SAFE HANDLING OF PRESCRIPTION FORMS FOR PRIMARY AND UNPLANNED CARE DIVISIONS

STANDARD OPERATING PROCEDURE SAFE HANDLING OF PRESCRIPTION FORMS FOR PRIMARY AND UNPLANNED CARE DIVISIONS Issue History Issue Version Purpose of Issue/Description of Change Planned Review Date One To ensure robust systems are in place to maximise the security of prescription forms against theft and abuse within Wirral Community NHS Trust 2014 Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Section:- Medicines Management Quality, Patient Experience and Risk Group Target Audience August 2013 MMSOP42 All prescribers and staff involved in the handling of prescriptions in Primary and Unplanned Care UNLESS THIS VERSIONHAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

CONTROL RECORD Title Safe Handling of Prescriptions Forms for Primary and Unplanned Care Divisions Purpose To ensure robust systems are in place to maximise the security of prescription forms against theft and abuse within the Trust Author Quality and Governance Service (QGS) Impact Assessment Incorporated into procedure Yes No Subject Experts Jackie Edwards Trust Pharmacist Lisa Knight - Medicines Governance Pharmacist Document Librarian QGS Groups consulted with :- Medicines Management Group Infection Control Approved Not relevant for this SOP Date formally approved by August 2013 Quality, Patient Experience and Risk 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 J Edwards N To fit the purpose of Primary and Unplanned Care Divisions. Status New / Revised / Trust Change Standard Operating Procedure: For Safe Handling of Prescription 2/23

NAME OF DISCIPLINE: PRIMARY CARE DIVISION OBJECTIVES To ensure robust systems are in place to maximise the security of prescription forms against theft and abuse within the NHS. SCOPE TARGET GROUP (Staff authorised to follow this SOP) CROSS REFERENCE RELATED POLICIES EVIDENCE SUPPORT PROCEDURE To cover all aspects of stock control, the stages of ordering, delivery, receipt, storage and distribution of prescription forms and the actions to be taken in the event of loss or theft of prescription forms. All prescribers employed within the Primary and Unplanned Care Divisions, Wirral Community NHS Trust (WCT) All designated staff members who are involved in the handling of prescription forms Trust Safe Handling and Administration of Medicines Policy Trust Health Records Policy Security of Prescription Forms Guidance. March 2011 This document can be found at the following web site: www.nhsbsa.nhs.uk IT IS THE RESPONSIBITITY OF ALL STAFF COMPLY WITH RELEVANT TRUST POLICIES, PROCEDURES AND PROCOLS IN CONJUNCTION WITH THIS PROCEDURE PROCEDURE ACTIVITY RATIONALE RESPONSIBILITY 1. Responsibility of WCT It is the responsibility of the Director of Quality and Governance to oversee the handling of prescription forms throughout Trust. The Local Security Management Specialist (LSMS) will be responsible for investigation and advice regarding further action in the event of loss or theft of prescription forms and will liaise with the Trust Counter Fraud Officer All prescribers should have regular checks to ensure they are registered with the relevant Professional Council All health bodies should designate a member of staff with overall responsibility for overseeing the whole process Secretary of state for Health Directions 2003/04 Legal requirement Director of Quality and Nursing LSMS Head of Service Standard Operating Procedure: For Safe Handling of Prescription 3/23

The Head of Service is responsible for monitoring that these standards are adhered to within their service 2. Pro-security Culture The theft and abuse of prescription forms is a major problem in the NHS resulting in unsupervised treatment of illness, feeding of addiction, financial loss to the NHS and may contribute to violence and aggression. Prescription forms must be regarded as blank cheques which in the wrong hands would lead to a misuse of NHS resources. They can be stolen from a prescribers bag, car, home or whilst being delivered. Professional advice on general security management matters (such as access control, alarms and CCTV) maybe sought from the LSMS contact telephone number: 0151 514 2202 3. Ordering Prescriptions See Appendix 1 for the All Day Health Centre and Leasowe Primary Care Centre See Appendix 2 for GPOOHs See Appendix 3 for Walk-in-Centres Clinical governance and prevention of fraud To ensure all staff work to reduce the possibility of theft, prescription fraud and follow safe practice The LSMS is trained and accredited in the management of security in the NHS To maintain a clear audit trail that will enable immediate recognition of theft or fraud. Head of Service All prescribers and all designated staff members who are involved in the handling of prescriptions All WCT staff Practice Manager, Designated Staff Member 4. Delivery of Prescriptions See Appendix 1 for the All Day Health Centre To ensure safe and secure and Leasowe Primary Care Centre delivery. See Appendix 2 for GPOOHs 5. Receipt of Prescriptions See Appendix 1 for the All Day Health Centre and Leasowe Primary Care Centre See Appendix 2 for GPOOHs See Appendix 3 for Walk-in-Centres 6.Records Kept at Trust Services All recorded entries throughout must be witnessed by second designated member of staff The designated staff member must maintain a record of all prescription forms ordered, by recording details in the Prescription Ordering Log. (see appendix for examples) To ensure any discrepancies are seen as soon as possible and can be acted upon. Practice manager Designated Staff Member Standard Operating Procedure: For Safe Handling of Prescription 4/23

All order details should be entered at the time of the order and include the date of order. All delivery details should be entered upon receipt of order and include: The date of receipt The name of the person accepting the delivery What was received (quantity and serial numbers) All original orders, delivery notes and any supplied list of serial numbers should also be kept. Records of serial numbers must be retained for at least three years. As prescription forms are issued or distributed within the practice to designated printers or consulting rooms, all details should be entered into the main register (or each printer register) including: The date of issue The printer or room number The quantity of prescription forms issued The serial numbers of the prescriptions issued The name of the person issuing the forms The name of the person receiving the forms A log should be kept with the in use prescription box, to track which printer folder each bundle of 100 forms is allocated to. Each room with a prescription printer should have two folders A prescription forms in use folder. And a Top up folder This folder should hold 100 prescription forms with the serial numbers already documented and allocated to that printer. In the event of loss or theft, the record is immediately available so that the police, NHS Security Management Services, The Quality and Governance Service and local pharmacies can be alerted of the relevant details To maintain an audit trail To aid the reconciliation process and maintain an audit trail. To save time during the busy period of the day. Practice manager, Designated Staff Member Practice manager, Designated Staff Member Practice manager, Designated Staff Member Practice manager, Designated Staff Member Standard Operating Procedure: For Safe Handling of Prescription 5/23

These forms should be used if the printer required topping up during the day, and replaced with another 100 forms ready for use on the next day. Using the prescription box log together with the printer folder logs, a monthly reconciliation process should confirm that the number of prescription forms issued and the number of forms remaining in the box, balance. Where prescription forms are issued directly to doctors e.g. for home visits. The following should be entered into the register including: To whom they were issued The number of prescription forms issued The serial numbers of the prescription forms issued When prescription forms are returned unused for destruction, or destroyed following a prescriber leaving the practice, systems must be in place to recover and destroy all unused prescription forms. The following details should be entered in the register: The date of destruction. The serial numbers of the prescription forms (in the case of a part used pad then the 1 st and last serial numbers should be recorded) The names of the person who destroyed the prescription and a witness. In the case of a significant numbers of prescriptions requiring destruction these should be returned to the Quality and Governance Service to be destroyed in a secure manner. These must be hand delivered and signed for. To maintain an audit trail To maintain an audit trail To ensure that no further prescriptions can be issued bearing the details of the prescriber in question. To maintain an audit trail To maintain an audit trail Practice manager, Designated Staff Member Practice manager, Designated Staff Member Practice manager, Designated Staff Member Practice manager, Designated Staff Member The service must ensure they have in place a robust audit trail. Locums Surgeries must keep a record of prescription forms issued directly to locums To ensure a prescription can be traced from receipt of the blank form to when it is prescribed or destroyed. Practice manager, Designated Staff Member Standard Operating Procedure: For Safe Handling of Prescription 6/23

7. Storage of Prescriptions/ Stamps and Security of Computer Prescribing Systems Stocks of prescription forms should be kept in To aid security a secure cupboard within a locked room, with access limited to those who are responsible for prescription forms. Keys or access rights for any secure area This deters criminals from should be strictly controlled targeting Trust services Patients, temporary staff and visitors should and reduces the number of never be left alone with prescription forms or forms vulnerable to theft allowed into secure areas where forms are stored It is advisable to hold minimum stocks of prescription stationery Doctors and surgery stamps should be kept in a secure location separate from prescription forms and to the same standard of security as prescription forms. Single sheet prescription forms, used in printers, should be afforded the same security controls as prescription pads. Prescription forms should be removed from printer trays at the end of the last session of the day or overnight, whichever is the earliest. Between surgery sessions unoccupied consulting rooms must be locked. When the printers are being replaced or if there is concern over existing arrangements, consideration should be given to fitting a secure device to the printer to prevent theft of prescription forms from printer trays Where possible the printers should be positioned within consulting rooms, away from where the patient has direct access The practice should clearly define which staff have access to the system and which staff have access to the functions that generate prescriptions All staff with access to the computer system must have an individual password, known only to the individual concerned Each member of staff is responsible for the security of their logged in computer session and any drugs that are prescribed during that It is more difficult to detect a stolen prescription form that has been stamped. Single sheet prescription forms are acceptable in handwritten form and this makes them a target for theft and fraud To maintain security and deter offenders All prescribers and all clinic staff who are involved in the handling of prescriptions All prescribers and all clinic staff who are involved in the handling of prescriptions All prescribers and all clinic staff who are involved in the handling of prescriptions The Practice manager, Head of Service or manager in conjunction with all prescribers Standard Operating Procedure: For Safe Handling of Prescription 7/23

time. Computer terminals must be locked when left using ctrl/alt/del as per Trust information governance policy. WCT services should not store prescription forms for other healthcare providers. 8. Distribution within the practice or service Prescribers are responsible for the security of prescription forms once issued to them, and should ensure they are locked away when not in use. When making home visits prescribers should take suitable precautions to prevent the loss or theft of forms, such as carrying them in unidentifiable lockable carrying cases and not leaving them on view in a vehicle Prescribers should keep the prescription forms on their person at all times, if in exceptional circumstances prescription forms have to be left in a vehicle, they should be stored in a lockable compartment Prescribers on home visits must record the serial number of any prescription forms they are carrying and only carry a small number. The same precautions will also be relevant when prescribers visit care homes. Blank prescription forms must never be left in a care home. The practice Head of Service or operational manager must ensure a system is in place for recording this information. 9. Using Prescription Forms Blank prescriptions should never be presigned. Where possible, all unused forms should be returned to stock at the end of the session or day. If this is not possible prescribers must store prescription forms securely in their own homes. Prescription pads must not be kept in vehicles overnight. WCT are not responsible for the security of other organisation s prescription forms To maintain security and deter offenders. This will help to immediately identify any prescriptions lost or stolen. Prescriptions are less likely to be stolen from locked cupboards. All staff who are involved in the handling of prescriptions All prescribers All prescribers and all practice or service staff who are involved in the handling of prescriptions Standard Operating Procedure: For Safe Handling of Prescription 8/23

Prescribers must ensure that they comply with the relevant legal requirements when writing prescriptions for controlled drugs (CDs). If an error is made in a prescription, best practice is for the prescriber to do one of the following: (1) put a line through the script and write spoiled on the form (2) cross out the error, initial and date the error, then write the correct information (3)Destroy the form (i.e. shred) and start writing a new prescription. Where prescriptions are written correctly but later found to be surplus to requirements a record should be made and then securely destroyed i.e. via shredding and disposal via confidential waste. This should be witnessed by another member of staff. The destruction record should include serial numbers and be retained for a minimum period of eighteen months. There must be an audit trail for prescription forms, so that the practice, or service, knows the serial numbers of the forms or pads that they have received and which have been issued to each prescriber, consulting room or printer, as appropriate. Ensure security systems are effective 10. Actions to be Taken in the Event of Incidents Incidents involving the loss, theft or misuse of To initiate investigation prescription forms must be reported immediately to the Divisional Manager - Primary Care Division and/or the practice manager and where possible an incident form must be completed in the same span of duty. Outside office hours Merseyside Police should be contacted directly on: 0151 777 5856 The incident must also be reported to: The Head of Nursing, Quality and Governance Service The Accountable Officer for Controlled Drugs, Director of Quality and Nursing To initiate investigation All prescribers All prescribers and all practice or service staff who are involved in the handling of prescriptions All prescribers and all practice or service staff who are involved in the handling of prescriptions The prescriber, practice manager, operations manager or designated member of staff Standard Operating Procedure: For Safe Handling of Prescription 9/23

The Local Security Management Specialist (LSMS) should be contacted using the Missing/Lost/Stolen Prescription Form see Appendix 9 The LSMS will initiate an investigation and send the notification form by e-mail to SecurityManagement@nhsprotect.gsi.gov.uk for input on the national database The LSMS will retain copies of these forms as part of the Trust s audit trail The findings of the LSMS will be shared with the Accountable Officer for Controlled Drugs and the Local Counter Fraud Specialist (LCFS) if required Staff must report any concerns about fraud to the Trust s Counter Fraud Officer on 0151 6513879 ext.1592 Alternatively staff may prefer to use the confidential NHS Fraud and Corruption Reporting Line on 08000284060 The Accountable Officer will liaise with the police, the LSMS and the LCMS and report the incident to COM. COM will fax an alert to all pharmacies alerting them of the incident, and informing them that the prescriber will write all prescription forms in a particular colour for a period of two months. The investigation will review any weaknesses or failures that have allowed the incident to occur. 11. 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 Policy. To initiate investigation To investigate and escalate for inclusion on National data base To share information with other NHS bodies and Health Providers via local intelligence networks To report any concerns regarding security of prescriptions To reduce the possibility of stolen prescriptions being dispensed To highlight actions that need to be taken to prevent further loss or diversion To maintain patient safety and comply with Trust Incident Reporting system for effective clinical governance LSMS Accountable Officer for Controlled Drugs All Trust Staff COM Quality and Governance Service Health professional or delegated staff member EQUALITY ASSESSMENT 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 evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the Standard Operating Procedure: For Safe Handling of Prescription 10/23

delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place TRAINING SPECIALIST COMPETENCIES OR QUALIFICATIONS CONTINUING EDUCATION & TRAINING RISK ASSESSMENTS ORGANISATION DEPARTMENT (IF APPLICABLE) All staff in the Trust are required to comply with mandatory training, as specified in the Trust s Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. All staff involved in prescription handling will: be appropriately informed about this SOP on induction and following any updates. As required by Professional Body and appraisal system in the Trust Loss or Theft of Prescription Forms Wirral Community NHS Trust Primary and Unplanned Care services STANDARD OPERATING PROCEDURE APPROVED BY: Peer Review Forum Medicines Management Group Trust Formal Approval Quality, Patient Experience and Risk Group Standard Operating Procedure: For Safe Handling of Prescription 11/23

All Day Health Centre and Leasowe Primary Care Centre Appendix 1 Prescription ordering. Prescription forms and pads are requested from Central Operation Mersey (COM) Tel No 296 7000 FAX No 296 7189 All orders for GP prescriptions must be submitted on form FP30(P) The form should be faxed to Central Mersey (COM) FAX No 0151 296 7189 All order details must also be recorded in a prescription form register. ( see appendix for sample forms) For any queries regarding prescription orders, contact the Supervisor for Stationery and Stores COM. Tel: 0151 296 7185 To maintain a clear audit trail that will enable immediate recognition of theft or fraud. Practice Manager, Designated Staff Member Delivery of prescriptions The service should be notified in advance of the date of delivery. Prescriptions will only be delivered to the address stated on the prescription, by Medical Courier Services (MCS), on behalf of COM. A list of serial numbers should be included within the delivery note if available (if not provided a photocopy of the driver s delivery sheet should be made) Receipt of prescriptions A permanent member of staff must sign an acknowledgement of receipt of the prescription form order after checking all packaging is sealed and unbroken. A designated staff member will at the earliest opportunity, check the prescriptions received To maintain a clear audit trail that will enable immediate recognition of theft or fraud. To maintain a clear audit trail that will enable immediate recognition of theft or fraud. Practice Manager, Designated Staff Member Practice Manager, Designated Staff Member Standard Operating Procedure: For Safe Handling of Prescription 12/23

are as requested and record the delivery, in the Prescription Form Register. o Where possible this member of staff should not be the person who placed the original order This record must be witnessed by a second designated member of staff The serial number on the prescription forms is positioned at the bottom of the form. The first 10 numbers are the serial number (these numbers run in sequence); the last (the 11 th ) character is a check digit and does not run in sequence). For prescription pads, the first and the last number of each pad should be recorded All of the above should, as far as possible, always be done away from public/patient view. Ideally, a drop off point for delivery vehicles should be as close as possible to the clinic. If there are any irregularities at the delivery stage, the driver should be asked to remain on site whilst the supplier is contacted If the forms do not arrive on the due date, the service should notify the suppliers of the missing prescription forms. Standard Operating Procedure: For Safe Handling of Prescription 13/23

GPOOHs Appendix 2 Prescription ordering Prescription forms and pads are requested from Quality and Governance service (QGS), Wirral Community NHS Trust All orders must be emailed to: Q&Gteam@wirralct.nhs.uk For any queries regarding orders contact QGS on 0151 514 2202 Delivery of prescriptions Prescription forms will only be delivered by 3M to the address stated on the prescription. The service should be notified in advance of the date of delivery. A list of serial numbers should be included within the delivery note. Receipt of prescriptions A permanent member of staff must sign an acknowledgement of receipt of the prescription pad order after checking all packaging is sealed and unbroken. The designated staff member will at the earliest opportunity, check the prescriptions received are as requested and record the delivery, in the Prescription Form Register. (see the appendix for sample forms) The serial numbers of the prescription pads received must checked against the delivery note and then be recorded in the Prescription Pad Register. The serial number on the prescription is positioned at the bottom of the form. The first 10 numbers are the serial number (these To maintain a clear audit trail that will enable immediate recognition of theft or fraud. To maintain a clear audit trail that will enable immediate recognition of theft or fraud. To maintain a clear audit trail that will enable immediate recognition of theft or fraud. Designated Staff Member Designated Staff Member Designated Staff Member Standard Operating Procedure: For Safe Handling of Prescription 14/23

numbers run in sequence); the last (the 11 th ) character is a check digit and does not run in sequence). The first and the last number of each pad should be recorded All of the above should, as far as possible, always be done away from public/patient view. Ideally, a drop off point for delivery vehicles should be as close as possible to the clinic. If there are any irregularities at the delivery stage, the driver should be asked to remain on site whilst the supplier is contacted If the forms do not arrive on the due date, the service should notify the suppliers of the missing prescription forms. Standard Operating Procedure: For Safe Handling of Prescription 15/23

Walk-in-Centres Prescription ordering Prescription forms are requested from Quality and Governance service (QGS), Wirral Community NHS Trust All orders must be emailed to Q&Gteam@wirralct.nhs.uk For any queries regarding orders contact QGS on 0151 514 2202 Receipt of prescriptions A designated staff member must make an appointment with the QGS to collect the order The designated staff member must show their WCT identity badge before signing an acknowledgement of receipt of the prescription forms. The designated staff member will at the earliest opportunity, check that the order is correct and record the serial numbers of the prescription forms received in the Prescription Form Register. (see the appendix for sample forms) The serial number on the prescription is positioned at the bottom of the form. The first 10 numbers are the serial number (these numbers run in sequence); the last (the 11 th ) character is a check digit and does not run in sequence). The first and the last number of each box should be recorded All of the above should, as far as possible, always be done away from public/patient view. To maintain a clear audit trail that will enable immediate recognition of theft or fraud. To maintain a clear audit trail that will enable immediate recognition of theft or fraud. Appendix 3 Designated Staff Member Designated Staff Member Standard Operating Procedure: For Safe Handling of Prescription 16/23

REGISTER FOR SAFE HANDLING OF PRESCRIPTION FORMS Appendix 4 ORDER, RECEIPT AND STRAGE OF PRESCRIPTION FORMS Date & Time Order Placed Date Time Quantity Ordered & Type Of Forms Quantity Type Quantity Type Ordered By Notified Date Of Delivery Staff member name Date Method of order Date of receipt Name of person accepting delivery Staff member name What was received (Quantity & type of forms) Quantity Type Checked against serial numbers list by Staff member name List Of Serial Numbers Received To Where they are stored (lockable cupboard) and by whom Location: By: To To Form to be retained for a minimum of 3 years

Service Name Appendix 5 Log sheet for the Order, Receipt and Storage of Prescription Forms Order date Quantity ordered Ordered by Date Order received Serial Numbers (use a separate line for each pad or box received) Received by Witness Stored by Witness Form to be retained for a minimum of 3 years Standard Operating Procedure: For Safe Handling of Prescription 18/23

Service Name Appendix 6 Log sheet for the Distribution of Computer Single Sheet Prescription Forms To be distributed in batches of 100 (Do not include last serial number which is a dummy number) Consulting Room No Date Box Number Serial Numbers Name Witnessed by Standard Operating Procedure: For Safe Handling of Prescription 19/23 Form to be retained for a minimum of 3 years

SERVICE NAME. Appendix 7 LOG SHEET FOR THE DISTRIBUTION OF SINGLE FP10 PRESCRIPTION FORMS (for Home Visits) Date GP Serial Number Name Witnessed by Standard Operating Procedure: For Safe Handling of Prescription 20/23 Form to be retained for a minimum of 3 years

SERVICE NAME.. Appendix 8 Log Sheet for the Destruction of Prescription Forms (Do not include last serial number which is a dummy number) Date Serial Numbers Name Witnessed by Standard Operating Procedure: For Safe Handling of Prescription 21/23 Form to be retained for a minimum of 18 months

Appendix 9 Missing/lost/stolen NHS prescription form(s) notification form Health body: Wirral Community NHS Trust Contact name: Date reported: Contact telephone number: Contact address: The following numbered NHS prescriptions forms have been identified to us as lost or stolen: Date of theft/loss Name of person reporting (GP, practice manager, nurse, trust pharmacist) Telephone number Full details of theft/loss (please fill in details below) Include the following information: date and time of loss/theft date and time of reporting loss/theft place where loss/theft occurred type of prescription stationery serial numbers quantity details of the LSMS to whom the incident has been reported. Details of doctor/department/dentist/nurse etc from whom prescription form(s) have been stolen or lost Name Personal dispensing or identification code/number Address Serial number(s) lost or stolen From Details of NHS prescription form type lost or stolen (tick appropriate box) To Issue FP10NC FP10HNC FP10SS FP10MDAS FP10HMDAS FP10MDASP FP10MDASS Colour Green Green Green Blue Blue Blue Blue Please indicate type lost/stolen

FP10PN FP10CN FP10SP FP10P FP10D FP10PCDSS Lilac Lilac Lilac Lilac Yellow Pink FP10PCDNC Pink * updated current forms in use October 2006 Has this incident been reported to the police? Name and police station of investigating police officer (please fill in details below) Yes No Has an alert and warning been issued to all local pharmacies and GP surgeries within the area? (please tick box) Yes No Please give details of any ink change or security measures and the effective dates of these measures (please fill in details below) Name: Position: Signed: Dated: Return this completed form by email to SecurityManagement@nhsprotect.gsi.gov.uk Use most current version of this form available on the Trust Web Site Standard Operating Procedure: For Safe Handling of Prescription 23/23