NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDICINES IN THE OPERATING THEATRE AND RECOVERY

Transcription

1 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Reference CL/MM/014 Approving Body Senior Management Team Date Approved 6 September 2016 Implementation Date 6 September 2016 Summary of Changes from Previous Version Recovery guidance included in this version (previously theatre only). Differentiation of security, storage and documentation practice between theatre &recovery areas. Supersedes Version 3 November 2012 Consultation Undertaken Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Consultant Anaesthetists Assistant Clinical Services Lead Pharmacy Specialist Clinical Pharmacist Theatres Recovery Team Leaders Deputy Clinical Lead, Theatres Practice Development Matron 7 th January th January 2016 Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications 7 th January 2016 Medicines Act 1968 (with Amendments) Misuse of Drug Act 1971 (with Amendments) Target Audience All NUH staff who deal with medicines in Theatres Review Date January

2 Lead Executive Medical Director Author/Lead Manager James Hooley Chair, Medicines Management Committee Ext: Further Guidance/Information Shashi Gupta Specialist Clinical Pharmacist - Theatres Ext: Sonia Gilmore Secretary to Medicines Management Committee Ext

3 CONTENTS Paragraph Title Page 1. Introduction 4 2. Executive Summary 4 3. Policy Statement 4 4. Definitions (including Glossary as needed) 5 5. Roles and Responsibilities 5 6. Policy and/or Procedural Requirements Specialist professional groups authorised to handle medicines in theatres Prescribing and administration of medicines- 7 responsibilities of theatre staff 6.3 Issue and supply of medicines (other than Controlled 10 drugs) in theatres 6.4 Security of Medicines when theatres are not in use Administration of single use patients or vials Disposal of unused medicines Management of controlled drugs in theatres Local anaesthetics and epidural infusions Transfer of patients with infusions from the theatres 16 suite 6.10 Key security Training, Implementation and Resources Impact Assessments Monitoring Matrix Relevant Legislation, National Guidance and 21 Associated NUH Documents Appendix 1 Equality Impact Assessment 22 Appendix 2 Environmental Impact Assessment 25 Appendix 3 Here For You Assessment 27 Appendix 4 Certification Of Employee Awareness 29 3

4 1.0 Introduction 1.1 Practices involved in the prescribing and administration of medicines in operating theatres and recoveries differ substantially from those followed on hospital wards. The contents of other sections of the Medicines Policy still apply in theatres, subject to the special provisions detailed below. 2.0 Executive Summary 2.1 Anaesthetists All anaesthetists must be aware of the content of this theatre-specific policy in addition to trust-wide sections of the Medicines Code of Practice. It includes differences in second checking and labelling of medicines during the anaesthetic. Anaesthetists must document all medicines administered during the anaesthetic and must adhere to CD requirements as outlined in this document and the NUH Controlled Drug policy. Surgeons Verbal instructions to prepare medicines are necessary in a theatre environment where the surgeon cannot prescribe or handle nonsterile medicine containers intra-operatively. The policy outlines the roles of theatre practitioners to support preparation & checking of medicines intra-operatively. The surgeon must provide verbal confirmation of the same details as would be expected in a written prescription. The surgeon must provide a second check of all medicines requested and must document their administration in the operation note or drug chart at the end of the case. Recovery practitioners All recovery practitioners must have awareness of this policy 3.0 Policy Statement 3.1 The Trust supports the safe use (ordering, supply, storage, prescribing, administration and disposal) of all medicines used within 4

5 the theatre & theatre-recovery environments. The measures outlined in this policy (and corresponding sections of the NUH Medicines Policy: Code of Practice) must be adhered to by all staff to ensure security and safety in medicines use. 4.0 Definitions 4.1 Glossary: Doctor: The term doctor is applied to any medically trained professional who may administer medicines in theatre. In practice this is usually an anaesthetist or surgeon but the term encompasses all doctors using the theatre facilities. ODPs: Operating department practitioners (ODPs) Perfusionists: Clinical perfusion scientists PA-A: Physician Assistants Anaesthetics Registered practitioners- Registered ODPs and Nurses 5.0 Roles and Responsibilities 5.1 Committees Medicines Management Committee Responsible for ensuring this policy is in place and up to date 5.2 Individual Officers The Deputy Clinical Lead (Theatres Lead), in collaboration with the Chief Pharmacist, is ultimately accountable for ensuring secure systems for the ordering, custody and availability of medicines (including Controlled Drugs). The implementation of these systems may be delegated on a day-to-day basis to appropriately registered theatre practitioners by the theatre team-leaders or theatre coordinators. 5

6 5.2.2 Theatres and Recovery staff Theatre staff have varying responsibilities for the management of medicines in theatre (including controlled drugs) according to their professional registration and grade. The Deputy Clinical Lead must ensure that each member of staff is aware of their responsibilities as part of the job induction process. (See local procedures). 6.0 Policy and/or Procedural Requirements 6.1 Specialist professional groups authorised to handle medicines in theatres Operating department practitioners (ODPs) A registered ODP must be registered with the Health and Care Professions Council (HCPC). ODPs will be included under the term registered practitioner throughout this procedure. A registered ODP may be given the same responsibilities to a registered nurse regarding the management of medicines in theatre. A registered ODP who has received the appropriate training and assessment may undertake an expanded role in drug administration Clinical perfusion scientists Clinical perfusion scientists (perfusionists) are specialist autonomous practitioners involved in the management of patients undergoing cardiac surgical procedures. Qualified perfusionists employed by NUH must be registered with the College of Clinical Perfusion Scientists of Great Britain and Ireland. The perfusionists at NUH work under delegated authority from the Clinical Director/ Trust following detailed guidance and working to competencies as outlined in the Local agreement and Clinical Perfusion Medicines Management Protocols for Patients Undergoing Cardiac Surgery. This protocol stipulates the range of medicines, which may be administered, and in what circumstances. 6

7 The current version of the NUH Local Agreements for Drug Administration by Clinical Perfusion Scientists is available on the Medicines Management Committee website Physician Assistants Anaesthetics (PA-A) PA-As are practitioners trained to care for patients undergoing anaesthesia under the supervision of a Consultant Anaesthetist. They have a Postgraduate Diploma in Anaesthetic Practice and are affiliated to the Royal College of Anaesthetists. They administer medication under the Local Agreement for the Patient Specific Direction for the Administration of Medicines by a named Physician s Assistant in Anaesthesia (PA-A) The supervising consultant anaesthetist must prescribe medication for each patient using the locally-developed Patient Specific Directives that allow PA-As to check and administer drugs within appropriate limits. Patient Specific Direction for the Administration of Medicines by a named Physician s Assistant in Anaesthesia (PA-A) is on the authority of a named Consultant Anaesthetist. The formulary outlining the drugs, doses, routes and indications that the PA-A can administer is listed in the local agreement. All drugs administered to a patient by a PA-A will be recorded by the PA-A on the anaesthetic chart, and countersigned by the supervising consultant. The time period when the PA-A was alone in theatre will be clearly defined and signed by the PA-A. 6.2 Prescribing and administration of medicines The NUH Medicines Policy: Code of Practice CL/MM/006 (Prescribing) and CL/MM/008 (Administration) must be followed in theatre and recovery areas wherever possible Responsibility for preparing and administering medicines in theatre by Anaesthetists The anaesthetist who is responsible for the conduct of an anaesthetic, is responsible for the preparation and administration of all medicines that they administer (by any route) during the course of that anaesthetic. The anaesthetist is also responsible for the preparation and administration of medicines by a supernumerary 7

8 anaesthetist, physicians assistant, theatre practitioner or medical student within their sight and under their direct supervision. All doctors remain responsible for the drugs that they prepare and administer, trainees are actively encouraged to check drug preparation with their supervisor should there be unfamiliarity or any similar concern. It is recognised that it is considered impractical for anaesthetists to have a formal second check for each individual administration of medicines (by whatever route) during the course of an anaesthetic. However it is safer practice to ask for a positive check with another registered practitioner when the medicine is being drawn up and administered. Where dilution regularly occurs (e.g. paediatrics); where there is a critical or unusual dilution of drugs; or when the anaesthetist is unfamiliar with the medicine to be administered including (but not limited to) all cytotoxic drugs, inotropes and some anticoagulants, - then positive checking of the drug with a second registered practitioner is considered best practice Preparation of medicines in theatres by anaesthetists If possible, all medicines should be drawn up, prepared and labelled in an environment where disturbance of the anaesthetist is unlikely to occur. Sharing of any drug vials between patients is not permitted at NUH as this will compound any potential drug errors; refer to use of single dose and multiple dose vials policy, CL/MM/028 Unless drugs are to be used immediately and kept under direct supervision of the attending anaesthetist, they must remain clean (capped off) and be identified with an initialled label and only prepared for each individual case. Batch drawing up of drugs for several cases is not permitted as this practice could result in repeated errors re-occurring. Any emergency drugs drawn up can be kept for the duration of the 8

9 list, observing aseptic techniques and storage. These prepared drugs must be identified by a label and kept under the direct supervision of the attending anaesthetist. Tamper proof seals are available and should be used for emergency drugs Security of anaesthetist-prepared medicines in theatres A drug should not be used where the identity of who has drawn it up cannot be established or if the drug has not been held (prepared and labelled) under the direct supervision of the attending anaesthetist; as sterility, tampering and batch origin cannot be guaranteed. At all times, anaesthetists need to ensure that they know what drugs are contained within each drawn up syringe, and this can only be established if these drugs are kept under direct supervision, even if prepared for a pending theatre case Administering and recording medicines administration by the anaesthetist The practice of not immediately disposing of opened ampoules; keeping them for inspection (in a controlled & safe manner, away from medicines in current use) until the end of the anaesthetic can be recommended. It provides an additional opportunity to confirm which drugs have been administered and can greatly help in following up drug-related incidents such as anaphylaxis episodes. In order to minimise adverse events from residual IV agents, all lines and cannulas must be flushed with Normal Saline before the patient leaves the direct care of the attending anaesthetist (in reality, before going to recovery). The anaesthetist is responsible for recording all medicines given during the course of an anaesthetic on the NUH anaesthetic chart. Any medicines that may be continued into the post-operative period, or have been given in theatre which affects the subsequent dose of the same (or another) medicine must be documented on the inpatient prescription chart. This may include (but is not limited to) agents such as anticoagulants, antibiotics, antiemetics. 9

10 6.2.5 Roles of registered & non-registered theatre practitioners in assembling and preparing medicines for administration The theatre procedure Kardex (surgeon & procedure specific) may be used as a prompt to assemble routine medicines which are likely to be required during a case. However, the preparation (including decanting, dilution, mixing, connecting with sets/ pumps) should be supplemented with a verbal order from the doctor to ensure the formulation is appropriate for the individual patient. Non-registered theatre staff who have been trained to handle or prepare medicines, may do so under the direct supervision of the registered practitioner. The registered practitioner retains responsibility for second checking medicines with the doctor prior to administration Delegated administration of medicines to an appropriate registered practitioner A doctor using the operating theatre facilities, is responsible for ensuring the appropriateness of any medicine (including the dose/concentration/route) given by themselves or at their request. They may delegate the administration of medicines to a registered practitioner by means of a written prescription or verbal instruction. Any registered practitioner administering a medicine under this type of direction is responsible for ensuring that the medicine is administered in the correct manner, especially confirming patients possible allergies with the theatre team before administration to an unconscious patient. Where a verbal instruction is given to administer, the registered practitioner must repeat the verbal order back to the doctor to confirm the correct drug, dose, dilution and route and ask the doctor to second check. In these situations, the usual rules for training and second checking apply (see section CL/MM/008). Infiltration and irrigation are 10

11 considered to need the same checking process as intravenous medication and therefore the same training. For all medicines administered by all theatre staff groups, confirmation in writing must be made as soon as possible by the doctor either on the operation record or on the NUH inpatient prescription chart and signed by the practitioner who administered the medicine. 6.3 Issue and supply of medicines (other than Controlled drugs) in theatres and recovery Ordering of medicines In all theatre areas, pharmacy staff provide a regular top-up service for all stock medicines against agreed stock levels. Further emergency supplies can be obtained from pharmacy using an Emergency Stock Requisition signed by an authorised registered practitioner (Refer to CL/MM/003 of this Medicines Policy: Code of Practice) Transport and receipt Orders will be sent to theatres in sealed containers. These medicines must be put away securely in a timely fashion to prevent any unauthorised access to them. (Refer to local procedures) Managing discrepancies Refer to CL/MM/021 (Stock discrepancies) of this Medicines Policy: Code of Practice. 6.4 Security of Medicines in theatres and recovery Security of Medicines in theatres When a theatre is not in use, all medicines must be put away in a locked cupboard or fridge. Medicines must not be left in or on the anaesthetic machine. Part-used ampoules and medicines no longer required must be disposed of correctly. Below exceptions apply due to accessibility requirements: Emergency theatres- Medicines (with the exception of controlled drugs) must be accessible at all times unless there is a planned break in operating where no practitioner will be directly supervising the theatre. At these times the medicines must be put away in a locked cupboard or fridge and local arrangements exist to ensure the emergency theatre key- 11

12 holder is contactable at all times. Maternity theatre- an agreed stock of emergency medicines must be left accessible for the anaesthetist to prepare for emergency procedures before the theatre staff arrive. Warming cabinets- do not need to be locked. A label (NUH02070N) should be placed on the fluid with the date and time when the product entered the cabinet and this should be checked when removing to ensure it is within the altered expiry for that product following warming. The Pharmacy Medicines Information department maintain an updated document outlining any expiry modifications needed for agreed warmed fluids Security of medicines in recovery areas All medicines must be stored securely in locked cupboards as per CLMM004. Below exceptions apply due to accessibility requirements: Fridges should be accessible during working hours to allow access to emergency intubation boxes. NCH main recovery emergency drug cupboard stays open during working hours. This is located in the clean utility behind a restricted swipe access door. The security of medicines remains the responsibility of the qualified practitioner in charge. 6.5 Administration of single patient use ampoules or vials All ampoules or vials of medicines must be used for single patient use only. This includes the use of bags of intravenous fluids for dilution of medicines. Refer to CL/MM/028 of this Medicines Policy: Code of Practice (Use of Single and Multiple Use Vials). 6.6 Disposal of unused medicines Any medicines that are opened but not required must be disposed of according to Trust policy (see Section CL/MM/011 (Return and Disposal of Non-controlled Medicines) of this Medicines Code of Practice). It is the responsibility of the doctor or registered practitioner administering the medicines to ensure that waste medicines, ampoules, needles and syringes are disposed of safely & appropriately. Particular attention should be given to removing the remainder of any infusions from syringe drivers and disposing of these in accordance with Section CL/MM/

13 6.7 Management of controlled drugs in theatres and recovery Also refer to CL/MM/012 of this Medicines Policy: Code of Practice (Controlled Drugs) Ordering of CDs In all theatre and recovery areas, pharmacy staff provides a regular top-up service for all controlled drugs against agreed stock levels. Further emergency supplies can be obtained from pharmacy using the controlled drug order book signed by an authorised registered practitioner. (Refer to local procedures). The Controlled Drug Order book must be locked in a medicines cupboard when not in use (typically this will be the CD cabinet or an outer cupboard that houses the CD cabinet) Transport and receipt of CDs A porter/escort from theatres, who must be aware of the extra responsibility of handling controlled drugs, will collect the controlled drugs from pharmacy. Controlled drugs will be sent to theatres in a numbered sealed bag, which must be signed for on arrival in theatres (Refer to local procedures) Instances where the controlled drug key holder is unavailable Procedures must be in place to deal with the receipt of controlled drugs when theatre staff are unavailable to take receipt of the sealed bag from the porter/escort. (Refer to local procedures) Controlled drugs registers Registers must be kept within the locked controlled drug cupboard when the theatre is not in use. There are procedures in place for completing the controlled drug registers. (Refer to local procedures) THEATRE: A dedicated THEATRE controlled drugs register must be used for recording all controlled drug transactions in theatres RECOVERY: A WARD controlled drugs register must be used for recording all controlled drug administration within recovery (with the exception of CD epidurals ONLY which will be recorded in a theatre style register). 13

14 6.7.5 Issuing Controlled Drugs THEATRE CDs (plus CD epidurals ONLY in recovery): Registered practitioners must only issue the required number of ampoules for the current patient to the anaesthetist. At present PA-As are not able to remove (or sign for issue/receipt) of controlled drugs from the controlled drugs cupboard, unless their professional registration allows them to. This can only be undertaken by a doctor or registered practitioner. A qualified PA-A, who is also a registered practitioner can withdraw controlled drugs from the controlled drugs cupboard. When a controlled drug is removed for a patient, the registered practitioner must document the patients name, their name, the anaesthetist/pa-a and the amount in words. When handed to the anaesthetist/pa-a they must sign at the time of issue to acknowledge receipt and that they will be administering it. It is the equal responsibility of both the registered practitioner and the anaesthetist that all the information is correctly completed. A second check of the amount given and witnessed disposal of unused controlled drugs is considered best practice. The documentation of Controlled drugs in theatres is continually audited, with monthly database updates and referral to theatre heads of service. RECOVERY Controlled Drugs (except CD epidurals see above): Refer to CL/MM/012 of this Medicines Policy: Code of Practice (Controlled Drugs) Stock control of Controlled Drugs (CD Checks) THEATRE Two registered practitioners must undertake the controlled drug check twice a day. Both must sign and date the checklist on the appropriate pages at the back of the theatre CD register. These checks will usually take place at the start and finish of the 14

15 session or in the case of emergency theatres at an appropriate shift change time. Surplus or expired stock CDs must be removed from the theatre by a designated pharmacy practitioner. Refer to CL/MM/012 of this Medicines Policy: Code of Practice (Controlled Drugs) RECOVERY A record indicating this check is correct & complete (signed by both practitioners) must be kept either: I. As part of a CD-check/key-log booklet, which may be kept on the recovery workstation to facilitate accurate handover of keys Or II. A record sheet attached to the inside of the CD book Surplus or expired stock CDs must be removed from recovery by a designated pharmacy. Refer to CL/MM/012 of this Medicines Policy: Code of Practice (Controlled Drugs) Borrowing of controlled drugs The transfer of stocks of controlled drugs between theatres is not permitted. For an urgent clinical need, a single dose may be given to a named patient in one theatre from stock in another, with all the necessary entries being made in the Controlled Drug register of the issuing theatre Disposal/Return of Controlled drugs THEATRE (unopened ampoules/vials) The anaesthetist must return any unopened ampoules of controlled drugs to the registered practitioner who is holding the theatre keys after each case. Both the anaesthetist and the key-holder must ensure that these are returned to the controlled drug cupboard and that this is recorded in the theatres Controlled Drugs register. (Refer to local procedure in Controlled drug register). Theatre & Recovery (opened / part-used doses of CDs) Any controlled drugs which are prepared but not administered must be disposed of according to Trust policy (Refer to section 15

16 CL/MM/012 of this Medicines Code of Practice). The waste of controlled drugs should be witnessed by another registered practitioner, and the wasted drug must be recorded in the controlled drugs register. It is the responsibility of the doctor or registered practitioner administering the medicines to ensure that waste medicines, ampoules, needles and syringes are disposed of appropriately. (Refer to CL/MM/011 of the Medicines Policy: Code of Practice) Managing discrepancies Any discrepancies between the controlled drug register and the stock levels must be investigated immediately. Refer to the Local procedure outlined in the controlled drug register and CL/MM/012 (Controlled drugs) of this Medicines Policy: Code of Practice. 6.8 Local anaesthetics and epidural infusions Refer to section CL/MM/029 of the Medicines Policy: Code of Practice (Local anaesthetics including epidural administration). 6.9 Transfer of patients with infusions from the theatres suite If a patient is transferred from theatres to another clinical area with any medicine(s) by infusion (including infusions of controlled drugs), the syringe / infusion must be clearly labelled with the name of the medicine(s) and strength/concentration thereof. See Section CL/MM/008 (Administration of Medicines) of this Medicines Code of Practice. The volume of any infusion containing a controlled drug must be checked and documented by two practitioners on handover to the receiving ward 16

17 6.10 Key Security The Deputy Clinical lead for Theatres must ensure that every registered practitioner who is an authorised key holder has submitted a sample signature and this list is current, and that practitioners who no longer work in NUH Theatres/Recovery have this authorisation removed from the list. Theatres Registered practitioners must follow the local theatre Key holding procedure for allocation and documentation of keys at the beginning, during and end of the theatre session. Each operating theatre has its own set of keys which provide access to medicines and controlled drugs. This set of keys must not be divided unless the Deputy Clinical Lead for Theatres for that campus has given authorisation (Section CL/MM/004of this Medicines Code of Practice: Storage and Security). During a session, the theatre keys may be held by other authorised theatre practitioners but all handovers must be documented to establish an audit trail in the keys section of the Controlled drug register. Recovery Local procedures should be followed. Keys for cupboards or departments which regularly close may be removed from the main set and stored in a locked CD cupboard. The key log must be updated to document this storage. 7.0 Training and Implementation 7.1 Training All registered practitioners will complete the trust IV training package (with theatre specific questions) 17

18 Non registered staff: A medicines management awareness package has been developed and will be approved by Theatres & Recovery Governance Group (Jan 2016) 7.2 Implementation This is an update to an existing policy and the existing mechanisms will be used. 7.3 Resources 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. 18

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20 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Review of DATIX incidents relating to medicines security in theatres or recovery Responsible individual/ group/ committee Divisions, boards and local areas Process for monitoring e.g. audit Monitoring of DATIX Frequency of monitoring Ongoing Responsible individual/ group/ committee for review of results Specialty or Divisional forum or speciality group Responsible individual/ group/ committee for development of action plan Specialty or Divisional forum or speciality group Responsible individual/ group/ committee for monitoring of action plan Specialty or Divisional forum or speciality group Review of DATIX incidents relating to preparation or administration of medicines in theatre or recovery Divisions, boards and local areas Monitoring of DATIX Ongoing Specialty or Divisional forum or speciality group Specialty or Divisional forum or speciality group Specialty or Divisional forum or speciality group 20

21 Medicines Management Audit Specialty group Audit Annually Specialty group & MMC Specialty group Specialty group 21

22 10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 List all of the following which are relevant: Legislation Medicines Act 1968 (with Amendments) Misuse of Drug Act 1971 (with Amendments) National Guidance Guide to Good Practice in Clinical Perfusion (Dept of Health 2009) RCoA and AAGBI. Storage of Drugs in Anaesthetic Rooms: Guidance on best practice. June 2016 Associated NUH Documents(with NUH referencing) Medicines Policy: Code of Practice. CL/MM/003, CL/MM/004, CL/MM/006, CL/MM/008, CL/MM/011, CL/MM/012, CL/MM/021, CL/MM/028, CL/MM/029 Local agreement and Clinical Perfusion Medicines Management Protocols for Patients Undergoing Cardiac Surgery Local agreement for the Patient Specific Direction for the Administration of Medicines by a named Physician s Assistant in Anaesthesia (PA(A)) 22

23 Insert templates of relevant impact assessments (page break after each) APPENDIX 1 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 c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality 23

24 Sexuality n/a n/a n/a 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? None Q4. What data or information did you use in support of this EQIA? None 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 24

25 groups What By Whom By When Resources required None N/a N/a N/a Q7. Review date January

26 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 Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and materials Soil/Land Water Air 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 No No No No No No No No No 26

27 Energy Nuisances furnaces; combustion of fuels, emission or particles to the 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)? No No No No 27

28 APPENDIX 3 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit 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. 28

29 5. On Stage (patients feel safe) 1 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 29

30 APPENDIX 4 CERTIFICATION OF EMPLOYEE AWARENESS Document Title MEDICINES POLICY: CODE OF PRACTICE MEDICINES IN THE OPERATING THEATRE AND RECOVERY Version (number) 4 Version (date) 06 September 2016 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 Division/ 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 Divisions Divisional General Manager or nominated deputies Corporate Directorates - Deputy Director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilise this form in a similar way, but this would always be an additional (not replacement) action. 30