New v1.0 Date: Cathy Riley - Director of Pharmacy Policy and Procedures Committee Policy and Procedures Committee

Transcription

1 Clinical Pharmacy Services: SOP Document Control Summary Status: Version: Author/Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures New v1.0 Date: Cathy Riley - Director of Pharmacy Policy and Procedures Committee Policy and Procedures Committee Date: Date: Medicines Optimisation Strategy : Making the Most of Medicines February 2016 December 2018 Pharmacy, Services, Pharmacist Medicines Code 18/02/ /02/2016 Contents 1. Introduction Purpose Scope Body Text Process For Monitoring Compliance And Effectiveness References

2 Change Control Amendment History Version Dates Amendments V1.0 Dec 2015 SOP created from existing Medicines Code V6.10 Page 2 of 5

3 1. Introduction Pharmacy services are patient-oriented services developed to promote the rational use of medicines, and more specifically, to maximize therapeutic benefits (optimise treatment outcomes), minimise risk, reduce cost, and support patient choice and decisions, thereby ensuring the safe, effective, and economic use of medicine treatment in individual patients. 2. Purpose Authorised Pharmacy Staff must follow this SOP in order to provide effective and safe pharmacy services to patients and other members of staff within the Trust. 3. Scope This SOP is applicable to Authorised Pharmacy Staff only. 4. Procedure The role of the pharmacy is to: Advise on and monitor the safe, effective and economic use of medicines. Procure medicines. Supply and/or dispense ready to administer medicines. Review the medication history of patients. Provide medicines for discharge. Advise patients, relatives and carers and staff, on their use of medicines. 1. Medicines will be procured supplied and dispensed in accordance with the relevant legislation, professional standards and NHS recommended practice. 2. Pharmacists will monitor all new requests for medicines for patients in their care and place special emphasis on complex and potentially toxic medicines that require higher levels of monitoring. Continuing medicine treatment will be reviewed as necessary. 3. When a request for a new medicine has been made the pharmacist must check the prescription and other related patient records to ensure the safe, effective and economic use of medicines. Attention must be given to each step of the medicine use process. This includes the need for the medicine, the medicine selected, the dose regimen including the duration of treatment, the medicine formulation and the route of administration. In addition pharmacists must monitor for medicine interactions/adverse reactions and where possible whether the therapy is achieving the desired therapeutic end points. The pharmacist will initial and date each entry on the prescription chart to indicate that the professional (clinical) check has been completed. When there is an on-going issue with a prescription, which has not yet been resolved, the pharmacist will not initial or date the entry on the prescription chart, but annotate the pharmacy box with either P (problem) or I (investigating). Page 3 of 5

4 4. When the issue is resolved the P or I will be struck through, and the pharmacist will then initial and date the entry. 5. In order to clarify a prescription, Authorised Pharmacy Staff may annotate a prescription. This annotation should ensure the following are included on the prescription: a. Approved name or the name that appears on the pharmacy label where this is different; b. Maximum BNF dose for As Required medicines c. Frequency (where relevant) for As Required medicines d. Reason for administration for As Required medicines e.g. laxatives, analgesics, but not for anxiolytics or antipsychotics or other drugs which may be prescribed for a number of indications e. Route f. Precautions, to guide practitioners when they administer the medicine g. When medicines are detailed for administration under a Patient Group h. Direction, pharmacists may cancel administration boxes, so that no more than the total number of doses may be administered i. When regular medicines are to be administered less frequently, than daily, (e.g. weekly), the administration boxes may be annotated to clarify when the administration is next due j. When regular medicines are written in the variable dose or long-acting medication section or a titration sheet is being used, the pharmacist may add the drug to the regular medicines section, and include a written reference to the appropriate section 6. All annotations must be dated and initialled (using Pharmacy box). 7. Where a pharmacist wishes to make a recommendation to change or modify a patient's therapy, the pharmacist should record the recommendation either in the: a. patient's notes/integrated care record, if the intervention is of moderate to high importance. This will be highlighted to prescribers by attaching a pharmacy advice note to the treatment sheet, stating see pharmacy entry in notes. It is good practice to sign and date the recommendation and to provide some background details, or, b. only a pharmacy advice note will be written, detailing the issue, and attached to the treatment sheet for less important interventions. 8. Written and retrievable records should be made, of any verbal communication, with the prescriber concerning a patient s treatment, when the issue has posed significant risk to the patient. The treatment sheet should be annotated as necessary, in relation to dispensing record. Incident reports should be completed when appropriate. 9. Patients should be advised about their medicines by Authorised Pharmacy Staff. This should be a part of an agreed programme for each ward or unit. The Appointed Practitioner in Charge should agree with the pharmacist and consultant the arrangements for advising patients about their medicines. Page 4 of 5

5 10. Alternative arrangements for advising patients about their medicine may be provided if: a. The nature of the discussion is considered inappropriate by the consultant b. There is insufficient availability of suitably trained pharmacy staff Such alternative arrangements must identify the person responsible for the provision of information and the nature of the information to be provided. 11. Routine supplies of newly prescribed medicines are made when the pharmacy department is open. 12. Out of hours, the emergency cupboard is a source of medicines; all items should be logged out on the record sheet, and access is via the on-call care co-ordinator. Wards and on-call co-ordinators should have an up-to-date list of medicines kept in the local emergency cupboard. This is available from the local hospital pharmacy department. 13. All wards have access to an on-call pharmacy service via the on-call coordinator or duty manager. If an item is not stored in the local emergency cupboard, the on-call pharmacist will determine the clinical urgency of the items and arrange for the supply as appropriate. 14. Emergency medicines are available on each ward in the emergency medicines box, and medicines for anaphylaxis are found in the ward anaphylaxis tray. Stocks are obtained from the local pharmacy department. 15. Authorised Pharmacy Staff must be involved in advising on security and medicine storage conditions on the ward/unit or department, and liaise with auditors/ health professionals undertaking audit on safe and secure handling of medicines. 16. The pharmacy must provide a medicine information service for other healthcare staff as well as patients. 5. Process For Monitoring Compliance And Effectiveness Annual audit 6. References Medicines Code Page 5 of 5