DISPENSING AND STORAGE OF MEDICINES POLICY

DISPENSING AND STORAGE OF MEDICINES POLICY This is a working document and any changes that become necessary to this policy must be notified in writing to the Medicine Management Group via the Chief Pharmacist, East Cheshire Trust THIS POLICY MUST BE READILY ACCESSIBLE AT ALL TIMES AND AT THE POINT WHERE MEDICINES ARE USED. The Medicines Management Group Version 2.0 February 2017 Review: December 2019 1

Policy Title: Executive Summary: Dispensing and Storage of Medicines Policy This policy provides guidance to all staff in East Cheshire NHS Trust regarding all aspects of the dispensing and storage of medicines. Supersedes: Description Amendment(s): of Version 2.0 Dispensing and Storage of Medicines Policy No major amendments Inclusion of required actions during fridge temperature deviations (December 2017) This policy will impact on: All health professionals involved in the prescribing, supply, administration and handling of medicines Financial Implications: Financial impact to release staff time to address training needs. Policy Area: Medicines Document Management Reference: Version Number: 2.1 Effective Date: December 2017 Issued By: Chair of Medicines Review Date: December 2019 Management Group Author: Chief Pharmacist Impact Assessment Date: December 2016 Consultation: Approved by Director: APPROVAL RECORD Committees / Group Management clinical and associate directors Specialist Advice (if required) Pharmacists, Lead nurses / matrons, consultants Other (please specify) Medicines Management Group Medical Director Director of Nursing, Performance & Quality Date February 2017 February 2017 February 2017 (Update approved December 2017) February 2017 Received for information: Trust SQS Committee February 2017 2

POLICY FOR THE DISPENSING AND STORAGE OF MEDICINES Table of Contents 1 INTRODUCTION... 4 1.1 Policy Statement... 4 1.2 Definitions... 4 1.3 Organisational Responsibilities... 4 1.4 Planning and Implementation... 5 1.5 Measuring Performance... 6 1.6 Legislation... 6 1.7 Audit... 6 1.8 Review... 6 1.9 Training... 6 1.10 Dignity, Equality and Diversity... 7 2. DISPENSING AND SUPPLY OF MEDICINES... 7 2.1 Medicines Supply... 7 2.2 Use of patient s own medicines... 9 2.3 Dispensing & Supply of Chemotherapy... 10 2.4 Transport and receipt of medicines... 10 2.5 Supplying medicines for patients to use outside hospital... 11 2.6 Supply of medicines to clinical areas when pharmacy is closed... 13 2.7 Specific considerations for paediatrics... 16 2.8 Dispensing/ Supply Medicine Errors... 16 3. STORAGE & SECURITY OF MEDICINES... 17 3.1 Introduction... 17 3.2 Storage & Security of medicines within clinical areas... 17 3.3 Patients Own Medicines... 21 3.4 Mediwell Cabinets... 21 3.5 Keys... 22 3.6 Controlled Drugs & Illegal or suspicious substances... 23 3.7 Missing medicines... 23 3.8 Controlled Stationery... 23 Appendix one... 25 Appendix two... 30 Appendix three... 33 Appendix four... 34 3

1 INTRODUCTION 1.1 Policy Statement 1.1.1 The prescribing of medicines for patients is the most common intervention made as part of the treatment provided to patients during a hospital admission. This policy is for the use of all staff who involved in the management of medicines as part of their duties as an employee of East Cheshire NHS Trust. This policy must be complied with. If there is any cause for concern with respect to medicines usage in any area, staff are encouraged to contact the Chief Pharmacist. 1.1.2 The purpose of this policy is to: Provide guidance to all Trust staff on the procedures relating to the dispensing, safe and secure handling and storage of medicines. Avoid patients, staff and visitors being put at risk as a result of the incorrect handling of medicines. Ensure all legislation and guidance is adhered to with respect to medicines. Provide robust systems for storing, supplying, transporting, of medicines. 1.2 Definitions 1.2.1 Medicines Management Medicines Management in hospitals encompasses the entire way that medicines are selected, procured, delivered, prescribed, administered, and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes of patient care (Audit Commission 2001). 1.2.2 Registered Nurse Throughout this policy a registered nurse is taken to mean any nurse, midwife and specialist community public health nurses who are registered with the NMC (http://www.nmc-uk.org/registration/useful-information/registrationqualifications/) 1.3 Organisational Responsibilities 1.3.1 Chief Executive Has ultimate responsibility for the implementation and monitoring of the policies in use in the Trust. This responsibility may be delegated to an appropriate colleague. 1.3.2 Medical Director 4

Has Trust Board responsibility for all aspects of medicines management. The Medical Director is responsible for reporting any medicines management issues identified to the Trust Board. 1.3.3 Chair of Medicines Management Group The Chair of the Medicines Management Group has responsibility for coordinating the activities of the Medicines Management Group to ensure that good practice relating to medicines, as described in this policy, becomes embedded in to everyday working practice across the Trust. The Chair will raise any medicines management issues at the Trust SQS Committee. 1.3.4 Chief Pharmacist The Chief Pharmacist has responsibility for ensuring the Trust complies with local and national guidance relating to medicines, and to ensure the Business Units are fully informed of their role in maintaining the required standards of practice relating to medicines. 1.3.5 Directorates It is the responsibility of the Clinical Directors and Associate Directors to ensure that all staff are trained to carry out the tasks required of them in the prescribing, administration and management of medicines. 1.3.6 Ward / Department Managers Responsibility for the operational implementation of the Medicines Policy, including ensuring staff within their ward / department attends appropriate training. 1.3.7 Pharmacy Staff Responsibility for; providing information and advice to Trust personnel on the handling and storage of medicines used within the Trust, assisting where appropriate in formulating local procedures at ward/departmental /business unit level, ensuring that the laws relating to the safe and secure handling and storage of medicines are complied with. 1.3.8 All staff Are responsible for attending appropriate medicines management training and following guidance set out in this Policy. 1.4 Planning and Implementation This policy has been circulated to the clinical directors and matrons for comment The policy will be approved by the Medicines Management Group (MMG). The policy will be uploaded onto the Trust internet and an email containing a link to the policy will be sent to all staff. It is the responsibility of the ward and department managers to inform their staff of the changes in the policy. All staff groups involved in the management of medicines should receive training related to medicines management. The training should be tailored to the requirements of the staff group involved. 5

1.5 Measuring Performance The Trust may be measured for compliance with NHSLA standard C4 criteria 6, and by the Care Quality Commission 1.6 Legislation 1.7 Audit This policy complies with all relevant legislation and guidelines that are considered to be good practice which relate to the prescribing, supply, storage, security and administration of medicines. East Cheshire NHS Trust recognises its responsibility to check practice in adherence to all trust policies including The Safe and Secure Handling of Medicine Policy through audit. Aspects to be audited as part of a rolling audit programme should include: Storage and security of Medicines There will be rolling audits to assess safety and security of medicines on the wards All audits should be registered with the Trust Department for Clinical Effectiveness. Audit results should be discussed by the Medicines Management Group to identify areas of good and poor practice, and to highlight training needs. A Medicines Management report will be submitted to the Trust SQS Committee annually. 1.8 Review It is the responsibility of the Medicines Management Group to review and amend this policy. This policy will be reviewed and up-dated every 2 years. The review of the policy will include feedback from the performance review, audit and training related to the policy. 1.9 Training All staff groups involved in the management of medicines should receive training related to medicines management. The training should be tailored to the requirements of the staff group involved. Aspects of training should include: All groups of staff involved in the management of medicines should receive a medicines management training session as part of their induction Training specifically for medical staff should include sessions about various aspects of medicines management - delivered as part of the F1/F2 training programme 6

Training specifically for nursing staff should include: a training session and assessment for all nurses before undertaking administration of intravenous drugs Training specifically for pharmacy staff should include: completion of a postgraduate certificate / diploma in clinical pharmacy for junior grade pharmacists; minimum of NVQ 2 Pharmacy Services for all Technical Staff as well as the completion of registration qualifications for ALL Pharmacy Technicians. This may be supplemented by attendance of inhouse and external training sessions for all pharmacy staff. Training specifically for non-medical prescribers: completion of level 3 / 4 Non-Medical Prescribing Course prior to commencing supplementary / independent prescribing The objectives and contents of all in-house medicines management training should be discussed and approved by the Medicines Management Group. Training needs specifically tailored to individuals, or departments, may be identified following a review and identification of trends from the Trust Drug Incident Reporting scheme. 1.10 Dignity, Equality and Diversity This policy has been impact assessed with regards to dignity, equality and diversity with respect to patient s age, choices, lifestyle and cultural / religious beliefs (see appendix one) 2. DISPENSING AND SUPPLY OF MEDICINES 2.1 Medicines Supply 2.1.1 All medicines for use within the hospital must be supplied through the Trust pharmacy department. Patient s own medications validated as suitable for administration may also be used. Pharmacy staff are responsible for the safe and effective procurement of all medicines to be used in the Trust. 2.1.2 It is not acceptable for staff to acquire medicines directly from companies/company representatives this includes sample products 2.1.3 Medicines supplied by the Trust pharmacy department must not be used for the treatment of anyone other than Trust patients currently undergoing an episode of care. They are not to be used for the treatment of relatives or friends of the patient or for the treatment of hospital staff. The Pharmacy Department operates a Pharmacy shop where staff, relatives and patients may be able to purchase some over the counter medications if appropriate. 2.1.4 Medicines Supply Ward Stock 2.1.4.1 Each clinical area will have a range of medicines which are kept as stock. The pharmacy department and the manager of the clinical area will determine the list of stock items. 7

2.1.4.2 Ward stocks are topped up regularly by pharmacy staff. The frequency and day of the top up is agreed after discussion with the ward manager and pharmacy. 2.1.4.3 If stock levels of a medicine are low, the nurse should firstly liaise directly with their ward based team to arrange urgent stock replenishment. If the ward based team is unavailable the nurse should leave a message on the pharmacy stores telephone answering machine (Ext 1565). Paper-based ordering systems are available (e.g. the ward pharmacy diary or the ward medicines requisition book); however these should not be relied on if ward stock is urgently needed. At risk medicines Diazepam/Codeine Phosphate/Co-codamol may only be ordered for stock when a paper requisition is written. Paper-based requisitions should be complete, legible and signed, and then sent to the pharmacy department. 2.1.4.4 Wards/ clinical areas using Mediwell 365 cabinets will have orders transmitted automatically to Pharmacy on a daily basis, as stock is used. These orders will be accessed by the Pharmacy team and replenished back to the Mediwell cabinets on agreed days of the week. 2.1.4.5 Some clinical areas order their own stock medicines from an agreed stock list. These areas will receive their stock on the agreed day(s) of the week. 2.1.4.6 For the supply of controlled drugs as stock, please refer to the Trust Policy on the Safe and Secure handling of Controlled Drugs. 2.1.4.7 Stock items will not routinely be supplied at the weekend or out of hours, except for clinical urgency. 2.1.5 Medicines Supply Non-Stock 2.1.5.1 Wards should liaise directly with the ward based Pharmacy team, who will raise the order as an electronic Ward one stop request from the ward. This will be transmitted to the Pharmacy Dispensary and dispensed, checked and then transported back to the ward. Urgently required items can be electronically tagged to provide communication to the Pharmacy Dispensary as to their urgent need 2.1.5.2 For the supply of medicines to wards without a clinical (ward) pharmacist, in urgent circumstances and at weekends, the inpatient medicine chart must be sent to pharmacy along with a Pharmacy requisition clearly identify what medicines are required. The inpatient medicine chart must have all the relevant details completed accurately, including the current ward and consultant. 2.1.5.3 It is vital that if more than one chart is in use that ALL charts are sent to pharmacy to enable an appropriate clinical assessment to be made. Medicines required for discharge within a blister pack must be requested only after an assessment has been completed to ensure stability of the medicines and suitability of the patient for such a device. 8

2.2 Use of patient s own medicines 2.2.1 It is the policy of East Cheshire NHS Trust that on admission to hospital, patients are asked to bring their own medicines with them. Medicines brought in by patients should only be used within the Trust when they can be positively identified. Medicines will be assessed as per the Trust Procedure for the Assessment of Patient s own Medicines for use in the Hospital by pharmacy staff at the earliest opportunity. 2.2.2 Patients own medicines used in the Trust must be prescribed on the inpatient medicine chart. 2.2.3 A pharmacist or a trained pharmacy technician must assess patients own medicine for its suitability for use. 2.2.4 Out of hours, a registered nurse may complete the assessment of a patient s own medicine for administration against a valid prescription against the critera in 3.2.6 below. If a nurse has made this assessment a pharmacist or trained pharmacy technician must assess the medicine at the next available opportunity. 2.2.5 Patients own medicines, to be administered by staff in the community should also be assessed, using the criteria below (3.2.6), to ensure they are appropriate to use. 2.2.6 Assessment of patient s own medicines must comply with the following: Visibly intact, clean packaging Clearly labelled with the patient s name, medicine name, strength of the medicine, name and address of the supplier and date of dispensing (which should be no greater than six months prior to the current date) or the medicine expiry date (whichever is the shortest) For medicine dispensed in a brown bottle, the medicines must be of a good visible quality and not mixed with other medications. Extra caution should be exhibited when checking medicines not dispensed in patient packs (i.e. pre-packaged in foil containers which help in the identification of the product) Care should be taken to note any specific storage requirements 2.2.7 Patients bringing medicines into the Trust in monitored dosage systems (blister packs) may have medicines administered from the pack, provided that each blister contains a single medication that is clearly labelled and that the medication in the pack, as stated by the community pharmacy labels, match the medicine prescribed. 2.2.8 Patients Own Medicines will be returned to the patient on discharge if they are consistent with their discharge medicines. 2.2.9 All acute wards have a daily visit (Monday Friday) from the ward pharmacist who will clinically assess patients prescribed medicines. Ward pharmacy technicians also work alongside Pharmacists as a team to organise supply for newly prescribed items, discharges and liaise directly with the Pharmacy Dispensary. 9

2.3 Dispensing & Supply of Chemotherapy 2.3.1 All oral chemotherapy agents must be handled with care and dispensed in original packs where possible. The dispensed item will be clearly labelled Cytotoxic Drug. Cytotoxic drugs needing to be dispensed within a blister pack must have an assessment completed by the appropriate healthcare professional accompanying the request 2.3.2 All intravenous cytotoxic medicines will be dispensed in a ready-to-use form by pharmacy aseptic services. Separate policies ensure safe preparation in pharmacy facilities. A full risk assessment should be completed if cytotoxic medicines are to be prepared in any area other than the Pharmacy aseptic suite. 2.3.3 The person undertaking the manipulations to prepare the dose must be doing so safely and within his or her own scope of competence and wearing appropriate protective clothing. A cytotoxic spillage kit must be available. 2.3 Transport and receipt of medicines 2.4.1 Transport of Medicines in the Hospital 2.4.1.1 If a patient moves from one ward to another, any medicine supplied for their use from pharmacy or any patient s own medicine must be transferred with them. In the case of controlled drugs, please refer to the Trust Policy on the Safe and Secure handling of Controlled Drugs. 2.4.1.2 Where medicines need to be transported between wards and departments, transfer should be carried out in such a manner that prevents loss or improper use. 2.4.1.3 Medicines will normally be transported in security sealed transit bags or boxes. Exceptions to this are supplies of bulk fluids. The container must be either handed to a member of ward staff or left in a suitably safe ward area where it must be brought to the attention of the nursing staff. Medicines requiring refrigeration will be brought to the attention of the nursing staff for immediate unpacking and placing in the refrigerator (in some cases this is done through using separate labelled container). 2.4.1.4 Any member of staff collecting medicines from pharmacy must produce a valid hospital identification badge. Failure to do so will result in pharmacy refusing to supply the medicines. 2.4.1.5 When receiving stock items onto a ward the order should be checked against the delivery note and the delivery note signed and dated by the person reconciling the order. The delivery note must be returned to Pharmacy within 24 hours. Any discrepancies should be immediately notified to the pharmacy department. 2.4.1.6 Controlled Drug orders must be signed by ward staff immediately on receipt on the ward/clinical area. 2.4.1.7 All hospital discharge medicines must be received by a registered nurse/midwife who must lock them in a medicine cupboard immediately, until required. 10

2.4.1.8 Consignment notes for Controlled Drugs, at risk medicines and medicines requiring refrigeration (e.g. vaccines) must be completed by both staff transporting and receiving medicines. Staff should print their name on the consignment note, indicate the seal number, sign and date and return to pharmacy within twenty four hours. 2.4.1.9 Whenever possible, medicines should not be carried by health professionals outside Trust premises. However, in some circumstances certain designated people may need to carry medicines, e.g. pharmacy staff, community midwives, district nurses, community psychiatric nurses, community learning disabilities nurses, health visitor s etc. The responsibility for the security of the medicines lies with the individual carrying the medicines. These designated people must ensure that medicines are transported in a safe and secure manner at all times. It is expected that each practitioner will use their judgement to choose the safest method of transportation under the circumstances. 2.4.2 Transport of Medicines by Community Services Staff 2.4.2.1 Community nurses are not normally advised to carry medicines that have been prescribed / dispensed for named patients. 2.4.2.2 Patients/carers should collect prescriptions themselves. Where this is not possible many local pharmacies operate a delivery service. 2.4.2.3 School Health Nurses, District Nurses and Health Visitors are permitted to carry vaccines for domiciliary vaccination as per policy and administer them as stated in the appropriate Patient Group Direction or prescription. School Health Nurses may transport vaccines for school immunisation programmes. In each case, vaccines must be stored in cool boxes (appendix two). 2.4.2.4 In exceptional circumstances Health Care Professionals may carry Controlled Drugs or Prescription Only Medicines that have been prescribed for named patients. The Health Care professional collecting such Controlled Drugs or Prescription Only Medicines will be required to produce identification to the pharmacist/dispensing GP in the form of either their Trust or Employers ID badge. The medicines must be transported from the dispensing Pharmacy/GP directly to the patient, out of sight in a locked car. Medicines should not be left unattended in a car. 2.4.2.5 Health professionals may carry medicines necessary for them to fulfil their professional duties in accordance with relevant directions or guidance from their professional regulatory bodies, or as authorised by the Trust (e.g. nursing staff who have undergone approved training for the management of anaphylaxis, may carry adrenaline injection 1 in 1000 to respond to anaphylactic reactions when undertaking vaccination clinics). 2.5 Supplying medicines for patients to use outside hospital 2.5.1 Medicines supplied for a patient to take away from the Trust must state: Patient s name 11

Date issued Medicine name, strength and form Quantity supplied Name and Address of the supplier (The Trust) Directions for use They can only be issued: From a pharmacy dispensed hospital discharge prescription (ednf) From a pharmacy dispensed outpatient prescription As a pharmacy pre-labelled pack under a Patient Group Direction As a pharmacy pre-labelled pack against the prescription of a doctor Patient s Own medicine returned to the patient at discharge 2.5.2 Medicines supplied for specific named patients to take out of hospital on discharge or outpatient prescriptions must not be issued to another patient. 2.5.3 General unlabelled ward stocks must not be given to patients to take home. 2.5.4 Supply of Hospital Discharge Medication: 2.5.4.1 All medicine required by the patient on discharge should be written on e-dnf. This should be written when the patient is amber on the discharge traffic light system to expedite the discharge process. This should be completed the day prior to discharge. 2.5.4.2 The nurse should inform the ward pharmacist or pharmacy technician of any patients due for hospital discharge. The pharmacist will clinically check the e- DNF, the pharmacy technician may then check the patient s medicine in the POM box against the e-dnf on the ward. The patient should receive a minimum of 7 days supply of their discharge medicines (14 for items newly initiated or modified during their admission). 2.5.4.3 If there is insufficient supply in the POM box, existing home supplies of regular medications will be confirmed. Where the patient requires an additional supply of medicine this will be provided. If the supply is complete on the ward by the Pharmacy ward based team, the e-dnf can be signed off on the ward. Discharge medicine is supplied to the patient in the green medicine bag and the patient counselled appropriately. Discharges requiring the pharmacy dispensary to complete the supply can only be completed if the drug chart and patients own medications are returned to the dispensary. The e-dnf will then be signed off in the Department by the staff on duty 2.5.4.4 In-patient supplies are dispensed in original packs labelled with directions so that the medicine is available and ready on the ward when the patient is due for hospital discharge. 2.5.4.5 If the ward pharmacist or pharmacy technician are unavailable the nurse must bleep their designated ward pharmacy team for advice before sending all the patients medicines in the POM box to pharmacy in a green medicines bag along with the medicines chart in a sealed blue pharmacy bag 12

2.5.4.6 All discharge medicines sent from pharmacy to the ward should be checked against the prescription by a nurse before giving to the patient and counselling provided appropriately. 2.5.4.7 Nurses on surgical wards may provide simple analgesia, laxatives and proton pump inhibitors for a patient to take home when following the guidance in: Protocol for the Supply of Medicine to Patients for Discharge by Nurses within the Surgical Division. 2.5.4.8 If required, the Trust has a number of link worker interpreters who may be able to offer language/communication support. An interpreter should be used if there are difficulties explaining medicine instructions to patients or their carers where English is not a first language and where alternative forms of communication support are required. 2.6 Supply of medicines to clinical areas when pharmacy is closed 2.6.1 Emergency Medicine Mediwell 2.6.1.1 Pharmacy provide access to Emergency Medicines out of hours via an electronic Mediwell Cabinet and is located on the bottom corridor, opposite A+E entrance. 2.6.1.2 Access is available only to Pharmacy staff or registered nurses with access (this may also include bank staff). The outer door is swipe access and upon entering the cupboard the alarm must be deactivated. Failure to deactivate will result in the alarm going off. The Mediwell cabinet is accessed using a combination of biometrics (fingerprint analysis) and hospital identification badge swipe access. For full details of access and operation, please refer to the Mediwell Cabinet Operational SOP. 2.6.2 Emergency Duty Pharmacist / Out of Hours Pharmacy Service (see appendix four) 2.6.2.1 Pharmacists provide a 24 hour service for emergency and urgently needed supplies and advice on medicines. They do not provide a dispensing service for discharge prescriptions or outpatient prescriptions. 2.6.2.2 For access to medicines out of normal working hours, the Stock Location list should have been consulted first. This list can be found on the Trust Internet site. Select Trust Intranet site at the bottom of the Trust Internet home page. Once on the Trust Intranet home page, select Useful Links > Departments > Pharmacy > Emergency Medicines. If the medicine needed is not listed, Contact the night sister/ on-site Manager who will confirm that the correct procedure has been followed and then they must contact switchboard and request the switchboard operator to ring the Pharmacy pager for that on-call period and connect them while they wait. 2.6.2.3 The Emergency Duty Pharmacist may advise: borrowing the medicine from another clinical area (for further information see section 3.6.3), or waiting until the pharmacy is next open 13

contacting the prescriber to amend the prescription to an item more readily available that the patient s own supply is brought in from home 2.6.3 Borrowing medicines 2.6.3.1 Medicines must not be borrowed from other clinical areas when pharmacy is open. 2.6.3.2 It is unacceptable to borrow controlled drugs from another clinical area, except in exceptional circumstances - (please refer to the Trust Policy on the Safe and Secure handling of Controlled Drugs). In accordance with robust stock management, it is the responsibility of the registered nurse/midwife in charge of a clinical area to ensure that controlled drug stocks are sufficient to cater for out of hours periods. At risk drugs such benzodiazepines should not be borrowed between wards without the authorisation of the on-call pharmacist 2.6.3.3 To transfer stock between clinical areas within the Trust when the pharmacy is closed, the senior night sister / clinical co-ordinator on site cover must be contacted to authorise the transfer. 2.6.3.4 Only boxes or bottles in their original packaging may be borrowed (except for controlled drugs). Transfer of individual doses of medicines not in their original containers increase the risks of medicine administration errors. 2.6.3.5 The borrowing clinical area must, once authorisation has been received from the senior nurse on site cover: contact the ward holding the required medicine fill out the stock transfer form (appendix three) provide details of the request and of the member of staff being sent to collect the item ensure the member of staff collecting the item has their hospital identification badge and a copy of the chart where the medicine has been prescribed sign the Stock Transfer Form upon receipt of the item 2.6.3.6 The clinical area issuing the item must check the following prior to release of the item: ensure they have received an advanced request from the requesting ward detailing the request, if not they should contact that ward to verify the need for the item check the hospital identification badge of the member of staff collecting the item check the stock transfer form against the prescribed item on the medicine chart (ensuring the ward, patient details and dates match) and complete the form issue the item send a copy of the transfer form to the Pharmacy and send the original to the Nurse in Charge of that clinical area 14

2.6.3.7 Pharmacy MUST be involved if medicines are required from anywhere outside the Trust, including other acute trusts. 2.6.4 Obtaining patient discharge medicines out of hours 2.6.4.1 A patient s discharge from hospital should be planned and discharge prescriptions should be written in advance as per the Trust Discharge Policy. 2.6.4.2 It is the role of the Senior Sister or the nurse in charge of the ward to ensure that discharge prescriptions are written in a timely manner so dispensing can be achieved within pharmacy working hours. 2.6.4.3 It is not the role of the Emergency Duty Pharmacist to provide dispensing of discharge prescriptions. 2.6.4.4 If the hospital is undergoing a Trust-wide bed crisis, the Site Manager will consult with the Emergency Duty Pharmacist about the situation in the Trust and together will plan how best to manage the discharge of patients. 2.6.4.5 In some circumstances it can be possible to discharge the patient using: pharmacy pre-labelled packs patient s own medicines medicine provided for that individual patient as part of the one stop service In all of the above situations: a hospital prescription (TTO) must be written by a Trust approved prescriber the medicine must be assembled, ensuring that where any pharmacy prelabelled packs are supplied that the following are completed: o patient s name o date o directions each item prescribed must be checked for the following: o medicine name, form and strength matches the prescription o contents of the container contain the correct medicine o directions on the label match the prescription o the patient s name and the date are on the label o the medicine is in date o the quantity is appropriate a doctor or registered nurse must check the medicine against the prescription and endorse the prescription discharged from ward medicine checked by doctor and sign their name, print their name and date it a registered nurse should provide a second check of the medicine prior to giving it to the patient, should sign and print their name and date the prescription the patient is to have the medicine explained to them as per usual practice the pharmacy copy of the discharge prescription should be made available for pharmacy to check the following day 2.3.4.6 Patient s must not be discharged with medicines placed in envelopes. 15

2.6.4.7 Patients being provided with medication from the A&E Departments may be treated under Patient Group Directions. In this case, two nurses may check the medicine provided. 2.7 Specific considerations for paediatrics 2.7.1 Take Home Medicines 2.7.1.1 The majority of children will be discharged on a planned basis in the normal manner. However it is recognised that there may be a few exceptional cases when this will not occur. 2.7.1.2 There will be a limited supply of commonly used paediatric medicines dispensed and labelled ready for issue on a prescription from medical staff and held on the unit. The label must include the child s name and date of supply. If instructions need to be added to the label the doctor should do this. The nurse must check the label before the bottle is issued and this should be documented on the prescription sheet. Once the prescription has been dispensed and given to the parents a copy must be placed in the appropriate file in the ward to be collected by a pharmacy technician to enable the stock to be replenished on the Unit. 2.7.2 Hospital at Home 2.7.2.1 Qualified children s nurses staff the service and lead the care of the child, whilst a name paediatrician assumes overall responsibility. 2.7.2.2 Medicines are obtained from the Trust s pharmacy and it is the nurse s responsibility to ensure safe guards for storage and transport to and from the child s home. 2.7.2.3 Take home medicines for IV antibiotics will have the dosage on the label, taking into account the displacement volume, along with a brand specific sheet that accompanies the IV antibiotics clearly recording the appropriate displacement value calculation 2.7.2.4 The registered nurse may administer IV drugs in the absence of a second nurse. They will ask a relative to confirm the drug whenever possible. 2.8 Dispensing/ Supply Medicine Errors 2.8.1 Any medicine dispensed or supplied incorrectly must be reported using the Trust Incident Reporting process. Any incidents relating to fraud must be reported on Datix and also reported to the Chief Pharmacist. These will be forwarded onto the LCFS accordingly. 16

3. STORAGE & SECURITY OF MEDICINES 3.1 Introduction 3.1.1 The responsibility for organising, monitoring and reporting on a system for the safe storage and handling of medicine lies with the Chief Pharmacist of the Trust, in consultation with medical and nursing staff. 3.1.2 Pharmacy staff have a responsibility to advise practitioners on the safe and secure storage of medicines in clinical areas, the maintenance of an audit trail in relation to stocks of medicines and to ensure that medicines supplied are of a suitable quality and are stored in appropriate legal and environmental conditions. 3.1.3 Senior Sisters / lead professionals are responsible for ensuring that the security of medicines within their ward areas is maintained at all times. 3.1.4 In departments / clinics where there may be no registered nurse or midwife, the professional head of service is responsible to ensure compliance with this section of the policy. 3.2 Storage & Security of medicines within clinical areas 3.2.1 Each ward or clinical area will have a range of medicines which are kept as stock items. The Pharmacy Department or ward based Pharmacy team and the manager of the ward or clinical area will modify this list according to the speciality or requirements of that ward, and review this list every three months. Items required that are not stock, will be supplied as individual named patient supplies. 3.2.2 The Pharmacy Service will monitor the prescription and usage of medicines on a regular basis. Concerns will be reported to the Lead Pharmacist for the business unit and the manager of the clinical area. These should be escalated to the Chief Pharmacist where appropriate. Incidents concerning the storage and security of medicines must be reported using the trust incident reporting system. The manager of the clinical area and the Lead Pharmacist for the business unit are responsible for ensuring the incident is investigated, a record made of the process and recommended action. 3.2.3 All staff have a responsibility to ensure medicines are stored securely, however the manager of each clinical area will be accountable for the safety and security of all medicines issued to the clinical area. 3.2.4 The security of controlled drugs must be managed in accordance with the Trust Policy on Safe Management of Controlled Drugs. 3.2.5 Medicines must be stored in the containers in which they are supplied by the Pharmacy department. They must not be transferred to another container. 17

3.2.6 Medicines must be locked away when not attended. This includes medicine trolleys, refrigerators, cupboards, patients own medicine (POM) lockers and Mediwell cabinets. Where access to clinic rooms is via a PIN code then this PIN code should be changed every 6 months. 3.2.7 Different formulations of medicines need to be stored appropriately for their use. Products should be stored separately according to the following categories: Products For External Use Products for Internal Use Products for Parenteral Use Controlled Drugs Medicine Trolley Medicines/vaccines Refrigerator All products intended for external use must be stored separately from other medicines. This is a lockable cupboard for the storage of lotions and other external medicines and for the storage of substances that are not intended for medicinal use, and that could be harmful; e.g. disinfectants, HAZ tabs, concentrated antiseptics, urine testing equipment. This cupboard can also be used to store topical preparations, enemas and suppositories. This cupboard should be locked when not in use. All products intended for internal use should be stored separately from other medicines. These should be stored separately from medicines for internal use. All CDs must be kept in the separate Controlled Drug (CD) cupboard (refer to Trust Policy on Safe Management of Controlled Drugs). The CD cupboard must be used only for the storage of CDs and other specified drugs (e.g. Concentrated Potassium Chloride Injection) The cupboard must comply with the design specification standards as required by the Controlled Drugs Safe Custody Regulations 1973. Where a medicine trolley is in use, it must be supervised at all times by a registered nurse administering medicines during medication rounds The trolley must be secured to an internal wall when not in use. This key must be different to all other cupboard keys and should be kept on the person in charge of the clinical area or a registered nurse or member of pharmacy staff. A lockable fridge is mandatory for the storage of internal and external medicines that need to be stored between 2-8 o C. It is the responsibility of the Ward Manager/responsible professional, to ensure the fridges in all clinical areas are in good working order, have uninterrupted electrical supply, be clean, and have min./ max temperature monitoring facilities. The temperature of the refrigerator must be maintained at 2 8 o C and should be monitored with a maximum / minimum thermometer on a daily basis. A log of maximum/minimum temperatures should be recorded daily, on days when the ward/clinic is in use. It is the responsibility of the professional in charge to ensure this is done. Where temperatures are found to have deviated outside of this range, advice should be sought from pharmacy on how to 18

manage the medicines stored inside the refrigerator. There will be at least an annual calibration of the fridge thermometer and service of the medicine/vaccine fridge. It is good practice that a log is kept of the time at which items are removed from the refrigerator, to ensure that items returned to the refrigerator have not been out for longer than the manufacturers specified time. When not refrigerated, vaccine must be stored in a cool box with a pre-frozen ice pack. Individual vaccines should not be returned to the fridge on more than one occasion. See Procedure for the safe storage of vaccines, for more detail on vaccine storage. Patients Own Medicines Boxes Intravenous Fluids and Irrigation Fluids The medicines fridge must not be used to store anything other than medicines (i.e. food or drink must not be stored in the medicines fridge) and should be locked when not in use. Where One Stop Dispensing service is in operation, all medicines should be stored in a Patients Own Medicine (POM) Box which should be attached to either the wall near to the patient or the bedside locker. The person in charge of the clinical area, a registered nurse or a member of pharmacy staff should keep the keys to these boxes. Patients may also keep a key if they have been assessed as suitable for self-medication in accordance with East Cheshire NHS Trust Policy. Intravenous fluids and irrigation fluids should be stored in such a way as to avoid selection errors. Fluid bags should not be mixed. They should remain in the original box. Emergency Resuscitation Medicines Fluid boxes should be stored neatly, so as not to cause an obstruction in the clinical area Emergency medicines are stored in red (adult) or blue (paediatric) boxes on the emergency trolleys. Neonatal Resuscitation drugs are stored in grey boxes in the hospital setting. In the community setting, medicines for emergency use, should not be locked away during clinic sessions, but should be stored with the appropriate accessibility. They should be stored in a tamper evident container and labelled for emergency use. They should be stored securely when the clinic is not running. These should be stored in a way that does not affect the integrity of the product. Medical gases When an emergency pack is opened, it must be replaced. The number of cylinders held as stock in any department should be as small as possible The cylinders should be stored in a clean, secure area, under 19

cover (preferably inside) and not subjected to extremes of heat. Safety chains, or a stand should be used to ensure that nonportable cylinders are physically safe and prevent them from falling over. Naked flames, or lights and heat sources must be avoided. This includes adjacent areas inside and outside the building. If necessary, warning signs should be affixed on external walls of the building. Naked flames or heat sources, including smoking, should be avoided near the area where the gases are stored. It should be remembered, smoking is not permitted on Trust grounds. No oil or grease, should be applied to the cylinder or tap connector. Allow for segregation of full and empty cylinders and permit separation of different gases within the store. Cylinders with damaged valves and defective equipment must be labelled appropriately and withdrawn from use. Flammable Liquids It is advisable to notify the emergency services of the location and contents of the medical gas cylinder store. COSHH data sheets should be available for all staff for any flammable liquid kept on the premises. Store in a locked cupboard that displays appropriate hazard sign. Keep stock levels to a minimum to reduce the risk of combustion or explosion. Avoid spillage keep bottle closed securely and replace cap immediately after use. Keep well away from naked flame, electrical apparatus or source of heat. Do not store in a refrigerator. 3.2.8 All cytotoxic medicines/chemotherapy must be stored in an appropriate secure environment as advised by the Pharmacy department. A dedicated locked refrigerator is available in the Macmillan Cancer Resource Centre for the storage of intravenous chemotherapy. 3.2.9 Where premises are shared by a number of clinical services, each clinical service is responsible for its own stock of medicines, which will be stored separately. 3.2.10 In the community setting, all medicines cupboards must comply with the current British standards. Approved NHS hardware suppliers will provide medicine storage containers that met, or exceed, current regulations. (The current standard is BS2881 (1989) NHS Estates Building Note No 29). 20

3.2.11 In a patient s own home, staff should encourage patients to store all medicines (including medical gases) in a safe place, out of the sight and reach of children and according to the manufacturers instructions, that ensures the integrity of the product. 3.2.12 Statutory warning notices should be displayed where potentially hazardous products are stored. 3.3 Patients Own Medicines 3.3.1 It is the policy of East Cheshire NHS Trust that on admission to hospital patients are asked to bring their own medication with them. On admission, the nurse should gain the patient s consent and place all the patient s own drugs in the patient s POM box on the wall/locker after first checking that the POM box is empty. If the patient does not already have one, a green medication bag should be placed in the POM box. 3.3.2 If the patient does not consent to having his / her medicines put into a POM box the patient should be asked to have the medicines taken home. A new supply of medicines will be provided by the hospital pharmacy which should be locked in the POM box. 3.3.3 Medicines brought in by patients should only be used within the Trust when they can be positively identified. Medicines will be assessed as per the Trust Procedure for the Assessment of Patient s own Medicines for use in the Hospital by Pharmacy staff at the earliest opportunity. 3.3.4 Any patient s own controlled drugs, including those of patients who are self medicating, should be stored in the ward CD cupboard and a record of this made in the controlled drug register (see Trust Policy on Safe Management of Controlled Drugs). 3.3.5 A master key to all POM boxes will be held on the nurse s key bunch. The patient will not have access to the box without a nurse/pharmacist being present, unless as part of a self-administration scheme. The Pharmacist will also hold a master key. 3.3.6 Medicines supplied from pharmacy for a particular patient must be stored in the patient s POM box. Exceptions apply to reliever inhalers, eye drops for dry eyes and glyceryl trinitrate sprays that are required as necessary for treatment of chest pain. These may be stored on the patient s bedside locker. 3.3.7 When the patient is transferred to another ward the patient s medicine must be removed and transferred with the patient to the other ward. 3.4 Mediwell Cabinets For wards and clinical areas using Mediwell cabinets, please refer to Mediwell Standard Operating Procedure and policy. 21

3.5 Keys 3.5.1 The safekeeping of the keys for medicine storage areas is the responsibility of the nurse in charge of the ward, the most senior midwife or clinical professional on the ward, theatre, department or clinic. 3.5.2 All acute wards should have no more than 2 sets of medicine cupboard keys and a set of Controlled Drug cupboard keys. POM box keys can be attached to each bunch of keys on the ward. These should be able to be used to open the boxes without detaching the key bunch from the uniform. 3.5.3 The controlled drug cupboard keys should be held by the nurse in charge and attached to the uniform on a red curly whirly. The keys may be handed over to other trained staff but should be returned after use. It is the responsibility of the nurse in charge to hand over the keys at the end of the shift to the incoming nurse in charge. 3.5.4 In Community services, the keys should be kept on one key ring, solely for storage of medicine cupboard keys, and be in possession of the responsible professional who controls access to medicines. When not in use, the keys should be stored in a locked key cupboard. 3.5.5 Keys may be temporarily handed to medical and pharmacy staff, as necessary, for fulfilment of their duties. On such occasions, that particular clinical professional is responsible and accountable for ensuring that all relevant medicines policies and procedures are correctly adhered to, including the safe return of any keys to the registered nurse or midwife in charge. However, the most senior registered nurse/midwife retains the overall responsibility for medicines security for that area. 3.5.6 An auxiliary nurse can have possession of the keys to clear POM boxes or access external medication cupboard but they must NOT have the CD cupboard keys. The keys must be returned to the appropriate trained nurse as soon as they have been used. 3.5.7 Keys must not be left in the locks of POM boxes, fridges, medicine cupboard or trolleys when not in use, and should be kept on the person of a registered nurse at all times. 3.5.8 Any loss of keys should be reported immediately to the appropriate clinical manager or senior nurse on duty and Pharmacy (the on-call pharmacist if out of hours). Investigation of the loss of keys must be an immediate priority. Every effort needs to be made to recover the keys. An incident form must be completed. If the keys have left the hospital, the incident must be escalated to the Associate Director of the directorate or site manager if the keys cannot be retrieved. The risks of this will need to be assessed and the need to change locks considered. For clinics in community services which have drug cupboards, there must be an agreed lost key procedure, and all staff must be made aware of this. 3.5.9 Duplicate/ spare keys are placed in the emergency key cupboard. When accessing these keys the senior nurse must complete an incident form and make a record of where the keys are to be used. 22

For community services, who are based outwith the Macclesfield District General Site, a suitable, locked, secure storage site, should be identified for spare sets of keys. There should be a local protocol, to ensure all key members of staff, know how to access the spare keys. 3.5.10 Wards must not keep spare sets of keys in the ward safe. 3.5.11 When a ward, department or theatre is temporarily not involved in the active treatment of a patient or is closed e.g. overnight or weekend, the drug cupboard keys must be returned to a place of safe keeping and be managed in such a way as to prevent unauthorised access. The advice of the Pharmacy Department must be sought if the duration of closure is longer than overnight or a weekend. 3.6 Controlled Drugs & Illegal or suspicious substances 3.6.1 For guidance on the storage and security of CD s and dealing with illegal or suspicious substances, please refer to the Trust Policy on Safe Management of Controlled Drugs. 3.7 Missing medicines 3.7.1 Missing medicines must be immediately reported to the lead senior nurse for the area and the pharmacy. Out-of-hours, they should be reported to the appropriate clinical manager and senior nurse on duty and the lead senior nurse and pharmacy should be informed as soon as possible. 3.7.2 The person making the report must complete a Trust Incident Report Form and provide a signed, written statement. 3.8 Controlled Stationery 3.8.1 Controlled stationery is any stationery that could be used to obtain medicines fraudulently (Duthie Report, 1988 updated 2005). 3.8.2 Within the hospital setting controlled stationery refers to the controlled drugs order book used to requisition controlled drugs for clinical areas. This book is kept in a locked drawer or cupboard in each clinical area. 3.8.3 Within outpatient clinics, this refers to FP10 (HP) prescription pads (where in use), which are used to prescribe medicines by approved practitioners. 3.8.4 Controlled stationery, within the hospital is currently held and supplied by: Pharmacy Department (controlled drug order books, FP10 (HP)s) 3.8.5 Controlled stationery remains under the control of the departments listed above. A designated person within each of those departments is responsible for the receipt and issue of controlled stationery. A member of pharmacy should check records periodically and any anomalies investigated. 3.8.6 Stock/record sheets will be kept for the receipt and issue of all controlled stationery, including the following information: 23