CONTROLLED DRUG STANDARD OPERATING PROCEDURE

Transcription

1 Appendix CONTROLLED DRUG STANDARD OPERATING PROCEDURE Title: ed By: Gurj Bhella By: /03/17 1 of 6 Objective To provide a standard procedure to be followed when patient s own controlled drugs are to be destroyed (denatured) in clinical areas. To provide a standard procedure to be followed when ward stocks of controlled drugs are to be destroyed (denatured) in clinical areas. Scope The Controlled Drugs Accountable Officer (CDAO) or his/her named authorised person(s). The list of authorised persons is maintained by the Pharmacy Department. As a minimum the list contains the Deputy who may act as an authorised person. *Registered nursing staff may need to destroy surplus individual doses/amounts of controlled drugs only (where the strength prescribed is not available as a standard formulation), or remnants of liquid controlled drugs administered to patients or individual doses of controlled drugs which have been prepared for administration but then not given, in the presence of another member of registered nursing staff. In this case, individual/part doses can be placed into a medication disposal bin as below: Tablet Place directly into medication disposal bin. Capsule Open and pour into medication disposal bin. Liquid Pour directly into medication disposal bin. Ampoule Open and pour into medication disposal bin. Patch Remove from packaging, fold onto itself and place into medication disposal bin. 1. Identify controlled drugs which need to be destroyed PATIENTS OWN CONTROLLED DRUGS ONLY CDAO / Authorised persons may destroy: o No longer current treatment o Expired Medication o Patient has been discharged or died Registered nursing staff may destroy (See above): o Surplus/remnants of a dose following administration to a patient o Individual dose of a prepared controlled drug not administered to a patient 1

2 ed By: Gurj Bhella, By: 2 of 6 WARD STOCK CONTROLLED DRUGS ONLY CDAO / Authorised persons may destroy: o Expired ward stocks of drugs o Excess ward stocks of drugs 2. Assemble the appropriate apparatus / documents required to denature the drugs: CD Register / Record Book CD Denaturing Kit (ward/clinical area to obtain) Medicines disposal bin or other appropriate waste container Disposable gloves / other appropriate PPE as required A controlled drug ceases to be classified as a controlled drug once it has been rendered irretrievable, i.e. all controlled drugs once disposed of should be unrecognisable as a controlled drug and unusable as a controlled drug. 3. Medications should be denatured as follows Solid Dose Formulations a. Remove the tablets or capsules from packaging b. Add to CD denaturing kit c. Follow instructions on CD denaturing kit d. Place the CD denaturing kit in a medication disposal bin and seal or Liquid Dose Formulations a. Pour from the original container into the CD denaturing kit b. Follow instructions on CD denaturing kit c. Place the CD denaturing kit in a medication disposal bin and seal or Parenteral Formulations a. Liquid ampoules should be opened and as much of the content as possible emptied into the CD denaturing kit 2

3 ed By: Gurj Bhella By: b. Ampoules containing CD powder should be opened, water added to the ampoule to dissolve the powder, and the resultant mixture poured into the CD denaturing kit c. Follow instructions on CD denaturing kit d. Place the CD denaturing kit in a medication disposal bin and seal or 3 of 6 Fentanyl and Buprenorphine Patches a. Remove the patch from its packaging b. Remove the backing from the patch c. Fold the patch over on itself d. Follow instructions on CD denaturing kit e. Place the CD denaturing kit in a medication disposal bin and seal or Aerosol Formulations (including Sativex spray) NB: It is advisable for staff to wear a face mask and perform the task in a well ventilated area. a. Expel into water b. Mix the resulting solution into a CD denaturing kit. c. Follow instructions on CD denaturing kit d. Place the CD denaturing kit in a medication disposal bin and seal or Syringe Driver Waste a. Expel the contents of the syringe driver directly into a CD denaturing kit b. Follow instructions on CD denaturing kit c. Place the CD denaturing kit in a medication disposal bin and seal or 4 Make an entry in the controlled drugs register on the appropriate page detailing the date, time and the quantity of medication destroyed. Two members of staff, i.e. registered pharmacist and a registered nurse 3

4 ed By: Gurj Bhella, By: 2 of 6 registered pharmacist and registered pharmacist registered pharmacist and registered pharmacy technician Both staff must both sign the register to confirm the destruction and update the stock level. If destroying patient s own controlled drugs and the patient is still an inpatient, a Patients Own Medicines Destruction/Return Consent Form must be completed prior to destruction. Please see Appendix 1 6 Where CD medication is to be transported to main pharmacy by a registered member of the pharmacy team, the (Pharmacy Team) Transport Form for Controlled Drugs should be filled in appropriately. Please see Appendix 2 4

5 ed By: Gurj Bhella, By: of 6 APPENDIX 1 Patients Own CD Destruction/Return Consent Form [ ] I give my consent for BCPFT Staff to destroy medicines which I no longer need Patient Name Patient Signature Date [ ] The patient isn t able to give informed consent, e.g. does not have capacity, is deceased, or has been discharged. (Details to be documented in patient s notes) Staff Name & Designation Staff Signature Date List controlled drugs including Name, Form, Strength and Quantity Reasons for destruction/ Information given: [ ] I do not want my medicines to be destroyed. I understand I MUST check with my doctor (GP) before using them again. I have had the risks explained to me. Patient Name Patient Signature Date Staff Name & Designation Staff Signature Date Details (If necessary) The form should be stored by pharmacy for 2 years, and be made available for inspection by the CDAO or police / appropriate regulatory body.

6 STOCK CONTROLLED DRUGS ed By: Gurj Bhella, By: /3/17 6 of 6 APPENDIX 2: (PHARMACY TEAM) TRANSPORT FORM FOR CONTROLLED DRUGS This form must be completed where upon visiting the ward/unit, the pharmacist/ pharmacy technician wishes to sign the controlled drugs out of the ward/register and personally transport to pharmacy department (Penn or Hallam Street) for storage in Safe/CD Cupboard Ward / Unit / Site Delete as appropriate Transported to Penn Pharmacy / Hallam Street Pharmacy * Name of Controlled Drug Form Strength Quantity e.g. Morphine Sulphate Oral solution 10mg/ml 0ml Pharmacist / Registered Pharmacy Technician Name Signature Date Registered Nurse Name Signature Date *Substances must not be left unattended at any time during transport. The form should be stored by pharmacy for 2 years, and be made available for inspection by the CDAO or police / appropriate regulatory body. 6