Medication Supply within the Maternity Department protocol (CG532) Approval Approval Group Job Title, Chair of Committee Date Maternity Clinical Governance Committee Chair, Maternity Clinical Governance Committee 14 th July 2017 Drug and Therapeutics Committee Chair, Drugs & Therapeutic 7th June 2017 Committee Change History Version Date Author, job title Reason 1.0 April 2015 Joanne Collins, Lead Maternity and Children s Services Pharmacist New policy 1.1 May 2017 Samuel Bundu-Kamara, Deputy Chief Pharmacist Reviewed minor change to Lead Maternity pharmacists name, now a protocol Location: Policy hub/ Clinical/ Maternity/ Professional guidelines/ CG532 This document is valid only on date last printed Page 1 of 11
Contents 1.0 Purpose... 3 2.0 Scope... 3 3.0 Roles and Responsibilities... 3 3.1 Midwives... 3 3.2 Ward managers... 3 3.3 Pharmacists... 4 4.0 Definitions... 4 5.0 Back ground... 4 6.0 Process... 5 6.1 Discharge prescription... 5 6.2 Supply under midwife exemptions... 5 6.3 Pharmacy service... 5 6.4 Outside of pharmacy opening hours... 5 6.4.1 Supply of medication by ward staff... 6 Figure 1. Flow diagram of medication supply process in maternity.... 7 7.0 Consultation Undertaken... 8 8.0 Dissemination/Circulation/Archiving... 8 9.0 Implementation... 8 10.0 Training... 8 11.0 Monitoring of Compliance... 9 12.0 Supporting Documentation and References... 9 13.0 Equality Impact Assessment... 9 Appendix 1 Ward discharge prescription... 10 Other relevant corporate or procedural documents: This document must be read in conjunction with: The Code: professional standards of practice and behaviours for nurses and midwives. Nursing and Midwifery council - 2015. Medicines Policy version 5 CG078. Royal Berkshire NHS Foundation Trust. March 2017 This document is valid only on date last printed Page 2 of 11
1.0 Purpose This protocol has been developed to promote timely discharge of women within the maternity service, by optimising midwife led discharge, simplifying the supply process and reviewing the availability of suitable packs for medications that fall within the exemption lists for midwives, as well as reviewing the use of over-labelled medication. 2.0 Scope This protocol applies to the supply of discharge medications for women cared for within the maternity service within Royal Berkshire NHS Foundation Trust. 3.0 Roles and Responsibilities The following staff must comply with the relevant duties and responsibilities with regards to the supply of medication. 3.1 Midwives Each registered midwife is accountable for his/her own conduct and practice in accordance with the Nursing and Midwifery Council s (NMC) Code of practice. In exercising their professional accountability each midwife will: Always act in a manner so as to promote and safeguard the interests and well-being of patients and clients Ensure that no action or omission on their part, or within their sphere of responsibility, is detrimental to the interests, condition or safety of patients or clients Maintain, update and improve their professional knowledge and competence Acknowledge any limitations in their knowledge and competence and decline to supply medication unless they are able to do so in a safe manner. Report to a senior person or authority any circumstance in which safe and acceptable care cannot be provided to patients and clients. Avoid any improper delegation to others, which compromises the interests, wellbeing or safety of patients and clients. 3.2 Ward managers Ward or department managers are responsible for ensuring that midwifery staff meet competency for the supply of medicines listed within the midwife exemptions and are familiar with this protocol. It is every manager s responsibility to ensure that all their staff are informed as to which members of the team are deemed competent. It is the responsibility of the ward manager to ensure that the practice of supplying medication within line with midwife exemptions and over-labelled packs is audited to ensure that it is being carried out in accordance to the process outlined in this protocol. Where concerns are raised about the practice it is the This document is valid only on date last printed Page 3 of 11
duty of ward manager to report this to the Lead Maternity and Children s Services Pharmacist. 3.3 Pharmacists It is the responsibility of the Lead Pharmacist for Maternity and Children s Services to act on any concerns raised by midwifery staff, ward managers and consider withdrawing the service should this be appropriate. 4.0 Definitions GSL NMC P PGD POM Over-labelled pack Supply TTO Validate/validation General Sales List medicine Nursing and Midwifery Council Pharmacy medicine Patient Group Direction Prescription Only Medicine Pre-labelled medication for supply to patients. To lawfully provide a medicinal product directly to a patient or to a carer for administration to a patient To take out ; referring to discharge medications. The clinical checking and endorsing of a prescription by a pharmacist complete with information necessary for it to be dispensed and checked. 5.0 Background Supply of discharge medication is an avoidable cause of delayed discharge for maternity inpatients. The prescription and supply of all medicines in hospital should ensure maximum safety of patients combined with maximum benefit. Numerous national reports on the use of medicines in UK hospitals insist that all hospitals should be rigorous in their approach to safety of patients by eliminating hazards in the prescribing and supply of medicines. Under the Medicines for Human Use Act 2010, there are exemptions allowing midwives to supply and/or administer a specific list of prescription only medication (POM), and all Pharmacy (P) and General Sales List (GSL) medications within the course of their professional practice, without the need of a prescription. These exemptions allow the midwife to supply, but not to dispense; therefore over-labelled medication may only be supplied in accordance with a legally valid prescription. Trust guidance states that the use of over-labelled medications may be considered for: patients with relatively minor problems and whose medicine needs are simple, uncomplicated and not long term and who spend little time in the system and the ward stock the appropriate medication properly labelled and packaged This document is valid only on date last printed Page 4 of 11
and the registered professional (nurse or midwife) dispensing has received the appropriate training and understands his or her responsibilities. The majority of the women seen in the Maternity department fall within these parameters as they only require simple medications for minor conditions caused by their pregnancy or from delivering their baby. 6.0 Process 6.1 Discharge prescription A maternity discharge prescription (Appendix 1) must be completed for all patients requiring medication on discharge. The prescription is divided in to two parts. The first section is for medications that fall in to midwife exemptions and allow the supply of a standard pack (not over-labelled with directions) by a midwife without a prescription for a woman under their care. Section 2 is for medications that do not fall within the midwife exemptions and require a prescription. 6.2 Supply under midwife exemptions Any item required for supply under midwife exemptions may only be supplied by a midwife. The patient must be known to the midwife making the supply and the supply be made within the course of their professional practice. The patient should be directed to take the medication according to the manufacturers directions printed on the pack. The supply requires a check from a second midwife. 6.3 Pharmacy service A ward pharmacist will visit Marsh and Iffley wards on a daily basis Monday to Friday to deliver a clinical pharmacy service. As part of this service the pharmacist will validate all TTO medications that are prescribed in time for the visit. Where possible the discharge medication will be dispensed at ward level from the satellite using ward stock medication which the pharmacist labels or over-labelled packs. If this is not possible, the prescription will be sent to pharmacy for dispensing. On weekends and bank holidays, during pharmacy opening hours, the TTO prescription and the patient s drug chart must be sent to the pharmacy for clinical validation and dispensing. 6.4 Outside of pharmacy opening hours Outside of pharmacy opening hours an over-labelled pack may be considered for supply against a legally valid prescription if a suitable pack is available on the ward. This document is valid only on date last printed Page 5 of 11
6.4.1 Supply of medication by ward staff Registered midwives and nurses with current NMC registration may supply over-labelled medication that has been prescribed by a doctor or independent prescriber working within their field of practice. The over-labelled pack must be ward stock. Supply of an over-labelled pack by ward staff is classed as dispensing and must only occur outside of pharmacy working hours. The law requires that all dispensed medication is labelled with minimal information. This requirement includes the name of the patient and the date of dispensing. Appropriate dosage information, warnings and additional directions must also be stated. It is the responsibility of the midwife or nurse involved to ensure that each pack is complete, and understands important side-effects, contraindications and interactions. As part of the dispensing process a double check is required by another registered health care practitioner (a student is not acceptable). The dispensing must be documented on the discharge prescription. Any patient safety concerns must be raised immediately and reported to the nurse or midwife in charge. The lead pharmacist should be informed of any concerns at the next available time during pharmacy opening hours. This document is valid only on date last printed Page 6 of 11
Figure 1. Flow diagram of medication supply process in maternity. Medication supplied by midwives will be stocked in the Marsh discharge medication cupboard. This document is valid only on date last printed Page 7 of 11
7.0 Consultation Undertaken This protocol has been produced following consultation with the following individuals and groups: Pharmacy: Samuel Bundu-Kamara, Deputy Chief Pharmacist. Obstetrics and midwifery: Drug and Therapeutics committee Chair Maternity Clinical Governance Chair 8.0 Dissemination/Circulation/Archiving This protocol will be circulated to all maternity ward mangers for dissemination in relevant maternity areas. The Head of Governance will be responsible for archiving old versions of this document. 9.0 Implementation This protocol will be provided to all new midwives working in relevant maternity areas during their induction. 10.0 Training All midwives will be assessed as competent to undertake this role and newly appointed midwives will be assessed after being qualified for greater than six months. There is no mandatory training associated with this procedure. If staff have queries about its operation, they should contact their line manager in the first instance. This document is valid only on date last printed Page 8 of 11
Age Sex Disability Race Gender Reassignment Religion or Belief Sexual Orientation Marriage and Civil Partnership Pregnancy and Maternity Medication Supply within the Maternity Department (CG532) July 2017 11.0 Monitoring of Compliance Aspect of compliance or effectiveness being monitored Safety of supply against midwife exemptions Monitoring method Datix reports. Pulling notes Individual or dept. responsible for the monitoring Frequency of the monitorin g activity Group/committee which will receive the findings/ monitoring report Ward manager Yearly Maternity Clinical Governance Committee/ individual responsible for ensuring that the actions are completed Ward manager The Trust reserves the right to amend its monitoring requirements in order to meet the changing needs of the organisation. 12.0 Supporting Documentation and References 12.1 Changes to midwife exemptions, Nursing and Midwifery Council Circular. July 2011. 12.2 The Medicines for Human Use (Miscellaneous Amendments) Order 2010. No. 1136. Statutory Instruments. 12.3 Medication Supply within Maternity (including Midwife Exemptions). Portsmouth Hospitals NHS Trust. August 2010. 13.0 Equality Impact Assessment Do different groups have different needs, experiences, issues and priorities in relation to the proposed protocol/change proposal? Is there potential for or evidence that the proposed protocol/change will not promote equality of opportunity for all and promote good relations between different groups? Is there potential for or evidence that the proposed protocol will affect different population groups differently (including unintended discrimination against certain groups)? Is there public concern (including media, academic, voluntary or sector specific interest) in potential discrimination against a particular population group or groups? N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N This document is valid only on date last printed Page 9 of 11
Name of Protocol: Medication supply within the Maternity Department Do different groups (age, disability, race, sexual orientation, gender, religion or belief) have different needs, experiences, issues and priorities in relation to the proposed protocol? This service is specific to maternity services and therefore its use is specific to women. Is there potential for or evidence that the proposed protocol will not promote equality of opportunity for all and promote good relations between different groups (age, disability, race, sexual orientation, gender, religion or belief)? No Is there potential for or evidence that the proposed protocol will affect different population groups (age, disability, race, sexual orientation, gender, religion or belief) differently (including possibly discriminating against certain groups)? No Is there public concern (including media, academic, voluntary or sector specific interest) in potential discrimination against a particular population group or groups (age, disability, race, sexual orientation, gender, religion or belief)? No Based on the information set out above I have decided that a full equality impact assessment is not necessary. Name: Samuel Bundu-Kamara, Deputy Chief Pharmacist. Department: Pharmacy Date: June 2017 This document is valid only on date last printed Page 10 of 11
Appendix 1 Ward discharge prescription This document is valid only on date last printed Page 11 of 11