FP10 HNC PRESCRIPTION POLICY MAY This policy supersedes all previous policies for FP10 HNC Prescription Policy

Transcription

1 FP10 HNC PRESCRIPTION POLICY MAY 2016 This policy supersedes all previous policies for FP10 HNC Prescription Policy

2 Policy title FP10 HNC Prescription Policy Policy PHA37 reference Policy category Clinical Relevant to All staff handling FP10 prescriptions Date published May 2016 Implementation May 2016 date Date last Feb 2016 reviewed Next review May 2018 date Policy lead Lucy Reeves, Chief Pharmacist Contact details Accountable director Approved by (Group): Approved by (Committee): Document history Membership of the policy development/ review team Consultation Dr Vincent Kirchner Medical Director Drugs and Therapeutic Committee Quality Committee Date Version Summary of amendments July Review and update Jan NHS England process for reporting Feb Review and update Chief Pharmacist Members of the Drugs and Therapeutics Committee and the LSMS DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. I FP10 HNC POLICY_PHA37_MAY 2016

3 Contents Page 1 Introduction 3 2 Aims and objectives 3 3 Scope of the policy 3 4 Duties and responsibilities 3 5 Prescribing on FP10s 4 6 Setting up or amending FP10 sites 5 7 Ordering & supply of FP10s 6 8 Recording Receipt of FP10s at team base 8 9 Storage of FP10s 8 10 Recording use of FP10s 9 11 Spoiled prescriptions 9 12 Destruction of FP10s 9 13 Lost or stolen prescription forms / prescription forgery Forged prescriptions / unauthorised alterations Dissemination and implementation arrangements Training requirements Monitoring and audit arrangements Review of the policy References Associated documents 13 Appendix 1: FP10 authorised prescriber form 14 Appendix 2: Request for new FP10 code / notify / amendments 15 Appendix 3: FP10 (HNC) prescription link record 16 Appendix 4: Flow chart for missing/lost/stolen FP10 forms 17 Appendix 5: Missing/lost/stolen NHS prescription form(s) notification form 18 Appendix 6: NHS England alert form 20 Appendix 7: Incident response 21 Appendix 8: Key responsibilities in incident investigation 23 Appendix 9: Equality impact assessment 25 II FP10 HNC POLICY_PHA37_MAY 2016

4 1 Introduction 1.1 This policy has been written to promote a safe system for the management of FP10HNC prescriptions. It fulfils the guidance set by the NHS Business Services Authority and the NHS Protect (March 2011, updated August 2015). The purpose of this policy is to ensure that FP10HNC prescriptions are used in an appropriate and consistent manner within the Trust. The security and issuing of FP10s laid out in the policy are to minimise the risk of prescriptions pads being lost, stolen of used in an unauthorised way. 2 Aims and objectives 2.1 To facilitate a consistent process within the Trust: To provide clear procedures for staff who order, issue, handle and manage FP10HNC prescriptions To ensure the Trust follows the NHS Protect, Security of Prescription Forms Guidance (March 2011, updated August 2015). 3 Scope of the procedure 3.1 This policy applies to all prescribers, nursing and pharmacy staff working in the trust who issue, handle and manage FP10 HNC prescriptions. 3.2 This policy does not cover the handling and use of FP10 MDA-SS prescriptions used in Substance Misuse Services 4 Duties and responsibilities 4.1 Drug and Therapeutics Committee approves this policy and has responsibility to ensure serious incidents related to the misuse/theft/loss of FP10s are discussed. The misuse of FP10s may result in the unauthorised and illegal dispensing of medicines leading to clinical harm and/or a financial loss to the trust. 4.2 Controlled Drug Accountable Officer (CDAO) has the overall responsibility for monitoring FP10 prescribing and usage of controlled drugs (CDs) in the trust. The CDAO should conduct investigations in the event of inappropriate prescribing of CDs outside the scope of practice or for lost/stolen FP10s in relation to CD prescribing. 4.3 Chief Pharmacist is the designated Responsible Person in the trust with overall responsibility for overseeing the ordering, receipt, storage, transfer, access, monitoring and overall security of prescription stationery. The Chief 3 FP10 HNC POLICY_PHA37_MAY 2016

5 Pharmacist has corporate responsibility for medicines management and overseeing the correct use of FP10 within the procedures. 4.4 Medical & Non Medical Prescribers are responsible for following these procedures. Prescribers have a duty to: Ensure an auditable record is maintained so the issue of each FP10 is documented in the FP10 record form Ensure the secure and safe handling of FP10 prescriptions while they are in use during clinics. 4.5 Pharmacy Staff monitor and provide assurance that all FP10s are stored, recorded and used appropriately by undertaking a quarterly FP10 audit. Designated pharmacy staff are responsible for the ordering and issuing of FP10s to team within the trust in accordance with this policy and departmental procedures. 4.6 Local Security Management Specialist (LSMS) is trained and accredited in the management of security within the NHS and the Trust. The LSMS has a key responsibility to: Ensure comprehensive and robust FP10 procedures are developed, implemented and reviewed at regularly and whenever situations arise that necessitate an earlier review e.g. following and incident. Develop a strong pro-security culture by working closely with senior management and professionals at a local level Ensure appropriate procedures are in place for the immediate reporting if any loss/theft of prescription stationery and staff are aware of what action they need to take if this occurs Ensure completed Missing/lost/stolen NHS prescription form notification form is submitted to NHS Protect national database. To liaise with their counter fraud colleague, the Local Counter Fraud Specialist about all reported cased of loss or theft if prescription stationery 5 Prescribing 5.1 The trust must have a record of all prescribers authorised to use FP10 prescriptions. A list of current prescribers authorised to use FP10s at each team, where relevant, should be completed by the lead consultant / service manager and sent to Pharmacy, HMHCpharmacy@candi.nhs.uk. The list should be reviewed and updated every 6 months. See appendix 1 for template 5.2 FP10 HNC prescriptions must only be used for patients registered with C&I NHS Foundation Trust i.e. patients with a C&I hospital number. 5.3 Only medicines for mental health conditions and on the trust formulary (or approved non formulary) may be prescribed. Under no circumstances should FP10HNCs be used to avoid formulary restrictions. Prescribing outside the scope of C&I treatment is considered inappropriate e.g. physical health care 4 FP10 HNC POLICY_PHA37_MAY 2016

6 conditions. Schedule 2 Controlled Drugs should not be prescribed on FP10HNC forms. 5.4 An approved or generic name should always be used and the supply limited to a maximum of 28 days. 5.5 Registered non medical prescribers must make clear, on the prescription, their status (e.g. IP for independent prescriber) and identification number (issued by the professional body) 5.6 All prescribers must follow the trust Medicines Management policy. 5.7 Prescriptions should be: Written legibly in ink or otherwise to be indelible Dated and include the name and address of the patient Signed in ink by the prescriber Cross through blank areas of the FP The age and date of birth of the patient should preferably be stated, and is a legal requirement when prescribing for children under 12 years. 5.9 To reduce the risk of misuse, blank prescriptions should never be pre-signed 5.10 The prescription forms have pre-printed details for each service. This includes the team name, address, contact telephone number and site identifier code. Prescribers should only use the FP10 prescriptions designated for the team in which they are working and have been authorised to use Under no circumstances should FP10s be used for self-prescribing or for the treatment of colleagues, family or friends Note: the removal of FP10HNCs off site to use on non C&I patients is regarded as theft. Where suspected, investigations will be carried out and may result in disciplinary action. 6 Setting up or amending FP10 sites 6.1 New service/team sites have to be registered with the NHS Business Authority before FP10s can be issued. An individual identifier code (RRQ ##) is allocated for each service and authorisation given to the NHSprinters to produce the pads with pre-printed contact details and code for the individual service/team. 6.2 Any services requiring FP10 supplies must send a request to the Chief Pharmacist. This should be done by the lead consultant or service/team 5 FP10 HNC POLICY_PHA37_MAY 2016

7 manager completing a Request for new FP10 prescription code or notification of amendment form (appendix 2). 6.3 Assurance must also be given that suitable storage facilities and governance procedures are in place at the team base. 6.4 Requests should be made well in advance ( at least 1 month) to allow sufficient time for the registration, printing and supply process. 6.5 Amending site details: If there are any changes made to a site or service details e.g. name, address, telephone number, the consultant or service/team manager must complete the relevant details on the Request for new FP10 prescription code or notification of amendment form (appendix 2) and send to the Chief Pharmacist. 6.6 Note: The Chief Pharmacist is the trust registered person authorised to submit new requests and changes to FP10 sites to NHSBSA. Forms may be sent to pharmacy department HMHCpharmacy@candi.nhs.uk to be forwarded to Chief Pharmacist. 7 Ordering & Supply of FP10s 7.1 FP10 prescription pads are ordered from the suppliers by pharmacy on receipt of an request from an authorised prescriber, service/team manager or pharmacist (SMS only). The consultant, service/team manager or pharmacist (as appropriate) should be copied in on the request. The request must include the following details: Type of prescription (FP10 HNC) Quantity (number of pads) Name of service and identified code (RRQ ## on bottom of prescription) 7.2 Requests should be ed to HMHCpharmacy@candi.nhs.uk The request must be filed and saved by pharmacy to ensure audit trail of all requisitions. 7.3 Back up stock of FP10 pads will not be kept in the pharmacy and orders will only be placed on receipt of the request. Therefore teams must monitor levels and ensure requests are sent to pharmacy allowing sufficient time (2 weeks) for ordering and collection. 7.4 Pharmacy will notify the team when the prescriptions are ready for collection and a suitable time can be arranged. 7.5 The prescriptions pads must be collected by an authorised member of staff from the pharmacy at Highgate Mental Health Centre. The member of staff must bring trust ID, a copy of the request and the completed link record sheets from previous supply. FP10s will not be handed out to any member of staff without a valid trust ID. 7.6 The FP10 HNC prescription pads are supplied as single pads of 50 prescription forms with 5 link record sheets pre-printed with the sequential serial numbers 6 FP10 HNC POLICY_PHA37_MAY 2016

8 for the corresponding pad. ie. each link record sheet contains 10 serial numbers. (See appendix 3 for example copy) 7.7 If there are gaps in the link record sheets (from previous supply), which cannot be accounted for, the Chief Pharmacist must be notified and an incident report completed on datix. An internal investigation must be carried out by the service/team manager/pharmacist (SMS) in conjunction with the consultant. Refer to section 13: Lost or stolen prescription forms / prescription forgery, for futher details on procedure. 7.8 All supplies of FP10 prescriptions will be recorded by pharmacy in the Prescription Issue Record Book, with the following details documented: Number of pads Serial numbers of the prescription forms Trust site identifier code Service/team name Date of receipt Date of issue and collection Name and signature of person collecting Name and signature of pharmacy staff issuing 7.9 The member of staff collecting the FP10s must check the serial numbers on the prescription forms before signing for receipt in the pharmacy Prescription Issue Record Book 8 Recording receipt of FP10s at team base 8.1 Upon return to the team base the authorised person must record receipt of the pads in the FP10 record book: Date prescription pads collected First and last serial number* of each pad of FP10 HNC prescription forms Name and signature This should be checked and counter-signed by a witness at the same time 7 FP10 HNC POLICY_PHA37_MAY 2016

9 8.2 * Note: The serial number is the 10 digit code at the bottom of the form. The last (11 th digit) is randomly generated and should not be recorded as part of the serial number sequence. 8.3 The FP10 record book must be kept on site at the team in a locked cupboard. There must be a clear audit trail for prescription forms so the trust and teams know which serial-numbered forms they have received and which have been issued. 8.4 All records must be kept for 3 years 9 Storage of FP10s 9.1 FP10s are controlled stationary and an NHS asset that must remain secure at all times. 9.2 Prescriptions may only be used by: Prescribers employed by the trust Authorised by the consultant Non medical prescriber in accordance with trust Non Medical Prescribing policy 9.3 Authorised staff handling FP10s will be held accountable for the security of the prescription pads whilst in their possession. It is the responsibility of individual prescribers issued with prescription forms to keep them secure at all times. This also includes the corresponding link record sheets. Records must be kept on the link record form accounting for all prescriptions issued to patients. 9.4 FP10s must not be lent or borrowed from other prescribers. 9.5 Full pads of FP10s must not be taken out of the cupboard for use by an individual prescriber. 9.6 When not in use FP10s must be stored in a designated locked cupboard (ideally digital keypad cupboard) within a section of the clinical area that patients do not have access to.keys / codes must be kept secure and access to the cupboard containing FP10s must be restricted to the authorised staff. FP10s must not be stored in cupboards used to store controlled drugs. 9.7 Blank prescriptions should never be pre-signed. Completed prescription forms can be left at the clinic, awaiting collection by the patient. These forms should be stored in a lockable cupboard/drawer that is not accessible to anyone other than the authorised members of staff. 9.8 Home visits: When making home visits, prescribers working in the community should take suitable precautions to prevent the loss or theft of forms, such as ensuring prescription pads are carried in a lockable carrying case or are not left on view in a vehicle. If they have to be left in a vehicle, they should be stored in a locked compartment such as a car boot and the vehicle should be fitted with an alarm. 8 FP10 HNC POLICY_PHA37_MAY 2016

10 9.9 Prescribers on home visits should also, before leaving the team base, record the serial numbers of any prescription forms they are carrying. Only a small number of prescription forms should be taken on home visits. 10 Recording use of FP10s 10.1 Due to the seriousness of offences which may be committed as a result of loss or stolen prescriptions forms, prescribing teams are required to document FP10 use noting: Date of prescribing Patient name Prescription details (i.e. medicine prescribed) Serial number Prescriber 10.2 The corresponding link record forms for each pad/prescription forms should be used to record this information. Additionally a record may be made in the patient notes The serial numbers of the remaining pad should be regularly (at least weekly) checked against the entries in the record book. All unresolved discrepancies must be reported to the Chief Pharmacist as soon as possible and investigated. 11 Spoiled Prescriptions 11.1 If an error is made on the prescription, best practice is for the prescriber to do one of the following: Cross out the error, initial and date the error then write the correct information on the same form Put a line through the script and write spoiled or void on the prescription form. Record on the link form, clearly indicating the script has been spoiled, sign and date against the serial number on the log. The spoiled form should then be stored in the secure cupboard pending destruction. 12 Destruction of FP10s 12.1 FP10s may be destroyed in the following situations: Individual unwanted FP10 forms (e.g. spoiled or cancelled e.g. due to change in medication) FP10 forms with outdated team details (once updated forms have been received) Team no longer in operation. Team no longer uses FP10 forms Any other situation where prescriptions are no longer required 9 FP10 HNC POLICY_PHA37_MAY 2016

11 12.2 A record of the destruction must be made in the FP10 record book. Destruction must be witnessed by the service/team manager or designated pharmacy staff The following must be recorded: Serial number of the individual form, or in the case of a full pad the first and last serial number. Name and signature of authorised prescriber destroying FP10s Name and signature of witness (service manager / pharmacy staff) Date 12.4 The forms must be shredded and disposed of in confidential waste The destruction record must be kept for at least 18 months. 13 Lost or stolen prescription forms / prescription forgery See appendix 4 for flow chart of procedure for missing/lost/stolen FP10 prescriptions 13.1 In the event of FP10s being misplaced the Chief Pharmacist / Controlled Drug Accountable Officer (CDAO) must be informed immediately. In the absence of the Chief Pharmacist a senior (lead) pharmacist must be informed Missing/lost/stolen NHS prescription from(s) notification form (appendix 5): All relevant details of the lost/stolen prescriptions forms must be recorded on the notification form and sent to the Chief Pharmacist (and lead pharmacist in the absence of the Chief Pharmacist) and the Local Security Management Specialist (LSMS) immediately NHS England alert form (appendix 6): The Chief Pharmacist / designated pharmacy staff or Consultant / service manager must complete the NHS England alert form providing as much detail as possible and specifying where the alert is to be sent out e.g. community pharmacies across Camden, Islington, Kingston and surrounding areas. The alert form must be sent to NHS 10 FP10 HNC POLICY_PHA37_MAY 2016

12 England (London) at NHS England will then cascade the alert across the relevant areas specified in the alert form All FP10 related incidents (e.g loss or theft) must be reported by completing a trust incident report on datix A record of the missing forms and serial numbers must be made in the record book (full pad) or the link form (individual forms) If controlled drugs are involved the Chief Pharmacist/CDAO will inform the CDAO NHS England (London) at england.londonaccountableoffice@nhs.net 13.7 If the missing forms cannot be accounted for the Local Security Management Specialist (LSMS) will inform the local counter fraud specialist and the police as required. The LSMS should initiate the investigation and submit the Missing/lost/stolen NHS prescription form(s) notification form to the NHS Protect national database prescription@nhsprotect.gsi.gov.uk (copy attached in appendix 5) The form may be completed by the reporting staff or the LSMS. If completed by the reporting staff, it should be forwarded to the LSMS so be submitted to the NHS CFSMS. This is to ensure that they are aware of the incident and can initiate an investigation if required Any theft or loss must include the following details: Date and time of loss/theft Date and time of reporting loss/theft Place where loss/theft occurred Type of prescription stationary Serial numbers Quantity Details of LSMS to whom the incident was reported The information submitted will be added to the national database, depending on the circumstances. The LSMS may circulate a regional or national alert about the incident. If an alert is sent out, the trust LCFS must be included on the distribution list. This will enable the LCFS to ensure that necessary information is shared with the health body and the neighbouring one to help detect the use of missing/stolen forms For further details on incident response and key responsibilities in incident investigation refer to appendices 7 & FP10 HNC POLICY_PHA37_MAY 2016

13 14 Forged prescriptions / unauthorised alterations 14.1 If there are any signs of alteration not authorised by the prescriber, the dispensing chemist should contact the prescriber to confirm authenticity of the prescription via telephone If a forgery or unauthorized alteration is confirmed, the following details of the caller should be recorded by the person taking the call: Name of caller and contact number Name and address of pharmacy Details of prescription and the date of issue 14.3 A trust incident report must be completed on datix Further guidance on forged prescriptions is available via the General Pharmaceutical Council at 15 Dissemination and implementation arrangements 15.1 The document will be circulated to all consultants and service managers who will be required to cascade the information to member of their team. It will be available to all staff via trust intranet. Managers must ensure that all staff are briefed on the contents and understand what it means for their practice. 16 Training requirements 16.1 None specific for this policy 17 Monitoring and audit arrangements 17.1 The use of prescription forms within the trust is monitored by the Chief Pharmacist The Prescription Pricing Division (PPD) of the NHSBA records details of all prescription forms on a restricted access database. This is after the prescription form has been dispensed by the community pharmacy and then submitted for payment to the PPD. FP10 prescribing is monitored via epact data on a monthly basis and anomalies in prescribing will be investigated The trust maintains an audit trail for prescription forms so that services/teams know which serial numbered forms they have Refer to the trust Controlled Drug Policy for further information on the monitoring of controlled drug prescribing Individual teams maintain records of prescription forms that are issued, voided, destroyed, lost or stolen The pharmacy staff will conduct audit checks on the safe and secure handling of FP10 prescriptions by each team on a quarterly basis Details of the audits will be included in the trust annual medicines management report and presented at the DTG and Quality Committee. 12 FP10 HNC POLICY_PHA37_MAY 2016

14 Monitoring of prescription forms Elements to be monitored Lead How trust will monitor compliance Frequency Reporting arrangements Acting on recommendat ions and Lead(s) Change in practice and lessons to be shared Safe and secure handling of forms FP10 prescribing Incidents Chief Pharmacist Chief Pharmacist Chief Pharmacist Audit epact data Quarterly Monthly DTG DTG Required actions will be identified and completed in a specified timeframe Datix Ongoing DTG Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 18 Review of the policy This policy shall be reviewed in 2 years or earlier should a new regulation came into effect. 19 References NHS Protect: Security of Prescription forms Guidance, Business Services Authority Security Management Service, March 2011, updated July 2015 Royal Pharmaceutical Society of GB: Medicines, Ethics and Practice: A guide for pharmacists: 36 th edition July Pharmaceutical Press 20 Associated documents Trust Medicines Management Policy Trust Controlled Drugs Policy 13 FP10 HNC POLICY_PHA37_MAY 2016

15 Appendix 1: FP10 HNC Prescriber Signature form This form should be completed / updated every 6 months and sent to Pharmacy HMHCpharmacy@candi.nhs.uk Team details: RRQ code Name of prescriber Registration No. Professional status Signature To be completed by Lead Consultant / Service manager This a current list of staff authorised to prescribe on FP10HNC prescription forms on behalf of the service. I will ensure that the above named prescribers are familiar with and follow trust policy for FP10 prescriptions I will ensure that FP10HNC prescription forms are stored securely in a locked cupboard and only accessible by authorised prescribers/nominated authorised person (see current Standard Operating Procedures). Lead Consultant / service manager Signature Date 14 FP10 HNC POLICY_PHA37_MAY 2016

16 Appendix 2: Request for new FP10 code or notification of amendment New hospital unit / new FP10 code request Deletion of hospital unit / FP10 code Change of address Change of telephone number Change of unit name Current details Updated details (including new site details) Name of Hospital Unit Address Postcode Telephone Number Hospital Unit Code (RRQ ##) Speciality Type Effective Date NB. You must allow 10 working days to process the information before ordering prescriptions Signed...(Authorised Signatory) Print name & job title Telephone Number.. Date... This form must be sent to the Chief Pharmacist to be processed. 15 FP10 HNC POLICY_PHA37_MAY 2016

17 Appendix 3: FP10 (HNC) PRESCRIPTION LINK RECORD Please fill in the details requested on this form each time an FP10 (HNC) prescription is issued for a patient from this pad. Please return a copy of this completed record sheet to pharmacy on collection of new pad: RRQ Pharmacy Department Highgate Mental Health Centre Dartmouth Park Hill London N19 5NX Serial No: From XXXXXXXXXX To XXXXXXXXXX Prescription Serial No. Date (that Prescription is issued to patient) Prescribers Name Prescribers Signature Patients Initials Prescribed Medicines and Quantity Missing/Void Prescriptions signature & date Non Medical Prescribers Those using FP10 HNCs, should stamp each form. Nurse Independent / Supplementary Prescriber and record their NMC PIN number, or Pharmacist Independent / Supplementary Prescriber and record their RPSGB registration number This record should be retained for 3 years from the last entry 16 FP10 HNC POLICY_PHA37_MAY 2016

18 Appendix 4: Flow chart for lost or stolen FP10 prescription forms Prescriber/NHS staff discovers Prescription form(s) Missing / lost / stolen Retrace steps to investigate missing prescription forms Inform Consultant, Service Manager and Chief Pharmacist (In absence of Chief Pharmacist inform Senior Pharmacist) Complete notification form (appendix 5) Send to Chief Pharmacist (and senior pharmacist) & Local Security Management Specialist (LSMS) Give details: -number of forms missing, serial numbers of the prescription forms, address on the pad/forms, site code (RRQ ##), when and where from the prescription forms are missing / stolen /lost Chief Pharmacist (or senior pharmacist) to complete alert form (appendix 6) and send to NHS England england.lon-alerts@nhs.net for cascading to local community pharmacies and neighbouring CCGs Chief Pharmacist (Trust Controlled Drug Accountable Officer - CDAO) to notify NHS England (London) CDAO england.londonaccountableoffice@nhs.net if controlled drug involved Chief Pharmacist and LSMS officer determine if local police should be contacted LSMS notifies NHS Protect (prescription@nhsprotect.nhs.uk) (LCFS is notified via NHS Protect national alert) Write prescriptions in specific colour ink for a minimum of two month after incident reported Pad holder must complete a Trust Incident Form on Datix Consultant, Service manager, Chief Pharmacist and LSMS must agree to decide how best to avoid a repeat incident occurring If the missing/lost prescription forms are found, the above persons must be notified 17 FP10 HNC POLICY_PHA37_MAY 2016

19 Appendix 5: Missing/lost/stolen NHS prescription form(s) notification form This form should be completed by consultant / team manager and sent to Chief Pharmacist & Local Security Management Specialist (LSMS) Organisation: Date reported: Name and position of person reporting: Contact Number: Contact/Team Address: Clinic/site identification code/number: RRQ The following numbered NHS prescription forms have been identified to us as lost or stolen (state the prescription form serial numbers): Issued to (patient initials): Patient DOB: / / Patient Address: From To Medication Prescribed (include supervised/unsupervised, dose and dates of prescription) Total number of prescription forms lost / stolen: Prescription Type: FP10HNC Pads FP10HMDA SS Box single sheet FP10HMDA S Box single sheet Green Blue Green Date & time of theft / loss: Place where loss/ theft occurred: Details of the clinic/doctor/nurse etc from whom prescription form(s) have been lost or stolen (include full name, position): Has theft been reported to police? Y / N Yes No 18 FP10 HNC POLICY_PHA37_MAY 2016

20 Name of police station and crime reference number: Has an alert and warning been issued to all local pharmacies and GP surgeries within area? (via NHSEngland ) Yes No Please give details of any ink changes or security measures and the effective dates if these measures: Name Position Signed Dated LSMS to return this completed form by to 19 FP10 HNC POLICY_PHA37_MAY 2016

21 Appendix 6 Private and confidential Urgent Communication Incident Memo To: (Specify community Pharmacies / GP) Re: Stolen/Lost Prescriptions GP/Prescriber name and GMC no Practice/Team address FP10 identifier code Pharmacy address Patient name(s) / identifier (if relevant) Description of person(s) (if relevant) Medicines name, dose and quantity (if relevant) Serial numbers of missing prescription forms Incident details (please include as much detail as possible about the nature of incident, the number of times incident or similar events have occurred, details on prescription if relevant (NHS or Private), is there a potential for harm or safety?) Send this form to England.lon-alerts@nhs.net 20 FP10 HNC POLICY_PHA37_MAY 2016

22 Appendix 7 Incident Response NATURE OF INCIDENT Discrepancy in prescription forms ordered and received. Following enquiries with the supplier, if discrepancy in prescription forms ordered and received cannot be accounted for, and forms are still missing. If prescription forms are lost through negligence or by accident. If prescription forms are stolen. If it is suspected that a presented prescription form is forged. WHO SHOULD BE CONTACTED? Contact supplier Ask the driver to remain on-site while the supplier is contacted. Notify the designated person with overall responsibility for prescription forms at the organisation, the CDAO, LSMS or nominated security management specialist and police as required. Report the matter using the organisation s incident reporting system. The matter must be reported as a security incident and an alert/warning circulated locally and/or nationally. Serial numbers of the missing forms must be submitted to the NHS Protect database using the appropriate notification form. Notify the designated person with overall responsibility for prescription forms at the organisation, the CDAO, LSMS and police as required. Report the matter using the organisation s incident reporting system. The matter must be reported as a security incident and an alert/warning circulated locally and/or nationally. Serial numbers of the missing forms must be submitted to the NHS Protect database using the appropriate notification form. Contact the police and report the matter using the organisation s incident reporting system. Notify the CDAO and LSMS or nominated equivalent. The matter must be reported as a security incident and an alert/warning circulated locally and/or nationally. Serial numbers of the missing forms must be submitted to the NHS Protect database using the appropriate notification form. Check with Prescriber then, if appropriate, notify the CDAO, police and contact NHS Protect via the NHS Fraud & Corruption Reporting Line Pharmacists may also wish to call the 21 FP10 HNC POLICY_PHA37_MAY 2016

23 If it is suspected that prescription forms are being misused. Pharmacy Reward Scheme on Check with Prescriber then, if appropriate, contact NHS Protect on ; contact the police and notify the CDAO. 22 FP10 HNC POLICY_PHA37_MAY 2016

24 Appendix 8: Key responsibilities in incident investigation Individual identifying loss of forms (e.g. Prescriber, Manager, person taking receipt of delivery) responsibilities Follow local procedures and guidance for the immediate reporting of incident (see annex A and C). Provide details of the number of prescription forms stolen, their serial numbers, and where and when they were stolen. Prescribers should follow local instructions following the loss or theft of prescription forms this may include writing and signing prescription forms in a particular colour for a period of two months. Organisation responsibilities Ensure matter is reported immediately to the supplier/police/cdao/lsms/lcfs/organisation as appropriate. Ensure a Missing/lost/stolen NHS prescription form(s) notification form is completed and submitted to the LSMS or nominated security management specialist (see annex B). Ensure incident form has been completed. Following the reported loss of a prescription form, the organisation will normally inform a prescriber to write and sign all prescriptions in a particular colour (normally red) for a period of two months. The organisation will inform all pharmacies in their area and adjacent CCGs/NHS England local area teams of the name and address of the prescriber concerned, the approximate number of prescription forms stolen and the period within which the prescriber will write in a specific colour. This will normally be put in writing within 24 hours with the exception of weekends. In consultation with the LSMS/LCFS, the organisation should take necessary action to minimise the abuse of the forms taken. The Local Security Management Specialist s responsibilities include: THEFT OF PRESCRIPTION FORMS (or lost or missing) Ensure matter has been reported to the police and CDAO and determine action taken/required. Ensure incident form has been completed on organisation s incident reporting system. Liaise with and inform relevant staff such as the chief pharmacist, medicines management team, director of clinical services and the nurse prescribing lead. This list is not exhaustive and the LSMS should inform all the appropriate staff. Investigate cases of THEFT by: taking a report of what has been stolen and where from, undertaking an audit trail, determining the value of the item, impact on healthcare, whether the incident was witnessed and, if so, taking witness statements where appropriate, co-ordinating the facts and concluding as applicable. Report investigations to the security management director. 23 FP10 HNC POLICY_PHA37_MAY 2016

25 Ensure a completed Missing/lost/stolen NHS prescription form(s) notification form is submitted to the NHS Protect national database. Liaise with/notify the LCFS or nominated anti fraud specialist as required. If legal advice is required, contact the NHS Protect Legal Protection Unit. The relevant NHS Protect Area Security Management Specialist can also provide support and advice. The Local Counter Fraud Specialist s responsibilities include: FRAUD/CORRUPTION FORGERY OR MISUSE OF PRESCRIPTION FORMS Ensure matter has been reported to the police and determine action taken. Ensure incident form has been completed on organisation s incident reporting system. Liaise with and inform relevant staff such as the chief pharmacist, medicines management team, director of clinical services and the nurse prescribing lead. This list is not exhaustive and the LCFS or nominated equivalent should inform all the appropriate staff. Investigate cases of specific FRAUD/CORRUPTION using police powers where appropriate. Report investigations to the director of finance. Refer to NHS Protect all cases of FRAUD/CORRUPTION appropriate to them. Inform NHS Protect of all cases of suspected FRAUD /CORRUPTION being investigated. Send full reports of all cases where the director of finance believes FRAUD/CORRUPTION to be present to NHS Protect, audit committee, internal and external audit. Liaise/notify the LSMS or nominated equivalent as required. 24 FP10 HNC POLICY_PHA37_MAY 2016

26 Appendix 9: Equality Impact Assessment Tool Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? No No No No No No No No No No N/A No N/A N/A N/A 25 FP10 HNC POLICY_PHA37_MAY 2016