STANDARD OPERATING PROCEDURE THE TRANSPORTATION OF PRESCRIBED CONTROLLED DRUGS AND OTHER URGENTLY REQUIRED MEDICATION BY COMMUNITY NURSES Issue History Issue Version Purpose of Issue/Description of Change Planned Review Date One To ensure community nurses transport CDs only in justifiable exceptional circumstances in a safe manner 2015 Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Quality, Patient Experience and Risk Group December 2012 Section:- MMSOP09 Target Audience Community Nurses UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE ORGANISATIONS WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTROL RECORD Title Purpose Standard Operating Procedure (SOP) for: The Transportation of by Community Nurses To ensure that community nurses transport controlled drugs, or other urgently required medication, only in justifiable exceptional circumstances Quality and Governance Service (QGS) and L Knight Author Impact Assessment Incorporated into procedure Yes No Subject Experts Medicines Governance Pharmacist Document Librarian QGS Groups consulted with :- Medicines Management Group Infection Control Approved N/A Date formally approved by Risk December 2012 and Governance Group Method of distribution Email Intranet Archived Date Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 LK T Status New / Revised / Trust Change Review Date: 2015 Page 2 of 6
NAME OF DIS C IPLINE : COMMUNITY NUR S ING OBJECTIVES To ensure that community nurses transport controlled drugs, or other urgently required medication, only in justifiable exceptional circumstances SCOPE TARGET GROUP (Staff authorised to follow this SOP) EVIDENCE TO SUPPORT PROCEDURE To outline situations where it is appropriate for Trust employed nurses to transport prescribed controlled drugs and other urgently required medication and to outline an appropriate safe manner Policy Safe Handling and Administration of Medicines Policy (includes safe storage) Standards for Medicines Management Nursing and Midwifery Council 2010 A guide to good practice in the management of Controlled Drugs in primary care (England) National Prescribing Centre December 2009 IT IS THE R E S PONS IB ITITY OF ALL STAFF TO COMPLY WITH RELEVANT TR US T POLICIE S, PROCEDURES AND PROTOCOLS IN CONJUNCTION WITH THIS PROCEDURE Review Date: 2015 Page 3 of 6
PROCEDURE ACTIVITY RATIONALE RESPONSIBILITY 1. SITUATIONS WHERE IT IS APPROPRIATE TO TRANSPORT PRESCRIBED CONTROLLED DRUGS (CDS) AND OTHER URGENTLY REQUIRED MEDICATION CDs or other urgently required medication, should only be transported where there is no other reasonable mechanism available and when failure to transport the prescribed medication would result in unacceptable discomfort for the patient Community nurses should not routinely transport prescribed controlled drugs (CDs) 2. A RISK ASSESSMENT MUST BE COMPLETED A risk assessment must be completed, on every occasion, for all patients who require nursing staff to collect their prescribed CDs and/or other urgently required medication The risk assessment must include potential environmental factors from where controlled drugs or other urgently required medication are to be collected from The completed risk assessment must be filed in the base notes To manage any risks identified 3. ENVO PACK TO BE PICKED UP FROM NURSING BASE All prescribed medications and controlled drugs must be transported in an Envo Pack sealed with a numbered tag. An Envo Pack will be kept at each nursing base, for the purpose of transporting CDs and other urgent medication The Envo Pack must be signed out to the nurse requiring its use. Details to be recorded should include:- date name of patient date of birth of the patient name of the nurse, the reason why transportation of the CDs and other urgent medication is necessary confirmation that a risk assessment has been completed and filed in the base record. To maintain security To maintain an audit trail Review Date: 2015 Page 4 of 6
4. COLLECTION OF CDS FROM COMMUNITY PHARMACIES It is essential that nurses take their Identity Badge with them when picking up CDs and other urgent medication that have been prescribed for patients The nurse must know patient identifying information, e.g. address of patient, date of birth of patient A second employed member of the community nursing team will accompany the nurse whilst picking up prescribed CDs and other urgent medication Nursing staff picking up prescribed CDs and other urgent medication will be requested to sign the back of the prescription Nursing staff should check that the dispensed medication is correct Before leaving the pharmacy premises, the CDs and any other urgent medication must be placed in the Envo Pack and the numbered seal attached in the presence of a pharmacy staff member. The number on the seal must be documented in the community nursing records The nurse should ask a pharmacy staff member to sign the documentation To ensure the nurse has appropriate identification To ensure correct medication is issued to the nurse To maintain security This acts as a record for the community pharmacy to confirm receipt of the medication To reduce risk of dispensing error This acts as a record for the community nurse to confirm receipt of the medication 5. TRANSPORT OF CDS IN THE CAR The prescribed CDs and other urgent medication should be placed in the designated sealed Envo Pack, and placed in the boot of the car The registered nurse must ensure that she/he travels directly to the patient s home 6. RECORD KEEPING On arrival to the patient s home the nursing staff must record receipt of the CDs in the patient s record The Envo Pack used to transport the CDs and other urgent medication should be returned to the nursing base at the nearest opportunity and recorded back into stock To maintain security and keep the CDs out of sight during transportation To maintain security To maintain an audit trail Review Date: 2015 Page 5 of 6
7. CLINICAL INCIDENTS Any related incidents arising from carrying out this procedure which may involve a clinical error or near miss must be reported following the Trust s Incident Reporting System. To maintain patient safety and comply with Trust Incident Reporting procedures for effective clinical governance Health professional or delegated staff member EQUALITY ASSESSMENT TR AINING SPECIALIST COMPETENCIES OR QUALIFICATIONS CONTINUING EDUCATION & TRAINING RISK ASSESSMENTS ORGANISATION DEPARTMENT (IF APPLICABLE) During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no clinical evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care the incident must be recorded using the Trust incident reporting system and an appropriate action plan put in place All registered nurses who have attended Medicines Management Training every two years and are aware of the content of this standard operating procedure 1.Staff must comply with the Trust s Training Matrix which specifies mandatory training requirements. 2.In addition staff must comply with their service level training matrix for training and competencies as required for role 3. All staff to have an annual appraisal To reduce risk of potential loss of substances liable to misuse and promote safety of staff Wirral Community NHS Trust Community Nursing STANDARD OPERATING PROCEDURE APPROVED BY: Peer Review Forum Trust Formal Approval Medicines Management Group Quality, Patient Experience and Risk Group Review Date: 2015 Page 6 of 6