ACUTE DAY UNITS MEDICINES MANAGEMENT STANDARD OPERATING PROCEDURE (SOP) May 2017
Policy title Acute day units medicines management standard operating procedure PD MP15 reference Policy category Clinical / Pharmacy Relevant to Clinical staff in acute day units and pharmacy staff Date published May 2017 Implementation May 2017 date Date last New SOP. reviewed Next review April 2019 date Policy lead Lucy Reeves, Chief Pharmacist Contact details Accountable director Approved by (Group): Document history Email: Lucy.Reeves@candi.nhs.uk Vincent Kirchner, Medical Director Acute Division (AD Com) May 2017 Date Version Summary of amendments May 2017 1 New SOP Membership of the policy development/ review team Consultation Beverly Boateng, Specialist Pharmacist Audrey Coker, Lead Pharmacist for Clinical Services. David Curren, Community Modern Matron, Acute Division Marian McHugh, Acute day unit manager Dr Toby Thompson, Consultant Psychiatrist South Camden Crisis Services Lucy Reeves, Chief Pharmacist DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. i
Contents Page 1 Introduction 1 2 Aims and objectives 1 3 Scope of the policy 1 4 Duties and responsibilities 1 5 Prescriptions 2 6 The Mental Health Act 2 7 Medicines reconciliation 3 8 Administration of medicines 3 9 Clozapine 4 10 Supply of medicines 4 11 Patient medicines information 6 12 Prepacks 6 13 Emergency medicines 7 14 Controlled drugs 7 15 Disposal of medicines 7 16 Audits 7 17 Medicines incidents 8 18 Frequently asked questions 8 19 Dissemination and implementation arrangements 8 20 Training requirements 9 21 Review of the policy 9 22 References 9 23 Associated documents 9 24 Appendix 1: Equality impact assessment tool 10 ii
1. Introduction NHS Trusts are required to establish, document and maintain effective systems to ensure that medicines and controlled stationery are handled in a safe and secure manner. The Trust Medicines Management Policy and Trust Controlled Drug Policy and Trust FP10 HNC prescription policy define the processes to be followed within Camden & Islington NHS Foundation Trust. This document defines the specific procedures to be followed in acute day units for the handling of medicines in accordance with the relevant overarching principles & processes set out in these Trust policies and procedures. This procedure must be read in conjunction with these Trust policies. 2. Aims and objectives To set out clear guidance and procedures to all staff involved in the management of medicines including controlled drugs. Ensure consistent, high standards of practice. Ensure safe working practices in the ordering, storage, prescribing, administration and disposal of medicines. To minimise risks and ensure the safety of service users and staff. 3. Scope of the policy This standard operating procedure relates to the services provided by rth Camden Acute Day unit and Jules Thorn Acute day unit. All health professionals who are involved in the prescribing, supervision, administering, ordering and monitoring of medicines. 4. Duties and responsibilities The acute day unit manager has overall responsibility for ensuring staff receive the necessary training and adhere to the procedures in this document. This includes regular monitoring of practice and ensuring any incidents are reported and managed appropriately. The overall availability and administration of medicines within the acute day unit is the responsibility of the most senior or designated registered nurse on shift. All staff are responsible for following these procedures and ensuring their knowledge and competencies are kept up to date and any incidents are reported promptly using the approved process. member of staff must accept a task beyond their capability or training. All individuals have a responsibility to ensure that they are competent in medicines management roles e.g. deliver medicines, administration, check the administration of a medicine, or supervise self-administration depending on the scope of their practice. 1
4.1. Roles and responsibilities Role Responsibilities Pharmacist Pharmacists provide a level 2 medicines reconciliation service for all patients. Pharmacists must screen all charts. Provide medicines information service. Patient counselling on request. Provide medication & wellbeing presentations on request Collect TTA prescriptions for return to pharmacy. Provide medicines management training for staff at least annually. Medical staff Prescribe appropriate medicines based on a thorough assessment. Prescribe medicines with the use of trust medicine charts, TTA forms and FP10s. Can issue prepacks in accordance with trust policy. Assess Patient Own Drugs (PODs). Medicines reconciliation. Nursing staff Administer or supervise self-administration of medicines. Issue prepacks in accordance with trust policy. Assess PODs as per the trust standard operating procedure (assessing and using patient s own drugs (PODs) standard operating procedure). Monitor side effects of medication. Monitor and support patient s concordance. 4.2. Pharmacist visit The pharmacist will visit NCADU, three times weekly on Monday, Wednesday and Friday mornings. Pharmacists do not usually visit Jules Thorn Acute Day Unit. However pharmacists can be contacted via available contact numbers. 4.3. Pharmacy services outside regular opening hours Every effort must be made for medicines to be ordered within normal pharmacy working hours (i.e. Monday Friday, 9.00am 5.00pm). 5. Prescriptions The acute day units use the crisis team medicine chart to prescribe all medicines belonging to the patient. If medicines supervision is required, the crisis team chart has an allocated section to document supervision of self-administration/administration. 6. The Mental Health Act Patients referred from the wards (on section 17 leave) must have copies of the T2, T3 or section 63 attached to the acute day charts (or crisis team chart where applicable). Some patients from the community may have community treatment orders (CTO12 forms) copies of which must be attached to the charts. Medicines prescribed and supplied, administered or supervised must adhere to the T2, T3, section 62 and CTO12 forms. Pharmacists must refer to the procedure for clinically screening prescriptions covered by section 58, section 62 of the Mental Health Act or a Community Treatment Order. 2
7. Medicines reconciliation Medicines reconciliation must be carried out for all patients referred from the Community. There are two stages to medication reconciliation: o Level 1 must be carried out by the nursing or medical staff and a crisis prescription chart written. If a patient is registered with a GP surgery, a copy of the GP patient summary must be obtained at the time (either from the GP or via access to national Summary Care Records (SCR) spine). Alternative sources of GP records are the Camden integrated digital record (http://cidrportal.camdenccg.nhs.uk ) and in Islington the shared record viewer (https://sharedrecordviewer.healthcaregateway.co.uk/home). o Level 2 must be carried out by pharmacy. The member of staff must make an entry into the electronic patient records. Level 2 medicines reconciliation must be completed within 72 hours. All medicines must be written on the prescription chart irrespective of whether these medicines are supervised/administered. Medicines not to be supervised can be written in the section of the chart Medicines obtained via the GP/over the counter and not prescribed or supervised. If medication needs to be taken at the acute day unit, it must be prescribed to enable supervision of self-administration to take place. Information about apparent side effects, non-adherence/partial adherence and incorrect dosage must be documented in the electronic patient record and fed back to the medical team/prescriber and discussed with a pharmacist as appropriate. See the Trust medicines reconciliation Procedure 8. Administration of medicines Patients that attend the acute day units may require supervision/administration of their medication. Administration of medicines can only be undertaken by registered nurses (RNs). Medicines supplied by the GP must be routinely used provided the prescription is up to date. Refer to assessing and using patient s own drugs (PODs) standard operating procedure to ensure their suitability (http://ciftap06/sorce/apps/sorce_doc_manager/actions/view_doc.aspx?docid=2276&revid=23 02). The purpose of this procedure is to outline the process of assessing PODs to determine their suitability for use and the appropriate action to take including the disposal of such medicines. RNs are responsible for the supply/issuing of TTA medication received from pharmacy or pre-packs. Administration of depot antipsychotic medication can be arranged with the patients community team. Assistant practitioners/support workers must not be involved in administration/supply of medicines. If the supervision of self-administration is clinically indicated, this must be supervised by nursing staff and the crisis team chart must be used which has an allocated section to document supervision of self-administration/administration. See the trust policy: Supporting the self-administration of medication (http://ciftap06/sorce/apps/sorce_doc_manager/actions/view_doc.aspx?docid=3234&revid=32 47). If the dose of a medicine is changed, a new supply with correct instructions must be requested from the pharmacy or via an FP10. The medicine instructions on the label must not be altered by the medical or nursing staff. 3
9. Clozapine When patients are referred for a clozapine titration by a community team, the referral must include information stating whether the patient has been assessed for capacity to consent to clozapine treatment including the associated necessary blood tests, BP and pulse monitoring. The patient must also demonstrate sufficient ability to cooperate with the requirements of the process. This patient should be willing and able to attend the Day Unit for at least 6 hours every weekday during the first two weeks of the titration, and to accept daily evening and weekend home visits. Alternatively if patient cannot attend the acute day unit, a referral must be made to the crisis team to undertake the titration. Patients who are prescribed clozapine as part of a re-titration must be under the care of both the crisis team and the acute day unit staff. This role involves the administration and supervision of clozapine. For new patients prescribed clozapine, it must be agreed (by the ADU and the referring community team) who will register the patient with Clozapine Patient Monitoring Service and facilitate blood tests. This information must be documented in the electronic patient notes. Staff must liaise with clozapine clinic staff regarding any patients under their care. Guidance on the dosing regimen can be obtained from the Clozapine treatment guidelines. If a patient misses one dose, the medical team responsible for prescribing clozapine must be informed. If a patient misses or refuses clozapine for more than 48 hours, the patient must be re-titrated from a starting daily dose of 12.5mg/25mg, back to the usual maintenance daily dose. A titration prescription must be written. The team pharmacist must be informed of this as soon as possible, and advice sought as appropriate. If the titration is to be undertaken, it must be prescribed on the titration section of the crisis team chart. Monitoring must be carried out as outlined in the Clozapine treatment guidelines Clozapine must be prescribed on the crisis team chart (variable section). This chart must be shared between both teams to reduce the risk of administration errors. The ADU and crisis team must make a decision of who will be responsible for prescribing the clozapine (usually the team with the most input into the patients care). For more information, refer to the Clozapine treatment guidelines on the trust intranet or the pharmacy department. 10. Supply of medicines Staff must ascertain whether service users obtain their medicines from their GP. Maintenance prescriptions already supplied by the GP, must continue to be supplied by the GP. If a medication is commenced or the dose changed by the acute day unit, then the following will apply:- 1. For NCADU: Medicines are requested with the use of TTA forms. This is collected by the visiting pharmacist on Mondays. 2. For JT: The prescription charts are sent to Pharmacy at St Pancras on Wednesdays and sent to Highgate mental health centre for dispensing. The prescriptions are for 7 days unless otherwise stated. For bank holiday periods, liaise with pharmacy to ensure that there is sufficient supply. 4
If medicines are required on days when there is no scheduled pharmacist visit, the prescription chart must be delivered to pharmacy (via courier or a member of staff) for the required medicines to be dispensed against the prescription chart. Medicines are not permitted to be dispensed from the acute day units (stock). 10.1. Supply of medicines to patients homes 10.2. Patients must be encouraged to collect medication by attending the acute day unit. If the patient does not collect medication, he/she should be encouraged to collect it on the next working day. 10.3. Medication on discharge Patients who have been discharged from acute day unit can be prescribed a maximum of 14 days medication. The patient must contact their GP for further supplies. TTAs must be prepared in advance of the pharmacist visits. If a TTA is required between visits, then the TTA and prescription chart will need to be sent to the dispensary by the Acute Day Unit staff. Medical and nursing staff must ensure that a discharge notification detailing medicines (i.e. medicines that have been stopped or started, remains unchanged etc) is sent to the GP within 24 hours. 10.4. Delivery of medicines NCADU: Medicines are delivered on Wednesday. For supply and delivery of medicines outside of these times, the original prescription and the TTA form must be sent to pharmacy via a courier. It is the responsibility of NCADU to organise for a courier to collect the medicines and deliver to the team base. JTADU: Medicines are delivered on Friday. For supply and delivery outside of these times, the pharmacist on site should be contacted to screen the prescription. It is the responsibility of JTADU to organise for a courier to collect medicines if required after/outside transport delivery times. These medicines must be delivered to the team base. 10.5. Receipt of delivered medicines Deliveries should be accepted by nursing or medical staff only. Medication bags are sealed and must only be opened by nursing or medical staff. Deliveries must not be left unattended at team bases or when there are no staff on duty or present. Nursing staff must check the delivery notes for prepacks and file for two years. A box file can be used for this purpose. TTA medication should be checked against the TTA form when giving it to the patient. Discrepancies must be highlighted to pharmacy immediately. If a doctor or nurse is not at the team base to accept a delivery, it may be accepted by another member of staff (assistant practitioner/support worker). The delivery should not be opened and should not be stored in an area which patients have access to. The delivery should be handed over to a nurse or doctor as soon as possible. The nurse or doctor should store the medication in the medicine cupboard. 5
10.6. Storage of medicines Medicines must be stored in a locked cabinet. Where appropriate, access to a locked medicines refrigerator may be required. Access to the medicine cupboard or refrigerator must be by authorised staff. Where there is not an authorised staff member to hold the keys at all times, then the keys must be stored in a wall mountable key safe with access restricted (e.g. digicode) to authorised staff only. Managers must ensure that there are duplicate keys available and appropriate staff are aware of the location and how to retrieve. Medicines must be stored in the medicine cupboard(s)/ medicine refrigerator as soon as possible after delivery. Medicines supplied by the GP must be stored in the medicines cupboard, clearly labelled and separated from prepacks. Medicines must not be left in the team office when not in use. Unused medication must be returned to the medicine cupboard/medicines refrigerator. The room temperature and medicines refrigerator temperature must be monitored on a daily basis and recorded on the appropriate temperature log as per Medicines Management policy. Patients must be encouraged to store medicines in a cool dry place, out of the reach of children and pets. 11. Patient medicines information Patient information leaflets may be accessed from the Choice and Medication website from the trust website and internal intranet. 12. Prepacks Acute day units have a designated stock list which must include medicines of frequent use. The stock list must be reviewed regularly in liaison with the visiting pharmacist. Orders must be emailed to pharmacy (HMHCPharmacy HMHCPharmacy@Candi.nhs.uk) or given in writing to the visiting pharmacist and will arrive within 7 days. Prepacks can be issued by medical staff or nursing staff in accordance with written prescriptions on the chart. Prepacks must never be packed down into smaller quantities i.e. removed from the pack and one dose given by hand for a later time, or dispensed into another box. If the quantity in the prepack box is not suitable, a TTA form or FP10 prescription must be completed. Issuing of prepacks must be documented on the prescription chart by listing: o The date o Number of days issued o Clinician s signature (doctor or nurse) o Quantity and strength o Signature of the issuer (doctor or nurse) The issue of prepacks must also be recorded in Care tes. Documentation (prescription charts) must be kept for a period of two years. If smaller quantities than those available as prepacks are required, then the medicine should be requested as a TTA or via an FP10. If a dose is required in an emergency, 6
then a dose can be prescribed for the patient on the crisis team chart. A prepack can be issued to the patient and self-administration of one dose supervised and documented on the prescription chart. The remaining medicine in the prepack should be kept in the medicine cupboard. Expiry date checks must be carried out monthly. Expired prepacks must be discarded as stated in section 15. 13. Emergency medicines An emergency bag is kept in the clinic room for medical emergencies for use by medical staff and nurses who are competent to do so. To maintain competence, staff should receive regular ILS training. Practitioners are responsible for ensuring that emergency resuscitation medicines supplied by pharmacy are replaced once expired or when the seal on the bag has been broken, whether the stock has been used or not. The seal must not be broken in order to perform checks on any emergency medicines. Expiry dates of emergency medicines bag must be checked weekly. See section 16. 14. Controlled Drugs (CDs) If a TTA for a controlled drug is requested, then the unit must have a controlled drug cabinet for storage and controlled drug register for recording its receipt and issue to the patient. The patient must then retain the controlled drugs at home. A controlled drugs order book is required for ordering midazolam for inclusion in the emergency bag. For further information see the trust Controlled Drugs Policy. 15. Disposal of medicines Medicines prepared ready for administration, or removed from the original container, but not used (including open ampoules), must be discarded into a sharps bin (yellow lid), labelled when sent for destruction according to the trust medicines management policy Appendix 8: Pharmaceutical waste disposal for more detailed information on pharmaceutical waste categories and containers. All medicines (except Controlled Drugs) with an expired date or no longer suitable for use must be discarded into a blue lidded bin in their original container or packaging. If Patient s Own medicines have been assessed and are not suitable/appropriate for use, then the patient s consent must be gained before the medicines are disposed of and recorded in Care notes. Controlled drugs should be destroyed as per the trust Controlled drugs policy. It is the responsibility of the practitioner in charge of a ward/clinical area to ensure that medicine storage areas are cleared of unwanted medicines on a regular basis 16. Audits There must be daily recording/documentation of fridge and room temperatures. The emergency medicines bag and emergency equipment must be checked and documented weekly as part of the medical device checklist in the Responding to the Deteriorating Patient (Community Setting) policy / Responding to the Deteriorating Patient (Inpatient Setting) policy. The emergency medicines bag must not be opened when checking the expiry date. Prepack expiry date checks must be carried out monthly. Medicine chart audit (Meridian) must be carried out weekly:- https://www.oc-meridian.com/candi/completion/custom/default.aspx?slid=167&did= 7
17. Medication incidents Medication incidents and near misses must be reported via the online incident reporting form (Datix) in accordance with the Trust Incident reporting Policy. 18. Frequently asked questions FAQ/Scenario Do all patients need a chart? In the following scenarios:- Patient was referred late in the day and pharmacy (last delivery has already been received). Patient has been prescribed new medication/run out of their own medication which needs to be given. Medication was ordered for a patient but it has not arrived from pharmacy. Patient has their own medication and staff are to supervise/administer, can patient s own medicines be used? Medication has been supplied, but the dose has been changed. There are concerns about leaving 7 day supply with patient due to risks. Can the prescription chart be copied and emailed to pharmacy for medicines requests? Patient has been discharged from the Acute Day Unit Answer If ADU are prescribing, supervising, administering, supplying, monitoring or changing any medication then YES. The following must be considered in this order:- 1. Check with prescriber if this can wait until the next working day when pharmacy re-opens. 2. Contact the pharmacy to arrange a supply. This will involve arranging a courier if outside the normal transport time. 3. Check if an appropriate prepack is available which can be issued to the patient. 4. Use an FP10 from the crisis team. Yes patient s own medicines must be used if assessed as suitable following the trust Patient Own Drugs procedure. Previously supplied medication and PODs with previous instructions need to be obtained and re-labelled with correct/new instructions. Liaise with pharmacy to supply in smaller quantities. (e.g. 3 days, 4 days to total 7 days)., the original prescription must be sent to pharmacy via courier or a member or staff If the patient has been collecting medicines from ADUs, discharge medication must be prescribed. Details of the medicine changes must be included in the discharge notification form to the GP as outlined in section 10.2. 19. Dissemination and implementation arrangements New policies are introduced to staff at Business Meetings as a standing agenda item. The team identifies training needs and staff are requested to discuss in clinical supervision if required. New staff are oriented to this policy as part of their induction 8
20. Training requirements Medicines management training provided by the pharmacy team can be arranged with the visiting pharmacist and must occur at least annually. 21. Review of the policy February 2018. 22. References Medicines Management Procedure for Crisis Teams 23. Associated documents Medicines Management policy FP10 HNC policy Medicines Reconciliation procedure Patient s Own Drugs procedure Controlled Drug Policy and SOP Trust formulary Clozapine treatment guideline Waste management policy 9
24. Appendix 1 Equality Impact Assessment Tool Yes/ 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, N/A 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? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? N/A 7. Can we reduce the impact by taking different action? N/A 10