Medicines Prescribing Policy

Transcription

1 Medicines Prescribing Policy Who Should Read This Policy Target Audience All Consultant/Senior Medical Staff All Junior Medical Staff All Non-Medical Prescribers All Pharmacy Staff All Ward/Unit Managers Version 2.0 November 2015

2 Ref. Contents Page 1.0 Introduction Purpose Objectives Process Procedures connected to this policy Links to Legislation, National Standards, Policies and References Roles and Responsibilities for this policy Training Equality Impact Assessment Data Protection Act and Freedom of Information Act Monitoring the policy is working in practice 25 Appendices 1.0 Confirmation of Verbal Order by a Doctor 26 Version 2.0. November

3 Explanation of terms used in this policy Medicines - are defined in the Medicines Act 1968 as 'pharmaceutical products in dosage form for administration to human beings'. Medical gases, vaccines and preparations of human blood are included in this definition. Medicines are categorised as: - General Sales List Medicines (GSL) these can be sold or supplied without pharmacist involvement, for example, small pack of paracetamol tablets sold at a supermarket - Pharmacy Medicines (P) these are only available from a pharmacy. P medicines may be purchased, or may be obtained on a doctor or dentist s prescription - Prescription Only Medicines (POM) these can only be obtained in accordance with a doctor's or dentists or other authorised prescriber's prescription. Antibiotics and vaccines are examples of Prescription Only Medicines. POMs can only be supplied from a pharmacy or from a dispensing doctor. Controlled Drugs are a special category of Prescription Only Medicines, to which the Misuse of Drugs legislation applies. BNF - British National Formulary (latest edition) COSHH - Control of Substances Hazardous to Health as per COSHH Regulations 2002 Care Quality Commission (CQC) - the independent regulator of all health and social care services in England Chief Pharmacist - the professional head and manager of the pharmaceutical service for an organisation Community Clinics - Trust premises, community clinics, health centres, Social Services settings, and psychiatric day hospitals Community Domiciliary - service provided by health visitors to patients in their own homes or nursing/care homes Community Nurse - a district nurse, health visitor, registered nurse, specialist nurse, psychiatric nurse working or carrying out their duties in the community, or a school nurse, a nurse advisor to the elderly, a palliative care nurse or a registered nurse working under the direction of a district nurse Controlled Drug (CD) - Controlled Drugs, regulated under the Misuse of Drugs Act 1971 and any medicine included in Schedules 1, 2 and 3 of the Misuse of Drugs Regulations 2001 Controlled Stationery - any stationery which, if misused, could be open to abuse within the system to obtain medicines fraudulently Deputy - a person who is authorised to act in place of another External Use - application to the skin, teeth, mucosa of the mouth, throat, nose, eye, ear, vagina or anal canal - it does not include throat sprays, throat pastilles, throat lozenges, throat tablets, nasal drops, nasal sprays, nasal inhalations, teething preparations or dental gels. GMC - General Medical Council GPhC - General Pharmaceutical Council HCPC Health and Care Professions Council Health Visitor - a qualified and registered nurse or midwife who has undertaken further (post registration) training in order to be able to work as a member of the primary healthcare team. The role of the health visitor is about the promotion of health and wellbeing and the prevention of illness. Healthcare Professional - a registered practitioner in an occupation which requires specialist education and training in practical skills in health care; the professions concerned are self-regulating and practitioners are expected to satisfy their profession s accepted standards of practice and conduct Version 2.0. November

4 Licensed Medicines - all medicines, oral, external, prescription only, pharmacy medicines, general sales list medicines, or controlled drugs with a valid Marketing Authorisation (MA) for use within the UK Medication error - any preventable event that may cause or lead to inappropriate medication use and/or patient harm while the medication is in the control of the healthcare professional, patient or carer. Medicines and Healthcare products Regulatory Agency (MHRA) - a government agency responsible for ensuring that medicines and medical devices work and are acceptably safe National Patient Safety Agency - a special health authority created to co-ordinate all the efforts of all those involved in health care to learn from patient safety incidents occurring in the NHS Patient Group Directions (PGD) - a specific written instruction for the supply or administration of medicines to clinical groups of patients who may not be individually identified before presentation for treatment Pharmacist - a person registered in the register of Pharmaceutical Chemists with the General Pharmaceutical Council established in pursuance of the Pharmacy Act 1852, and maintained in pursuance of Section 2 (1) of the pharmacy Act 1954 Pharmacy Technician - a person holding an NVQ Level 3, BTEC, SCOTVEC, City and Guilds or Apothecary Hall qualification in Pharmaceutical Science and registered with the General Pharmaceutical Council as a Pharmacy Technician PODs - Patients Own Medicines (or Drugs) this term is used in the context of medicines that are a patient s own property, brought into NHS premises for treatment of that patient Policy - sets out the aims and principles under which services, groups, or units will operate. A policy outlines roles and responsibilities, defines the scope of the subject covered, and provides a high level description of the controls that must be in place to ensure compliance. Prescriber - a healthcare professional that is legally authorised to prescribe a medicinal product, including medical and non-medical prescribers Prescription - an order for the dispensing of a medicinal product. The order is presented to a professional who is legally authorised to dispense. The order must be either:- a) in writing in a legally prescribed format and signed by the person authorised by law to prescribe b) made, using a Trust-agreed electronic prescribing system, by the person authorised in law to prescribe medicinal substances, and who has been provided with a secure, individual computer access password PRN Medication PRN is a Latin term that stands for pro re nata, which means as the thing is needed Self-administration - the process of patients administering their own medicines. Standard Operating Procedure (SOP) - a laid-down procedure detailing all relevant steps and activities to be followed in carrying out a given process, procedure, or in a given situation TTO (to take out) Medication a supply of medicines to take home on discharge from hospital Unlicensed Medicines - any medicine that has not been granted a valid Marketing Authorisation for use within the UK Writing - includes any form of notation, whether by hand or by printing and written has a corresponding meaning Version 2.0. November

5 1.0 Introduction Black Country Partnership NHS Foundation Trust is committed to managing medicines safely, efficiently and effectively as a key component for the delivery of high quality patient centred care. Medicines play a significant role in the care of the people who use our services and creating an effective system for managing medicines in an appropriate and timely manner is a vital component of providing the best possible care, positive outcomes and reducing incidents of harm. This policy applies to all individuals involved in prescribing employed or contracted by Black Country Partnership NHS Foundation NHS Trust, including all locum and agency staff and to all activities relating to the prescribing of medicines within inpatient, out-patient, community and any residential settings. Where there is a specific prescribing related activity which is not covered by this core document, a written standard operational procedure (SOP) will be produced to assist staff who prescribe 2.0 Purpose The aim of this policy is to describe the procedures and good practice that should be used by staff when prescribing medication to people who use our services and to make clear the legal and professional standards that are expected from them. 3.0 Objectives Promote the highest standards of medicines management and minimise risks associated with the use of medicines Compliance with the Care Quality Commission s Fundamental Standard for Safe Care and Treatment regarding the safe management of medicines, below which the provision of regulated activities and the care people receive must never fall Compliance with nationally agreed standards set out in the Duthie Report, Crown Report, relevant medicines legislation and guidance from the UK Nursing and Midwifery Council, General Pharmaceutical Council and the General Medical Council 4.0 Process for Prescribing 4.1 Prescription Form and Requirements 4.2 General Requirements 4.3 Patient Information 4.4 Name of the Medicine 4.5 Dose 4.6 Changing Drug Doses 4.7 Dose Deliberately Withheld by Prescriber 4.8 Frequency and times of Administration 4.9 Signature of Prescriber 4.10 Patients detained under the Mental Health Act 4.11 PRN Medication 4.12 Number of Forms 4.13 Cancellation of Treatment 4.14 Medicines Reconciliation 4.15 Oxygen Prescriptions 4.16 Validity of Prescriptions 4.17 Documentation of Allergies / Hypersensitivities Version 2.0. November

6 4.18 Verbal Prescriptions 4.19 Retention of Prescription Sheet 4.20 Security of Blank FP10 Prescription Forms 4.21 Specimen Signatures 4.22 Prescription Amended by a Pharmacist 4.23 Prescribing Unlicensed Medicines 4.24 Communication with GPs on Prescribed Medicines 4.25 Medicines on Discharge 4.26 Medicines for Trust Staff or family members 4.27 Alternative and Complimentary Medications 4.28 Patients at Risk from Self-Poisoning / Misuse of Medicines 4.29 Trust Medicines Formulary 4.30 Shared Care Agreements 4.31 High Dose Antipsychotic Medication 4.32 Hypnotic/Benzodiazepine Medication Prescribing 4.33 Prescribing incidents 4.34 Prescribing opiate substitution treatment 4.35 Monitoring side-effects / Adverse Drug Reactions 4.1 Prescription Form and Requirements Medicines Prescribing Policy - A prescription facilitates the provision of the correct medicine from Pharmacy - A prescription provides a permanent legal record of the patient s medication - A prescription directs administration of the medicine to the patient Prescriptions must only be written on charts or forms approved by the Trust s Medicines Management Committee. Guidance on prescription writing provided in the BNF should be followed at all times. 4.2 General Requirements Be appropriate, complete, unambiguous, legible and in capitals Preferably in black ink, otherwise dark blue but no other colour Be signed and dated appropriately Adhere to legal, formulary and Trust policy requirements 4.3 Patient Information The prescription must bear the patient s:- Forename, surname and address NHS Number Date of Birth Weight in kg (where appropriate) 4.4 Name of the Medicine The prescription must include:- Name of the Medicine Use the Recognised International Name (rinn) This should be written clearly and not abbreviated The trade name (proprietary or brand name) should also be used for combination products that have not been given a co- title by the BNF For mixed compound preparations the individual drugs contained should be stated where appropriate (e.g. co-tenidone = atenolol and chlortalidone) Version 2.0. November

7 The trade name should be used where appropriate, e.g. for ciclosporin, tacrolimus, lithium and theophylline and certain modified release products, because the various brands differ in length of action or bioavailability. 4.5 Dose Appropriate use of decimal points Quantities less than 1 gram should be written in milligrams (e.g. 500mg not 0.5g) Quantities less than 1milligram should be written in micrograms (e.g. 500 micrograms not 0.5mg) Quantities of less than 1 litre should be written in millilitres (e.g. 15mL, not 0.015L) When decimal points are unavoidable, a zero should be written in front for values less than 1 (e.g. 0.5ml not.5ml) Abbreviations of units should always be written in the singular, e.g. 10mg, not 10mgs For liquid oral medicines, the dose should be prescribed by mass rather than volume (e.g. milligrams) whenever possible. With some drugs, however, e.g. magnesium hydroxide, there is no mg dose and ml is acceptable. For mixed compound preparations, which are supplied as a unit dose, the number of tablets (or other units) to be given should be stated (e.g. co-dydramol tablets) The words: micrograms, nanograms, or units should not be abbreviated. Insulin must always be prescribed with units written out in full Use of the phrase as directed is not acceptable. Explicit dosage instructions, including route of administration should be stated Only use acceptable abbreviations as per the table below:- Between the lip and the gum = Buccal External use = Ext Inhalation = Inhal Intravenous = IV By Mouth = ORAL Per Rectum = PR Subcutaneous = SC Intramuscular = IM Nebulisation = NEB Per Oral = PO Per Vagina = PV Under the Tongue = Sublingual All other routes of administration must be written out in full. 4.6 Changing Drug Doses When a dose needs to be changed, it is mandatory for prescribers to completely rewrite the prescription to avoid misinterpretation. The original entry must be cancelled. Crossings out are not acceptable and can make retrospective analysis/audit of doses given to patients difficult. When amending a TTO prescription please ensure that all copies of the TTO and discharge summaries/letters are amended. 4.7 Dose Deliberately Withheld by Prescriber The dose administration box should be filled with than X and the reason for the decision should be documented on the treatment sheet and in the patient s notes. Version 2.0. November

8 4.8 Frequency/times of Administration The times of administration must be specified by the prescriber in the appropriate column on in-patient prescription sheets, together with instructions such as bd or tds. Abbreviations such as bd or tds are only to be used alone i.e. without times, for as required (PRN) medicines, and on take home/outpatient prescription sheets. The following table lists abbreviations that are the standard means of indicating a dose regimen:- Once a day = OD Each morning = OM Each night = ON Twice daily = BD Three times daily = TDS As per X Protocol = X Protocol Four times daily = QDS In the morning = Mane At night = NOCTE Once only = STAT As required with indication and interval stated = PRN All other dose regimens must be written out in full e.g. 6 hourly, 4 hourly etc. For Children: Always prescribe paediatric preparations whenever possible to avoid risk of giving an adult dose. For Weekly Doses: Prescribe using the word every followed by the day of the week. It is the responsibility of the prescriber to block out the administration boxes not required on the prescription to prevent the dose being given daily. The Trust Pharmacy Team can block out administration boxes if the prescriber has not done so. Please to NPSA alert for weekly oral methotrexate. For Depot Injections: Always prescribe in full generic form e.g. zuclopenthixol decanoate. Always prescribe with the interval expressed using the word every e.g. every 3 weeks; this can be abbreviated to 3/52, followed by the day of the week. It is the responsibility of the prescriber to block out the administration boxes not required on the prescription to prevent the dose being given daily. 4.9 Signature of Prescriber Each prescription item must be validated by the full signature of a registered medical practitioner or authorised prescriber. The signature should be legible and the printed name of the prescriber should be written next to the signature. Initials or abbreviated signatures are not an adequate means of identification of a prescriber or serve as authorisation of a prescription Patients detained under the Mental Health Act The Mental Health Act 1983 provides the prescriber with a three month period to develop a treatment programme to meet the patient s needs. The three month period starts on the occasion when medicines for the mental health disorder were first prescribed. Version 2.0. November

9 The MHA Office will remind the approved clinician at least 4 weeks before the expiry of the 3-month period. The approved clinician should seek the patient s consent to continuing medication and record the discussion in the medical notes including an assessment of the patient s capacity to consent. If the patient refuses consent or is deemed unable to provide a reliable consent the approved clinician must request a second opinion appointed doctor (SOAD) visit from the Mental Health Act Commission, which is co-ordinated by the MHA Office. Practitioners must not prescribe or administer medicines to patients detained under the Mental Health Act 1983 after the three month period without first ensuring that a valid T2, T3 or Section 62 form has indicated that the treatment can be given. These forms apply to medication prescribed to alleviate the symptoms of mental illness and their side effects as detailed in the Mental Health Act Pleas refer to the Mental Health Act Policy and associated documents on the Trust Intranet PRN Medication The indication for as required medication must be clearly stated. The hourly interval, monitoring requirements and the total dose in 24 hours must be clearly stated. Prescribe PRN medication by one route only. Care must be taken to avoid possible duplication or interaction of medicines prescribed PRN and those prescribed regularly. PRN medication must be reviewed frequently by the prescriber to inform alterations to regular medication e.g. management of side-effects Number of Forms Where there is a requirement for most drugs to be prescribed than spaces on one chart, then multiple charts may be used and they must be clearly marked 1 of 2, 2 of 2, etc. and must run concurrently. Old medication charts must be clearly cancelled by a diagonal line through the regular prescriptions page and a signature of the person cancelling and then be filed in the patient s notes. When supplementary forms are used for the dosage of anticoagulants, clozapine, etc., the drug must still be prescribed on the main prescription sheet. This also applies to depot antipsychotic medication in outpatient areas, where a separate prescription sheet for the depot is used for administration. If medication is required urgently and is not present as ward stock, the prescription should be drawn to the attention of the pharmacy department. A pharmacist will review the prescription and ensure it is appropriate, safe, legal, and unambiguous and does not interact with other medication before authorising the supply. Other medications which have been prescribed will be routinely screened by the clinical pharmacy team as part of scheduled ward visits. Version 2.0. November

10 4.13 Cancellation of Treatment It is important that a suitable way of cancellation of the prescription is adopted such as a bold cross or line being drawn across the prescription. The cancellation must be dated and signed in full and all detail must remain legible for audit purposes. The use of correction fluids or tapes is not permitted and must not be used. When the stop date box is used in anticipation of the treatment cancellation date, this indicates that at midnight on the date specified the prescription must be discontinued and no further doses are to be administered. Cancellation of areas of the medicines administration record by the prescriber is also another permitted way of indicating when the medicine should be administered and when it should be discontinued. In the case of time-limited prescriptions e.g. for seven days or review in a week the Pharmacist will either cancel or request confirmation that the prescription has been reviewed before a further supply is made Medicines Reconciliation The Trust s Medicines Reconciliation Policy requires that the admitting doctor ensures all available sources of medication history information (e.g. GP information, MAR chart, prescription from transferring hospital, insulin passport) are checked before a prescription is written. A copy of the source of the information should be attached to the prescription. Medicines reconciliation processes should be initiated by a healthcare professional within 24 hours of admission in line with the Medicines Reconciliation Policy. Please refer to the Medicines Reconciliation Policy on the Trust Intranet for more detailed guidance Oxygen Prescriptions Oxygen prescriptions must state on the inpatient prescription chart:- - Delivery device i.e. mask, nasal cannula - Percentage oxygen (for masks), or flow rate (for nasal cannulae) - The circumstances in which the patient should be given oxygen All prescribing of oxygen must be in accordance with British Thoracic Society guidelines. When a patient is to receive nebuliser therapy and oxygen is to be used as the carrier this must be prescribed as above. Please refer to the Trust s Prescription and Administration of Oxygen to Adults Policy and the NPSA alert for Oxygen and Trust Procedure for oxygen therapy for children guidance Validity of Prescriptions Prescriptions will remain valid unless:- For Inpatients: - They are discontinued - The duration of the course of treatment has been stated and reached. Antibiotic prescriptions must be reviewed daily and should only be continued beyond 2 days for intravenous, 5 days for oral, if the clinical condition requires it. - They relate to a previous admission - All administration recording spaces have been filled or cancelled - The drug prescribed is not covered by consent to treatment documentation required Version 2.0. November

11 under the Mental Health Act The prescription was more than 2 months ago For Outpatient / Community Settings More than 6 months old For Controlled Drugs All controlled drug prescriptions are only valid for 28 days and maximum supply is for 30 days. Please refer to the Controlled Drugs Policy for more detailed information. If the prescription becomes ambiguous or unclear at any time, the practitioner responsible for the administration of the medicine, or the pharmacist must request the prescriber to rewrite it Documentation of Allergies / Hypersensitivities All prescription charts must specify whether or not the patient has any drug allergies/ hypersensitivities. It is the responsibility of the admitting prescriber to record this information on admission (i.e. allergy details or No known drug allergy NKDA) on the prescription sheet as well as in the medical notes. No medication should be prescribed or administered to a patient in the absence of allergy status on the drug chart. Any administrations occurring will be classed as a medication error due to the risks involved Verbal Prescriptions A verbal order cannot be accepted on its own: there must be confirmation via . (SMS text message is also acceptable in exceptional circumstances where an is not practicable). It can only remain in force until the doctor has countersigned the verbal order and has written a new prescription (within 24 hours during the week, or 72 hours at weekends and bank holidays). Verbal prescriptions taken by nurses must only be in extreme circumstances or in an emergency situation Registered Nurses must be aware of Standards 11 and 12 issued by the Nursing and Midwifery Council in the Standards for medicines management (2010) The order must be taken by a registered nurse and verified by a Duty Senior Nurse where available or a registered second nurse or Healthcare Support Worker and repeated back to the prescriber over the telephone. The confirmation sheet (please see Appendix 1) must be used for recording the instruction. No medication can be given until verification by has been received from the prescriber. The doctor must send an to confirm the instruction, which the Nurse must print out for attachment to the prescription chart. SMS text is acceptable in exceptional circumstances, using the confirmation sheet to verify the instruction. The prescriber must state the following:- Name of the medication (excludes controlled drugs) Reason for the medication Dose and route to be administered Timing and frequency of administration Version 2.0. November

12 Maximum dose in 24 hours if PRN Patient s initials Last 4 digits of patient s NHS, OASIS or Mental Health number There must be no immediately patient identifiable data included. Medicines Prescribing Policy The registered nurse taking the verbal prescription must inform the prescriber of all other current medicines prescribed, any drug related allergies, sensitivities or adverse reactions as detailed on the medicines chart or in the notes. This is essential if a previously un-prescribed drug is required. In exceptional circumstances a Medical Practitioner may need to prescribe remotely for a previously un-prescribed medicine. The Registrant (Nurse) is accountable for ensuring all relevant information has been communicated to the prescriber and s/he may refuse to accept a remote prescription if it compromises care to the patient. In this instance s/he should document accurately why a refusal has taken place on these grounds. The verbal order must be recorded as a prescription on the prescription chart with the addition verbal order and the date, time, the two signatures of the nurse and second person and name of the prescriber giving the verbal order. Any prescriptions for one off medications should be recorded in the stat dose section of the prescription chart. The prescriber must countersign this prescription within normally 24 hours (up to 72 hours maximum) and write a new prescription. A record of the verbal order must also be documented within the patient s notes. The confirmation record must be filed in the notes when it has been countersigned by the authorising doctor. In any circumstances where the process is NOT followed this should be reported as incident via DATIX the trust s incident reporting system Retention of Prescription Sheet All prescriptions (except Out-patient and FP10 forms) must be permanently filed in the patient s notes, which are retained according to nationally defined minimum periods. Since the original TTO form and FP10 will be retained by the pharmacy when the medicines are dispensed, a copy of the TTO form or the number of the FP10 form and exact details of what was prescribed must be filed in the relevant patient notes Security of Blank FP10 Prescription Forms Please refer to Security of FP10 Prescription Forms Standard Operating Procedure 4.21 Specimen Signatures It is the responsibility of medical staffing to send specimen signatures of all authorised prescribers in the Trust, including Locums, on appointment, to the Pharmacy department. It is the responsibility of the Non-Medical Prescribing Lead to collate and send specimen signatures of all authorised Non-Medical Prescribers in the Trust, on appointment, to the Pharmacy department Prescription Amended by a Pharmacist The role of the Pharmacist is to ensure that all prescriptions for inpatients within trust settings undergo an appropriate professional/clinical screening process to ensure Version 2.0. November

13 they are accurate and safe and are suitably endorsed to indicate who has carried out this procedure. A medicine may be administered against a prescription, which has been clarified by a pharmacist. Pharmacist amendments will be in green ink and initialled. A pharmacist may amend a prescription to prevent misinterpretation by the person administering the medicine or to correct an obvious prescribing error. Pharmacists may also substitute one preparation for another in certain circumstances that have been agreed with the Medicines Management Committee. Pharmacists may continue a patient s existing drug therapy, adjust or correct dosages or frequencies, in accordance with their clinical judgement. The pharmacist will sign and date any entries and annotate with their title and whether the prescriber was contacted (p.c.) or not (p.n.c.). An entry in the patient s notes may be indicated and/or a conversation with the prescriber out of courtesy or for education depending upon the circumstances. Prescriptions amended by pharmacists should be held in the same authority as that of a doctor (i.e. they are valid for administration by other healthcare professionals and dispensing purposes.) Prescriptions may be endorsed in purple ink and initialled by a pharmacy technician (Band 5 given approval by the divisional pharmacist and Band 6 and above) with:- The Approved (generic) Name Other clarification in accordance with Pharmacy standard operating procedures 4.23 Prescribing Unlicensed Medicines Please refer to the Trust s Policy on Unlicensed Medication Communication with GPs on Prescribed Medicines Wolverhampton Sites Only In outpatient clinics, patients who require urgent changes to medication or to initiate treatment should be prescribed a 28-day supply, if clinically appropriate, using an FP10. Formal Information on any changes or new prescribing should be received by GPs within fourteen days so that further supplies can be arranged in good time through primary care. It is not acceptable to issue a white letter to the patient/carer to present to their GP to request a new supply or change of medication for Wolverhampton patients. Walsall, Dudley and Sandwell Sites In outpatient clinics, for patients who require changes to medication or to initiate treatment, it is acceptable to issue a white letter to the patient/carer to present to their GP to request a new supply or change of medication for patients. Primary care physicians will then ensure the prescriptions are raised and supplies made. In the case of urgent changes being required, an FP10 prescription may be written and issued to the patient Medicines on Discharge The discharge prescription chart, should be sent to, or collected by, pharmacy in good time and preferably at least 24hrs before discharge. In particular, patients who require a monitored dosage system (e.g. NOMAD ) will need more input and Version 2.0. November

14 time to dispense and organise the appropriate arrangements by liaising with the relevant community pharmacy. Discharge prescriptions for patients who are being started for the first time on a monitored dosage system should ideally be written 48 hours before discharge to give sufficient time for arrangements to be made. Where FP10 prescriptions are being used to obtain a discharge monitored dosage system for a patient, a Trust pharmacist clinical check should be undertaken on the FP10 prior to issue. Out of hours, a copy of the FP10 should be made and issued to the trust pharmacy by the next working day so that a retrospective clinical check can be performed. Nurses must never supply drugs from ward stock to patients going home. Patients should not be discharged from the ward without the appropriate drugs and a copy of the TTO. In exceptional circumstances, at the request of the Nurse in Charge and following the approval by Pharmacy, medicines may be dispensed directly to a patient from the Pharmacy Department. Details of discharge prescriptions using the appropriate section of the duplicate TTO form must be received by GPs as soon as possible and will indicate whether each medicine is to be continued. If an amendment is required on a TTO, all copies of the TTO should be amended, or the electronic copy corrected to ensure all parties receive the correct information. Changes to medication during the hospital stay should be explained in the discharge summary to the GP Medicines for Trust Staff or family members Medicines must NOT be taken from a ward or clinical area stock for personal use by staff, or administered to a staff member. - An FP10 prescription form must not be used for a staff member unless registered as a patient of the Trust - Doctors and other prescribers may not prescribe for themselves or anyone with whom they have a close personal or emotional relationship, and should be registered with a GP outside of their family - Nurse prescribers should refer to NMC standards: Practice standard 11: Prescribing for family and others - Pharmacist prescribers should refer to GPhC Professional standards and Guidance for Pharmacist prescribers August 2007 standard 2.6 when prescribing for family and others - Medical prescribers should refer to GMC Good practice in prescribing and managing medicines and devices March 2013, section 17 - The correct route for a staff member to obtain essential medicines is either via Occupational Health or via the GP. In exceptional circumstances, a consultant may prescribe for a member of staff after gaining express permission from the Chief Pharmacist or his deputy 4.27 Alternative and Complimentary Medications Complimentary Therapies are therapies that may be used in conjunction with orthodox medical, nursing, and paramedical treatments to enhance the well-being, Version 2.0. November

15 quality of life or symptomatic relief of the service user. If a service user wishes to administer to themselves, or requests administration of, complimentary or alternative medicines they must discuss this with the doctor responsible for their care. This discussion should normally include a pharmacist and nurse looking after the service user. This discussion should also include the mental capacity of the individual to understand any implications of using an alternative therapy opposed to conventional treatments. If the use of alternative or complimentary medication is agreed, this should be recorded on the prescription chart. The service user is responsible to provide medication and this must be brought to the attention of the nurse/doctor responsible for their care. The service user must be made aware that the Trust cannot accept responsibility for the quality or efficacy of these medications unless approved using the set process and this must be recorded in the medical notes 4.28 Patients at Risk from Self-Poisoning / Misuse of Medicines If a Nurse on a Community visit considers that a patient is at risk and capable of planned or accidental self-poisoning they should:- Remove the medicines from the home, preferably with the patient s or relative s permission, and store in the hospital medicine cupboard Notify the Consultant and/or GP Enter details of medicine, strength and quantity in the patient s nursing record If there are mental health capacity issues then the prescriber must be contacted for further discussion If the situation does not warrant immediate removal but the healthcare professional has a concern these must be documented and shared with the rest of the team and the prescriber. If a patient being discharged or given leave from hospital is similarly at risk, they should only be provided with a small supply of medicine e.g. for a day, a few days or a week. This should be discussed with the pharmacy team as necessary Trust Medicines Formulary The Formulary is an agreed list of medications by the local health-economy which are recommended to be prescribed based on the best available evidence. The aim of the formulary is to support best prescribing in both hospital and community settings to ensure consistent care across the health economy, increase knowledge and experience of a smaller number of medications and to decrease waste and maximise cost savings. Each new medication is assessed by the Trust s Medicines Management Committee and the Area Prescribing Committee for inclusion in the formulary by reviewing the clinical trial evidence and cost effectiveness. Prescribers should only prescribe medication from the formulary which is accessible via the Trust Intranet. Version 2.0. November

16 Range of Medicines that can be prescribed a. Only those medicines approved for use by the Trust s Medicines Management Committee b. The choice of medicines within the Formulary must be generally guided by the positioning advice within it, in order to maximise cost effectiveness c. Medicines newly introduced into the market place may only be prescribed within Black Country Partnership NHS Foundation Trust after due consideration and approval by the Trust s Medicines Management Committee d. Limited exception is given to the continuation of patients own medicines, for medicines undergoing clinical trial, or highly specialist treatment for individual patients. However, prior agreement must be obtained from the Trust s Pharmacy Department. e. A defined procedure authorised by the Trust s Medicines Management Committee must be followed in order to request a new medicines for use within Black Country Partnership NHS Foundation Trust. Please refer to the Managed Entry of Drugs Policy for more details Shared Care Agreements The aim of Effective Shared Care Agreements (ESCA) is to enable General Practitioners (GPs) to undertake prescribing responsibility for specialist therapies and other therapies that may affect / interact with specialist therapies e.g. Lithium therapy. An ESCA will only be written when it has been agreed that shared care is an appropriate option, and will include a statement of the specialist unit s / general practitioner s responsibilities. An ESCA will provide all of the necessary information to general practitioners about complex or high cost therapies that their patients may receive following specialist referral. The specialist prescriber will complete the ESCA for each individual patient and send it to the general practitioner. When the general practitioner confirms agreement to take on the responsibility for prescribing, the ESCA will be retained in the patient s notes. A general practitioner has no obligation to take part in shared care and if they decline, responsibility for prescribing and care will remain with the specialist prescriber. All Effective Shared Care Agreements are required to be endorsed by the Trust s Medicines Management Committee and the Area Prescribing Committee and therefore agreed across the local health economy. Please see Guidelines for the use of ESCAs document and associated drug specific ESCAs available on the Trust Intranet High Dose Antipsychotic Medication The Royal College of Psychiatrists 2006 Consensus Statement on High Dose Antipsychotics states, On the basis of current evidence, high dose prescribing, either with a single agent or combined antipsychotics, should rarely be used and then only for a time-limited trial in treatment resistant schizophrenia after all evidence based approaches have been shown to be unsuccessful or inappropriate... Version 2.0. November

17 High dose is defined as a total daily dose of a single antipsychotic which exceeds the upper limit stated in the Summary of Product Characteristics (SPC) or BNF or a total daily dose of two or more antipsychotics which exceeds the SPC or BNF maximum, using the percentage method The percentage method requires the conversion of the dose of each medication into a percentage of its BNF maximum dose, and adding the percentages together a cumulative dose of more than 100% is a high dose. Any medication prescribed in excess of BNF recommended doses must be discussed and recorded in the patient s notes, with an explanation and a clear care plan which must be reviewed by the multidisciplinary team at regular intervals. The patient and carers must where possible be informed and a note of this recorded in the patient s notes. Physical monitoring must be carried out at baseline and at regular intervals during treatment including an ECG. Please refer to the Trust s High Dose Antipsychotics Policy for more information Hypnotic/Benzodiazepine Medication Prescribing Prescribing of Hypnotic or Benzodiazepine Medication should be minimised and reviewed regularly to reduce dependence. Any hypnotic/benzodiazepine medication should be reviewed prior to discharge and only a small amount supplied to encourage a separate review of this medication in outpatients or by the patient s General Practitioner Prescribing incidents Although this list is not exhaustive, some examples of prescribing errors are the:- Incorrect medicine Incorrect dose of medicine Incorrect frequency Drug sensitivity / allergy box not completed Incorrect route Incorrect time of administration Failure to sign the prescription All prescribing incidents must be reported via the Trust DATIX Incident Reporting System. The Governance Team will ensure that the responsible consultant is informed of the incident and that this is formally addressed under supervision and in line with the Trust s Medication Errors Policy Prescribing opiate substitution treatment Always confirm a patient is using opiates (using a urine testing kit) or already being prescribed opiate substitution before prescribing. Always contact the patient s key worker at the local addiction service to confirm the dose, drug being taken and if the patient has been compliant. If the patient presents out of hours or the key worker cannot be contacted do not prescribe opiate substitution treatment. Reassure the patient that significant withdrawal does not occur until well over 24 hours from the last dose; treat any withdrawal with symptomatic medication only. Version 2.0. November

18 Prescribe opiate substitution on TTOs and leaves for information only. A supply of opiate substitution medication must only be ordered via addiction services. If not possible, the patient must return to ward to be administered their opiate medication on site under the supervision of BCPFT staff Monitoring side-effects / Adverse Drug Reactions Prescribers must fully inform all patients of all the side-effects that could be caused by a medication prior to prescribing it (Choice and Medication website). At each review prescribers should ask patients about any side-effects they are suffering including sexual side-effects if appropriate, and monitor physical parameters regularly against baseline tests taken on admission. Any observations from nursing staff or carers must also be sought and the use of PRN medication for side-effect management must be reviewed regularly. All severe and unexpected side-effects must be reported to the prescriber and also raised via the Trust DATIX Incident Reporting System and reported through the MHRA Yellow card reporting scheme Please refer to the Trust s Physical Assessment, Examination and On-going Care Policy for more detailed guidance 5.0 Procedures connected to this Policy Security of FP10 Prescription Pads Medicines Management in Crisis Resolution and Home Treatment Teams 6.0 Links to Relevant Legislation The Human Medicines Regulations 2012 The regulations replaced most of the Medicines Act 1968 and about 200 statutory instruments with a simplified set of rules following a review of the UK s medicines legislation. The regulations implemented European directive 2001/83/EC relating to medicinal products for human use (the medicines directive) and set out a comprehensive regime for the authorisation of medicinal products for human use; for the manufacture, import, distribution, sale and supply of those products; for their labelling and advertising; and for pharmacovigilance. The regulations also introduced greater involvement of patients and healthcare professionals in reporting medicine safety issues. The Misuse of Drugs Act 1971 The Act controls the availability of drugs considered to be dangerous or otherwise harmful, and which have the potential for diversion and misuse. These drugs are listed in the Act and termed controlled drugs. Controlled drugs are further classified according to their perceived harmfulness into Class A, B or C drugs, with Class A drugs being the most harmful. The Act introduced the concept of irresponsible prescribing and the terms controlled drugs to replace the previously used expression dangerous drugs. Version 2.0. November

19 The Misuse of Drugs Regulations 2001 The Regulations authorise and govern certain activities which would otherwise be illegal under the Misuse of Drugs Act. The Regulations identify those health care professionals who may legitimately possess and supply controlled drugs. They also establish a regime of control around prescribing, administrating, safe custody of, dispensing, record keeping and destruction or disposal of controlled drugs. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) These regulations introduce the new fundamental standards, which describe requirements that reflect the recommendations made by Sir Robert Francis following his inquiry into care at Mid Staffordshire NHS Foundation Trust. They enable the Care Quality Commission to pinpoint more clearly the fundamental standards below which the provision of regulated activities and the care provided to people must not fall, and to take appropriate enforcement action where we find it does. Part 3 has two sections: Section 1 describes the requirements relating to persons carrying on or managing a regulated activity. Section 2 introduces the fundamental standards below which the provision of regulated activities and the care people receive must never fall. They came into force for all health and adult social care services on 1 April Regulation 8: General Regulation 9: Person-centred care Regulation 10: Dignity and respect Regulation 11: Need for consent Regulation 12: Safe care and treatment Regulation 13: Safeguarding service users from abuse and improper treatment Regulation 14: Meeting nutritional and hydration needs Regulation 15: Premises and equipment Regulation 16: Receiving and acting on complaints Regulation 17: Good governance Regulation 18: Staffing Regulation 19: Fit and proper persons employed Regulation 20: Duty of candour Regulation 20A: Requirement as to display of performance assessments The Human Rights Act 1998 One of the main laws protecting human rights in the UK, it contains a list of 16 rights (called articles) which belong to all people in the UK, and outlines several ways that these rights should be protected. These rights are drawn from the European Convention on Human Rights, which were developed by the UK and others in the aftermath of World War II. The Human Rights Act may be used by every person resident in the United Kingdom regardless of whether or not they are a British citizen or a foreign national, a child or an adult, a prisoner or a member of the public. Version 2.0. November

20 The Human Rights Act has two main aims, to promote a culture of human rights by making sure that basic human rights underpin the workings of government at the national and local level and enabling access to human rights here at home, instead of only being able to go to the European Court of Human Rights It does this by placing a legal duty on all public authorities, including NHS organisations and staff and mental health tribunals carrying out public functions, to respect and protect human rights in everything that they do. This means that public authorities have legal responsibilities for respecting, protecting and fulfilling human rights. This duty is important in everyday situations because it enables individuals to challenge poor treatment and to negotiate better solutions. 6.1 Links to Relevant National Standards Care Quality Commission s Fundamental Standards introduced 1 April 2015 Regulation 11: Need for consent Where a person lacks mental capacity to make an informed decision, or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice. Discussions about consent must be held in a way that meets people s communication needs. This may include the use of different formats or languages and may involve others such as a speech language therapist or independent advocate. Consent may be implied and include non-verbal communication such as sign language or by someone offering their hand when asked if they would like help to move. Consent must be treated as a process that continues throughout the duration of care and treatment, recognising that it may be withheld and/or withdrawn at any time. When a person using a service or a person acting lawfully on their behalf refuses to give consent or withdraws it, all people providing care and treatment must respect this. Regulation 12: Safe care and treatment The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people s health and safety during any care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. 6.2 Links to other Key Policies Unlicenced Medicines Policy The manufacture and sale or supply of medicinal products is controlled by central European legislation (mainly Directive 2001/83/EC) and national legislation (The Human Medicines Regulations 2012); this ensures that the medicinal product is safe, effective and of appropriate quality. All medicinal products on the market must have a marketing authorisation, which is granted when regulatory authorities are satisfied that the drug in question has proven Version 2.0. November