update this Policy in accordance with need. Clinical Directors Responsibility to ensure medical staff are aware of and comply with the Medicines Policy within their directorates. Assistant Directors of Operations Operational responsibility for Trust policy implementation within the Care Groups. Matrons Operational implementation of the Policy within clinical areas. Ward Managers To ensure that practice relating to the safe and secure handling of medicines on their wards and departments is compliant with this Policy. Clinical staff Awareness and compliance with this Policy. Includes all staff with involvement with medicines: Doctors, Nurses, Midwives, Operating Department Practitioners, Radiographers, Physiotherapists, Dentists, Pharmacists, Pharmacy Technicians, Pharmacy Assistants, Students and pre-registration staff of all the preceding disciplines Non-clinical staff Awareness and compliance with relevant sections of this Policy. Includes: Porters, Receptionists Within this document, the term nurse, when used alone, refers to both registered nurses AND registered midwives. Page 5 of 46

6 1 PRESCRIBING OF MEDICINES 1.1 General principles All medicines intended to be administered to a patient under the care of the Trust must be prescribed by an authorised prescriber on an official Trust prescription document, except in strictly defined circumstances eg. under the terms of a PGD, midwives Definition of prescribing - to authorise, by means of a prescription, the supply or administration of a medicine to a named patient Official Trust Prescription Documents these include inpatient prescription kardexes, outpatient prescriptions, discharge prescriptions (TTOs), anaesthetics record sheets, ICU & HDU Drug Prescription Chart. Changes to all prescription documents, including the design of new documents must be approved by the Trust Medicines Management Committee The clarity of a prescribing instruction is the legal and professional responsibility of the prescriber. The prescription must be legible and it must not be open to variability in interpretation. The Trust considers that failure to prescribe clearly is a matter of professional misconduct The name of the medicine must be written in indelible ink and printed clearly using approved names as appropriate. Proprietary names (ie. brand names) must not routinely be used. Exceptions to this rule are multi-ingredient preparations with no approved names or products whose proprietary names define a specific formulation (eg. slow release theophylline and morphine preparations) DO NOT USE ABBREVIATIONS FOR DRUG NAMES - eg. ISMN, GTN, KCl The dose must be expressed in S.I. units. Quantities less than 1 gram must be written as milligrams. Decimal points should be avoided, for example 500mg should be prescribed instead of 0.5g so as to avoid potential errors. If a decimal point is unavoidable eg. for digoxin doses, great care must be taken by both the prescriber and the nurse administering the drug. The terms microgram and nanogram must not be abbreviated but must be printed in full and used for quantities less than one milligram. When the dose of a is expressed in units eg. insulin and heparin, the term units must be written in full and not abbreviated Only the following abbreviations are acceptable QUANTITY milligram gram kilogram litre millilitre millimole APPROVED ABBREVIATION mg g kg L ml mmol Page 6 of 46

7 The dose required must not be expressed in terms of the number of tablets/capsules/spoonfuls. For example Atenolol 2 tablets is not acceptable. It should be written as Atenolol 100mg Drugs which are to be administered via the intravenous route must clearly state the doses and the diluent to be used including any amount. Details of the precise method of administration must also be stated. eg. clarithromycin 500mg diluted in 250ml of 0.9% sodium chloride and infused over 1 hour The route of administration must be clearly indicated Only the following abbreviations are acceptable ROUTE Intramuscular Inhalation Intravenous Nasogastric Nebulised Percutaneous Endoscopic Gastrostomy Oral Rectal Subcutaneous Sublingual Topical Vaginal APPROVED ABBREVIATION IM INH IV NG NEB PEG PO PR SC SL TOP PV ALL OTHER ROUTES MUST BE WRITTEN IN FULL The following abbreviations for dosage instructions are considered acceptable when writing discharge or outpatient prescriptions Abbreviation Meaning of Abbreviation ac bd e/c hs mane nocte od om on prn Pc qds Page 7 of 46 Before food Twice daily Enteric coated At bedtime In the morning At night Daily In the morning At night When required After food Four times daily

8 q8h Every 8 hours qqh Every four hours sos When necessary STAT One-off dose tds Three times a day tid Three times a day Child resistant containers (CRCs) are used routinely on discharge and out patient prescriptions. If a member of staff judges that CRCs would be difficult for the patient to open, then plain tops will be fitted provided the doctor writes NO CRC on the prescription Documentation in medical notes. Details of new medicines, discontinued medicines and changes to existing treatments must be documented in the patient s medical notes. In particular, the rationale must be documented eg. indication for treatment, discontinued due to side effects etc. The intended plan of treatment should be indicated eg. duration, review, monitoring etc Blister packs. If compliance is thought to be a problem the Pharmacy will, if appropriate, provide blister packs. The doctor must clearly annotate the prescription BLISTER PACKS. It should be borne in mind that not all drugs are suitable for blister packing (speak to your ward pharmacy staff or pharmacy medicines information for advice). For outpatients or patients being discharged, consideration must be given to the continuation of the blister packing in primary care. Because of the time taken to prepare dispense a prescription into blister packs, 48 hours notice is usually required. The likelihood of children coming into contact with the medicines should be considered Medicines Formulary. Prescribers may only initiate prescriptions for medicines which have been approved by the Trust Medicines Management Committee for use within the Trust. There are exceptions to this rule in restricted circumstances. The approved drugs are listed in the Medicines Formulary which has been widely circulated. Extra copies can be obtained from Pharmacy. Individual patient needs may be taken into account and if the drugs listed in the Medicines Formulary are not appropriate for a particular patient, Pharmacy can authorise a non-formulary supply. Prescribers will commonly need to continue non-formulary drugs which have been initiated by another prescriber eg. a GP. Prescribers who wish a new drug to be added to the Formulary, or for other amendments to be made, are invited to correspond with the Medicines Management Committee via the Head of Pharmacy or the Chairman of the Committee. Prescribers are to be made aware that audit systems are in place both within the hospital and in primary care to monitor Formulary compliance. This includes the recommendation of non-formulary drugs by referral to GPs by letter Electronic Prescribing. Electronic prescribing systems will become widespread in the coming 5 years. In recent years, legislation which was originally produced for paper-based prescribing systems have been updated and amended to permit electronic prescribing. In early 2008, the Trust implemented electronic prescribing within the Haematology speciality. Only Page 8 of 46

9 specifically authorised prescribers who have been trained in its use will be permitted to prescribe electronically. Prescribers must abide by all relevant Trust policies relating to the use of Trust IT systems, particularly security. Key requirements of handwritten prescriptions which are detailed above will be adapted into electronic form eg. electronic signatures. 1.2 Prescribing Controlled Drugs Please refer to the Trust Controlled Drugs Management Policy and related procedures for advice on prescribing controlled drugs Methadone must NOT be prescribed for discharge where an addict has a registered pick-up point. If it is not possible to make arrangements the minimum possible quantity should be provided and an absolute maximum of 2 days prescribed for addicts. 1.3 Prescribing Cytotoxic Chemotherapy (including methotrexate for non-cancer indications) A separate policy exists for intrathecal chemotherapy. Unless you are trained, authorised and registered within the Trust to prescribe intrathecal cheomotherapy, you MUST NOT prescribe or administer these treatments Particular care is needed when a patient is treated with potent cytotoxic chemotherapeutic agents Records of the prescribing and administration of chemotherapy should be organised and clear so that the overall plan of treatment given is intended and clear Regimes must be prescribed on the basis of a protocol in regular use within the department. The first course must be prescribed by a Consultant, Senior Registrar, Staff Grade or Associate Specialist with appropriate training and experience Methotrexate. Methotrexate is often prescribed for non-cancer indications. These indications will usually be restricted to rheumatoid arthritis and psoriasis in which they are initiated by specialists. Patients are often admitted for other conditions whilst on methotrexate. Prescribers should note that methotrexate is prescribed as a WEEKLY dose on a specified day per week. Methotrexate must NEVER be prescribed daily for non-cancer indications. To avoid misinterpretation and accidental daily administration prescribers must cross off the days in the administration section of the kardex when patients are not to receive methotrexate. Methotrexate must not be prescribed in any circumstance with the dose, frequency or route specified as directed. Specific procedures are in place for managing oral methotrexate. These can be obtained from Pharmacy Medicines Information and will also be made available on the Trust Intranet. Page 9 of 46

10 1.4 Prescribing For Inpatients A new inpatient prescription must be written for each admission of an individual patient All drugs must be prescribed according to the general principles outlined in 1.1, 1.2 and The function of the inpatient prescription kardex (and other inpatient prescription charts) is: To provide a permanent record of the patient's medication. To indicate the patient s medicine sensitivities/allergies To facilitate the supply of the correct medicines from Pharmacy To direct the administration of medicines to the patient To record the administration of medicines All prescriptions must be written on an appropriate Trust-approved prescription document eg. inpatient prescription kardex, anticoagulation prescription, anaesthetic chart, intensive care prescription All prescriptions must be signed by one of the following: A registered medical or dental practitioner Provisionally registered medical or dental practitioners carrying out prescribing activities relating to their duties as house officers A nurse or midwife qualified and authorised by the Trust to prescribe. A pharmacist qualified and authorised by the Trust to prescribe Medical students employed as locums in the absence of House Officers ARE NOT allowed to sign prescriptions The patient s name, hospital number, date of birth, ward and the name of the consultant must be entered on the front of every medicine kardex. An addressograph label is recommended. For paediatric patients, the weight must also be entered. When a patient has more than one kardex, the number of kardexes must be clearly stated Allergies and other important information Details of any allergies should be clearly stated in the designated section on the front of the medicines kardex. If the patient has no known allergies then this should be clearly recorded using the approved abbreviation NKDA (No known drug allergies). This must also be entered on subsequent prescription sheets. The absence of allergy documentation will lead to delays in the administration of prescribed medicine. Other important information relevant to the safe prescribing and administration of medicines for an individual patient should be entered onto the front of the prescription sheet by the prescriber in the space provided. Such information includes renal or liver impairment, pregnancy, special diet or disability eg. blind. If it is considered inappropriate or impractical to enter such details on the kardex, a note on the kardex to direct other health professionals to refer to the medical notes for further information should be provided. Page 10 of 46

11 1.4.6 Validity of prescriptions. The date on which treatment is to commence must be written for each drug prescribed Unless the course of treatment is clearly specified, the prescription will be considered valid until cancelled by the prescriber or the patient is discharged. The prescriber may indicate the length of treatment eg. for 5 days. This may be made clearer on the kardex by crossing off the days on which treatment should not be given in the administration section of the kardex. Prescriptions must be re-written if the patient is re-admitted or transferred from another hospital. Only prescriptions on St Helens & Knowsley Hospitals NHS Trust prescription sheets are considered valid. Prescriptions must be re-written when the administration section is full All prescribed medicines must be written on the prescription sheet, including details of oxygen therapy, irrigations, parenteral nutrition and dressings supplied by Pharmacy, all of which are prescription only medicines. Dieticians will add dietary supplements to the prescription sheets. Cross-reference must be made on the prescription chart to other drugs prescribed on separate charts eg. anticoagulants, cytotoxics and dialysis fluids The route of administration must be specified for each medicine. For prn medicines it is sometimes clearer to prescribe the drug once on the kardex but to indicate the prescribed routes eg. O/IV. This is only appropriate when the doses by each route are the same eg. metoclopramide. If the doses by each route are different eg. prochlorperazine, each route required must be prescribed individually Prescriptions for medicines to be given when required should include full details of the criteria to be used by nursing staff in deciding when to give doses of those medicines. The frequency of administration must be written and a maximum dose in 24 hours must be stated eg. metoclopramide 10mg PRN is not acceptable but should be written metoclopramide 10mg every 6 8 hours PRN, MAX 30mg in 24hours For regular medicines the prescribing times should be in accordance with regular medication rounds wherever possible. Care should be taken to space the doses evenly especially in the case of vancomycin and enoxaparin. Consideration should also be given to the time of administration and the timing of samples for therapeutic drug monitoring eg. warfarin, digoxin Discontinuing Medicines The date of discontinuation must be entered into the finishing date box The entry must be initialled by the prescriber discontinuing the medicine A diagonal line should be drawn through the prescription so that its cancellation is obvious, but the prescription should not be obliterated Incorrect entries must be scored through and the word cancel written against them by the prescriber and signed Medicines prescribed on separate charts eg. warfarin must be discontinued on both documents Page 11 of 46

12 Re-writing of Prescriptions CAUTION the transcribing of information from one prescription sheet to another is the most common cause of prescribing errors. If a change in dose, frequency or route of administration is required the whole prescription (for the drug affected) must be re-written and the original entry discontinued. Prescription sheets must be re-written when they become untidy especially after several medications have been stopped and/or changed. When re-writing prescriptions, the prescriber must ensure that the dates entered relates to the date when the therapy commenced and not the date of re-writing. It should be indicated on the prescription that the treatment has been reviewed. The date of re-writing should be recorded on the top right hand corner of the front of the prescription sheet Prescribing by Telephone In the interest of patient safety, prescriptions must not be given or accepted over the telephone, except in an emergency (see section 4.3). Telephone orders will NOT be accepted by Pharmacy. 1.5 Prescribing for Discharge (TTOs) All drugs must be prescribed according to the general principles outlined in 1.1 and 1.2 above The function of the discharge (TTO) prescription is primarily: To facilitate the supply of the correct medicines from Pharmacy To provide a record of medicines supplied on discharge for the medical notes To provide a list of current medicines treatment to the GP for the purpose of handover of care and continuation of treatment To communicate general information about the patient to the GP prior to the receipt of the discharge letter All discharge prescriptions must be written on a Trust-approved discharge form TTO Prescriptions must be signed and dated by one of the following: A registered medical or dental practitioner Provisionally registered medical or dental practitioners carrying out prescribing activities relating to their duties as house officers A nurse or midwife qualified and authorised by the Trust to prescribe. A pharmacist qualified and authorised by the Trust to prescribe Medical students employed as locums in the absence of House Officers ARE NOT allowed to sign prescriptions The patient s name, hospital number, date of birth, ward (addressograph labels MUST be used) and the name of the consultant must be entered on each copy of the discharge form. For paediatric patients their weight must also be entered. The date and time of discharge should also be specified Page 12 of 46

13 1.5.5 The prescriber must prescribe every medication that the patient is taking and not just those that are required for discharge. Where supplies are not required this should be clearly indicated. Details of any changed or discontinued medicines must be provided on the discharge summary form if there is space available. Additionally, these details must be provided in the discharge letter Good advanced planning for TTO prescribing is essential. The multi-disciplinary team has a key role to play in discharge planning. Doctors are responsible for ensuring that TTO prescriptions are received in Pharmacy in sufficient time for them to be dispensed and returned to the ward, ideally 24 hours prior to discharge. Prescriptions received in Pharmacy after 3.30pm may not be received back on the wards until late in the evening, leading to delayed discharge or considerable inconvenience to patients and relatives who may need to return to collect the TTO medicines. If there are last minute changes to a patient s prescription prior to discharge, Pharmacy can dispense a one or two item extra TTO much faster than a patients core TTO requirements which are usually for an average of ten items TTO prescriptions must be checked against inpatient kardexes by a pharmacist before dispensing On wards where there is a regular ward pharmacist and/or pharmacy technician service the TTO prescription should ideally be retained on the ward until the ward pharmacist can check it for correctness against the kardex. This avoids the need for the kardex to leave the ward. Many wards have access to pharmacists and pharmacy technicians via a designated bleep which can be used to inform them that a newly written TTO is ready for checking. Wards which do not yet have a ward pharmacist or pharmacy technician service must send their TTOs to Pharmacy along with the corresponding medicines kardexes. TTOs cannot be dispensed unless they are checked against the kardex for correctness. Upon receipt in Pharmacy a pharmacist will check the TTO against the kardex and arrange for the kardex to be returned to the ward as soon as possible via the Pharmacy porters Pharmacy does NOT routinely dispense TTOs OUT of HOURS Discharge prescription dispensing systems Several systems of discharge dispensing are currently running in the Trust at the time of writing this Policy. In the historical system patients will receive a minimum of 7 days supply on discharge (more will be given to cover public/bank holidays) from Pharmacy. This should allow sufficient time for the discharge letter to get to the general practitioner (GP). In most cases Pharmacy will supply medicines in manufacturers original packs which usually contain 28 days supply of medicines. Wards on this old system are reducing in number and will be fully informed of their evolution to the new system when this is feasible. In the one stop dispensing (dispensing for discharge) system patients will be supplied with 28 days (where appropriate) of medication upon admission, fully labelled with instructions for use. These medicines are then Page 13 of 46

14 stored in a locked cabinet by each patient s bed. This system is used in conjunction with the Patients Own Drugs Scheme. This ensures that when the decision to discharge the patient is made, most if not all of their medicines will be already dispensed in a form suitable for patients to take home. This minimises the delays inherent in the historical system which relied upon all the TTO medicines being dispensed on the day of discharge. 1.6 Prescribing for Outpatients All drugs must be prescribed according to the general principles outlined in 1.1, 1.2 and The outpatient prescription enables the legal supply of medicines from the hospital Pharmacy only. They cannot be dispensed by community pharmacists in primary care Prescribers are asked to consider if it is necessary to prescribe for individual outpatients. They should not prescribe to replenish GP-prescribed medicines which the patient is running short of. If a treatment is not urgent and is for a non-specialist drug, consideration should be given to writing to the patient s GP requesting that they initiate the recommended treatment. This has the advantage of reducing waiting times in the outpatients pharmacy and also reducing confusion for patients (as community pharmacist dispensed medicines may differ considerably in appearance from brands used in hospital). Recommended treatments must still comply with the Formulary All prescriptions should be on the Trust-approved outpatient prescription sheet or where appropriate the green FP10 (HNC) prescriptions. Prescriptions should clearly bear the patients name, address, hospital number, date of birth (addressographs must be used where available) and consultant. Paediatric prescriptions should also include the patients weight The prescription should be clearly signed and dated by the prescriber. Only the following staff can sign outpatient prescriptions: Registered medical or dental practitioner Nurses qualified and authorised by the Trust to prescribe Pharmacists qualified and authorised by the Trust to prescribe Pre-registration House Officers and medical students employed as locums in the absence of House Officers ARE NOT allowed to sign outpatient prescriptions days supply will be dispensed unless circumstances dictate that a different supply is necessary. This includes: Antibiotics - 7 days unless otherwise specified Short term analgesics - original packs A&E prescriptions - 7 days unless otherwise specified Hospital only medicines these cannot be prescribed by General Practitioners Clinical Trial medicines Pulsed/cyclical treatment Page 14 of 46

15 Antidepressants prescribed by consultant psychiatrists to ensure continuity of treatment Reducing/ increasing doses of drugs e.g. steroids Drugs for tuberculosis treatment Haematology treatment Drugs with shared care agreements (e.g. donepezil, riluzole) Drugs to ensure continuous supply over public/bank holiday FP10(HNC) prescriptions A restricted number of clinics/prescribers are provided FP10 (HNC) prescription pads. These are for use outside of normal hours or for outreach clinics to allow patients to obtain medicines from community pharmacists, where it would be of great inconvenience to the patient insist on supply from the hospital pharmacy. FP10 (HNC) prescription forms are only for use for registered out-patients to take to outside pharmacies. Green FP10(HNC) must not be used to order food or toilet articles and other prescriptions which are not drugs or appliances other than those specified in the drug tariff FP10 (HNC) must not be used for prescribing outside of the Formulary guidance FP10 (HNC) must not be used to prescribe for in-patients, private patients or hospital staff or their families unless registered as NHS out-patients. Data relating to medicines prescribed using these forms are collated by the Prescription Pricing Bureau in electronic format, including prescriber details and the drugs prescribed. This information is audited regularly. Invoices will be raised if any unauthorised use is detected. 1.7 Patient Group Directions (PGDs) A Patient Group Direction is a written instruction for the supply and administration of medicines without a prescription to groups of patients who may not be individually identified before treatment Certain healthcare professionals within the Trust are authorised to supply and administer medication under a PGD. All such directions must be developed in accordance with the Trust Policy on the Development of Patient Group Directions and be approved by the Trusts Medicines Management Committee The person named in the direction is not authorised to delegate to a second person the administration or supply of the drug specified. Therefore all such drugs must be administered or supplied directly to the patient by the nurse named in the direction 1.8 Non-medical Prescribing Only Nurses and Pharmacists qualified and authorised by the Trust may prescribe. They must only prescribe in accordance with the Trust Non-Medical Prescribing Policy Page 15 of 46

16 1.8.2 A list of authorised Non Medical Prescribers is kept in the Pharmacy Department 1.9 Transcribing The transcribing of medication without the signature(s) of a registered prescriber is not approved within the Trust Prescribing by staff for themselves, their families, orders for personal supplies and duties outside of the Trust Within St Helens and Knowsley Hospitals NHS Trust medical staff must not prescribe for themselves or their families, in line with current General Medical Council (GMC) recommendations. Concerns regarding attempts to inappropriately prescribe will be passed to the Medical Director for attention In emergencies, medical staff should attend existing facilities in outpatients, the Accident & Emergency Department or Occupational Health, where a senior doctor will prescribe according to the Trust Medicines Formulary as necessary. The current prescription charge will be payable FP10 (HNC) prescription forms must never be used by medical staff to prescribe for themselves or their families Consultant medical staff only may purchase drugs from Pharmacy for professional use by providing a signed order. Drugs will be charged at cost price including VAT, plus an on-cost charge. Please note that large quantities of drugs or non-formulary items may not be immediately available and may have to be ordered from the manufacturers. The overuse of this service will lead to review and restriction as it falls outside of the core functions of the Trust s Pharmacy service Drugs from the following groups will only be supplied to Consultant Medical Staff after authorisation from the Head of Pharmacy or Deputy Controlled Drugs not available following recent change in law Hypnotics Anxiolytics Anti-psychotics Anti-depressants Sedatives High quantities of opioid analgesics (non-cds) Any other drugs with potential for abuse, including in sports eg. EPO, HGH Page 16 of 46

17 2 SUPPLY OF MEDICINES Staff are reminded that medication supplied to each clinical area is for administration the patients under the care of the Trust only. Misappropriation or theft of medicines by staff constitutes gross misconduct and will be managed in accordance with the Trust s disciplinary procedure. Reporting to the appropriate professional body will be strongly considered. Supplies from Pharmacy can only be provided against prescriptions, requisitions and signed orders provided on official Trust stationary or media eg. e-top up, e- prescribing. 2.1 The Formulary See information for prescribers in section 1. The St Helens & Knowsley Joint Medicines Formulary is the approved list of medicines for use within the Trust. Medicines for the disease areas covered in the Formulary but which are not listed, will not routinely available from Pharmacy. Newly prescribed items which are not included in the Formulary will need a consultant approval before they can be ordered. Forms for this purpose can be obtained from the ward pharmacist or via the Pharmacy Medicines Information department (ext. 1565). If a patient is admitted on a non-formulary medicine which is not stocked by Pharmacy, the patients own supply of medicines may be used, subject to them satisfying the criteria defined in the procedure for re-use of patients own medicines. If the patient s own supply of the medicine is not available and the treatment is appropriate, Pharmacy will order a small supply to cover the requirements of that particular patient. 2.2 Purchasing Medicines are unlike any other items of commerce and for this reason the purchase, storage and distribution must be under the control of a pharmacist. The Trust Standing Financial Instructions (contained in the Corporate Governance Manual) delegates the financial responsibility, within pre-set limits, for tenders and the signing of orders for medicines to the Chief Pharmacist and authorised deputies, who have procedures to ensure that legal and ethical requirements are met. Medical, nursing, technical and other staff are not permitted to undertake contracting or tendering for, or purchasing of, medicinal products intended for administration to patients within the Trust. All free samples provided by drug companies for use within the Trust must be authorised by the Medicines Management Committee and issued through the Pharmacy Department Quality of Purchased Medicines In NHS hospitals, substitution of branded products with generic equivalent products, where available, is standard practice. The quality of medicines is of Page 17 of 46

18 prime importance and is strictly controlled through the pharmaceutical drug contracts and purchasing procedures. New generic drugs are checked for quality by Pharmacy Quality Control Units throughout the country prior to contract award and existing drugs are monitored throughout the period of contract, so that staff and patients can have complete confidence in their use. However, if a problem arises as a result of poor quality it must be reported promptly to the Pharmacy so that corrective action can be taken. A national pharmacy network exists for reporting and disseminating drug defects to ensure patient safety All unlicensed products purchased for use within the Trust must be checked by the Pharmacy before issue. There may be delay in the availability of medicines whilst quality control analysis is performed, but this ensures that the quality and efficacy of these medicines (for which the Trust must take some liability) is suitable for their intended use (Refer to Trust Policy on Unlicensed Medicines). 2.3 Supply of Controlled Drugs (CDs) Please refer to the Trust Policy for the Management of Controlled Drugs and related procedures for further advice. 2.4 Supply of Cytotoxic Chemotherapy (Including Methotrexate) A separate policy exists for intrathecal chemotherapy. Only staff who are trained, authorised and registered to do so may supply or transport intrathecal chemotherapy. It is Trust policy that, unless supplied ready for use, injectable cytotoxic drugs MUST be prepared in Pharmacy or Clatterbridge Centre for Oncology. The only exception is on H4 for methotrexate used in tubal pregnancy termination. Pharmacy should receive adequate advance warning of intended injectable chemotherapy, even when this is provisional and the final decision to prepare and administer the medicine depends, for example on the patient s blood count Only specially-trained, designated Pharmacy staff may prepare cytotoxic chemotherapy The required medicines are prepared by the Pharmacy to be ready for use at the time indicated and should be administered as soon as possible after receipt. Some medicines deteriorate rapidly after reconstitution. Contact the Pharmacy Aseptic Dispensing Unit on ext 1514 if further advice is required. Storage conditions must be noted and the cytotoxic drugs must be kept separate from other drugs Methotrexate. Methotrexate is commonly prescribed for rheumatology and dermatology patients. As per national and local health economy policy, the only strength of methotrexate tablets which will be supplied will be 2.5mg. The dose of methotrexate for these patients will be once per week. If any other dose Page 18 of 46

19 frequency is prescribed, a supply will not be made until the correct dose frequency is verified. Prescriptions with the dose and frequency as directed will not be dispensed. Specific procedures and guidance are available for the use of methotrexate in accordance with NPSA recommendations. Non-cancer indications. Cytotoxic chemotherapeutic drugs are being used more commonly for indications outside of cancer/haematology. At the present time cyclophosphamide and rituximab are being used intravenously in rheumatology, intramuscular methotrexate in rheumatology and irrigations of mitomycin in urology. The same standards of supply and handling are required in these locations as in cancer wards & clinics. Please contact Pharmacy for specialised advice. 2.5 Supply of Medicines for Inpatients Clinical pharmacists will visit their wards on a daily basis (Monday Friday). Shorter visits also take place on Saturday mornings. The pharmacist will be responsible for checking each patient s ward and discharge prescription documents and arranging supplies of non-stock medicines. The pharmacist will endorse each patient s medicines kardex in green ink as follows: Any allergies should be documented on the front of the kardex in the space provided The approved name of the preparation if not already stated Any special instructions relating to administration in the additional instructions box S in the pharmacy box if the preparation is stock on the ward D if the item is non-stock and has been supplied The date the item was supplied Their initials The ward the item was supplied to As TTO if the item is suitable to take home e.g. Creams, Inhalers, HRT etc POD if the patient s own medicine is to be used Two systems of supply are currently in operation within the Trust. The historical yellow label system is being phased out to be replaced by the one stop dispensing (dispensing for discharge). This is a gradual process but wards will be aware of which system is in use for their patients. During the transition process wards previously on the old yellow label system will use the original pack dispensing system for most non-stock drugs Non-stock medication (Yellow Labels/Original Pack Dispensing) Non stock medication will usually be supplied by the Pharmacy as an original pack of medication labelled with the patient s name, the approved name of the preparation and administration instructions. Proprietary names will only be used when the proprietary name defines a specific formulation or combination (e.g. slow-release theophylline preparations). Solid oral dose forms of morphine will be labelled with both approved and proprietary name. Drugs with frequently Page 19 of 46

20 changing doses and also injections & infusions may still be supplied using the old, yellow label system. Medicines which have been dispensed in original packs with directions for administration should be stored in the patients bedside medicine cabinets. These medicines are suitable for patients to take home on discharge provided there is sufficient quantity. If a patient is transferred to another ward it is essential that these medicines are transferred with them. Patients own drugs may be re-used in hospital, but they must first be inspected and re-labelled, if necessary in accordance with the guidelines provided in Appendix 1. Patients own drugs must not be administered until they have been positively identified in accordance with Appendix 1. If the clinical pharmacist has already visited the ward earlier in the day and there are no arrangements to return, then the medicine kardex should be sent to the Pharmacy at the earliest opportunity to order the medication. If the patient has more than one kardex then they should ALL be sent to the pharmacy. (ICU and HDU do not need to send their Kardexes to Pharmacy). Non-stock medication is topped up by pharmacy technicians at set times, depending on the ward. It will be necessary for ward staff to put non-stock items away in the medicines trolley or bedside medicines cabinets after delivery. Special care should be taken when there is more than one trolley on the ward One Stop Dispensing This system has the benefit that all regular, non-parenteral medicines are individually dispensed for each patient ready for discharge. Every patient, soon after admission, will be supplied with 28 days of medication fully labelled with instructions for use (except controlled drugs and changeable treatments) The medication is stored in a locker by each patient s bed. Pharmacy technicians visit the ward regularly to review each patient s medicine kardex and order new items if required. Items where the dosage has changed will be relabelled by the Pharmacy if necessary. This system is used in conjunction with the reuse of patients own drugs scheme Ward/Department medicine stocks Many medicines will be held as stock on wards/depts. A copy of the stock list is held on the ward and additional copies will be supplied on request. Ward managers may request changes at any time and need to sign the list each time a new copy is produced Pharmacy Technicians and Pharmacy Assistants visit wards and departments regularly to top-up named-patient individual items and stock medicines respectively (they will not re-supply antibiotics unless the prescriber clearly indicates a longer than normal course). Page 20 of 46

21 Some wards are participating in trials with Pharmacy to modify and improve stock medicines supply systems. In the event of stocks of a medicine running short before the next top-up, one of the ward Pharmacy staff regularly visiting the ward should be informed. If the supply is urgent and required before Pharmacy staff next visit, the ward stock top-up sheet should be filled-in with the required extra medicines and sent to Pharmacy without delay. In the event of an urgent shortage of stock or any other medicines outside of normal hours, please call the on call pharmacist (via Switchboard) for advice Returning Medicines All stock and individually dispensed medicines which are no longer required should be placed in a Pharmacy Delivery Bag/Box and sealed. A goods return form must be completed. The person taking the box from the ward to Pharmacy must sign the form and take this, along with the bag/box and return it to the Pharmacy Department as soon as possible. A copy of the completed form remains on the ward. Pharmacy will sign and retain the form upon receipt of the sealed box/bag. Medicines which are suitable for re-use are returned to stock and the ward is credited. All other medicines are destroyed. Anyone unsure of how to dispose of, or to return a particular item should seek advice from Pharmacy. Patients own medicines remain the patient s property. If they are no longer required, they may be returned to the Pharmacy for destruction with the patients consent. 2.6 Supply of Medicines for Discharge (TTOs) TTOs must be received in Pharmacy before 3.30pm on weekdays to avoid delays in discharge and inconvenience to patients and their carers. Pharmacy will accommodate late delivery of work after 3.30pm, but will liaise with ward and directorate managers if this is due to sub-optimal management of work flows. Patients must always be dispensed supplies of medicines which comply with current legal and good practice requirements. Patient information leaflets must be provided within all packs of dispensed medicines wherever possible. Additional leaflets and cards will be provided or updated for specific medicines eg. steroids, anticoagulants, MAOIs. Compliance aids such as spacers for inhalers must be specified upon prescriptions to ensure supply. Pharmacy staff will routinely query obvious needs eg. spacers for inhalers, devices for insulin injection etc, but this should not solely be relied upon. Page 21 of 46

22 5ml spoons will be supplied as standard for administering liquid medicines. Administration instructions will be in multiples of 5ml spoonfuls. Oral syringes will routinely be supplied for young children and for adults requiring doses which are not multiples of 5ml. A separate oral syringe will be supplied for each prescribed liquid. Each syringe will be marked to indicate the volume of liquid to be drawn up. A bung to fix into the neck of each bottle will be supplied along with an instruction leaflet Historical TTO System Doctors are responsible for ensuring that TTO prescriptions are written leaving sufficient time for them to be checked and dispensed without delaying discharge. Wards should endeavour to retain newly written TTO prescriptions on the ward until the pharmacist or pharmacy technician visits at their agreed time. Those wards provided with a TTO bleep service should bleep the pharmacist/technician when there is a new TTO on the ward ready for checking. The ward pharmacy staff will check the TTO against the inpatient kardex for transcription errors and other problems, allowing the kardex to be retained on the ward. In the absence of ward pharmacy staff being available, the TTO prescription plus the corresponding inpatient kardex(es) must be sent to Pharmacy giving sufficient time for them to be dispensed and returned to the ward before the patient is discharged, ideally 24 hours. Any medicines which have been individually supplied and labelled for the patient being discharged (and usually stored in their bedside medicines cabinet) must be sent to Pharmacy along with the prescription and the kardex. The date and if possible, the time of discharge should be written on the TTO prescription The prescriber must prescribe every medication that the patient is taking and not just those that are required for discharge. Where supplies of medicines are not required this should be indicated. Each patient will normally receive at least 7 days supply from Pharmacy (more may be given over a bank holiday). This should allow sufficient time for the discharge letter to get to the General Practitioner (GP) before replenishment of their supplies is necessary. In an emergency, out of hours, the on-call Pharmacist should be contacted for advice; pre-packs are available in Accident and Emergency Rooms and on some wards. Pharmacy does NOT routinely dispense TTOs out of hours. Nurses MUST NEVER dispense from general ward stock for patients going home as this is specifically prohibited within the terms of the Medicines Act The Trust will accept no responsibility should a drug related incident occur in these circumstances. Provision for emergency and out-of-hours supplies of medicines are detailed in section Page 22 of 46