FP10 (MDA) PRESCRIPI FRM SADARD PERAIG PRCEDURE (SMS) JUL 2016 his policy supersedes all previous policies for handling and use of FP10 (MDA) prescription forms in SMS
Policy title FP10 (MDA) PRESCRIPI FRM SP (SMS) Policy PHA48 reference Policy category Clinical Relevant to All SMS staff handling FP10(MDA) prescription forms Date published July 2016 Implementation July 2016 date Date last March 2016 reviewed ext review July 2018 date Policy lead Lucy Reeves, Chief Pharmacist Contact details Email: lucy.reeves@candi.nhs.uk elephone: 02033173222 Accountable director Approved by (Group): Approved by (Committee): Document history Membership of the policy development/ review team Dr Vincent Kirchner, Medical Director Drug and herapeutics Committee (DC) April 2016 Quality Committee July 2016 Date Version Summary of amendments March 14 1 ew March 16 2 Routine review minor amendments Stuart Matousek (Lead), uk Sim Wong (SMS Pharmacist) Consultation SMS staff and members of DC D AMED HIS DCUME Further copies of this document can be found on the Foundation rust intranet. I
Contents Page 1 Introduction 1 2 Aims and objectives 1 3 Scope 1 4 Duties and responsibilities 1 5 erms and Definitions 1 6 rdering by Pharmacist 2 7 Supply 2 8 Distribution 2 9 Issuing 3 10 Voids 4 11 Accountability 4 12 Dissemination and implementation arrangements 5 13 raining requirements 6 14 Monitoring and audit arrangements 5 15 Review of the procedure 6 16 References 6 17 Associated documents 6 Appendix 1 Example of list sheet 7 Appendix 2 Cover Sheet 8 Appendix 3 Prescription record sheet (PHform01) 9 Appendix 4 Suggested table 10 Appendix 5 Equality impact statement 12 II
1. Introduction his procedure has been written to ensure accountability and security of use of FP10 (MDA) prescription forms within SMS, to provide an audit trail for all forms used and update procedures to be in line with national guidelines. See references. Prescriptions are controlled stationary and must be stored safely and securely. If lost stolen or a forgery is suspected then section 13 of the trust FP10 HC Prescription Policy must be followed. 2. Aims and bjectives he procedure aims to provide a robust yet manageable system for the ordering, storage, distribution, security and accountability for the use of FP10 (MDA) prescription forms within SMS in line with Security of prescription forms guidance. 3. Scope he procedure applies to all staff working in Substance Misuse Services in the rust who are involved at any stage of the FP10 (MDA) prescription handling process. his includes ordering, supply, storage, distribution, use, security, issuing and accountability. 4. Duties and responsibilities he substance misuse pharmacists are responsible for the development, implementation and auditing of this procedure. hey are also responsible for the ordering, distribution to keyworkers, monitoring and accountability of FP10 (MDA) prescription forms and for the security of such until they are issued to keyworkers. Keyworkers/prescribers to whom the forms are issued are responsible for them after they have been issued to them and they have signed to acknowledge receipt. When the prescription forms are transferred to individual client s prescription record sheets they become the responsibility of the keyworker of that client. his responsibility remains in place until the prescription is issued to the client and they have signed to acknowledge receipt. In the event of no pharmacist being available, two registered nurses who have been trained by the pharmacist may perform the supply and distribution tasks described in sections 7 and 8. 5. erms and Definitions Serial umber Spreadsheet: refers to the electronic document which facilitates the printing of the List sheets. It is available electronically on the pharmacy shared drive. List Sheets (appendix 1): are A4 pages containing the serial numbers of 50 consecutive FP10(MDA) forms with a column for the client name to whom the prescription is issued to be entered, a void by signature column and a destroyed by signature column. An example of one of these is shown in Appendix 1 for reference. 1
Cover Sheet (appendix 2): is the front sheet to be attached to the respective list sheets, and indicates the name of the individual to whom the prescriptions are issued, the serial numbers, date issued and date returned. Prescription Record Sheet (appendix 3): is the client specific record sheet on which the details of all prescriptions issued to clients are recorded. (PHform01) For the purposes of this procedure: Supply: stock supply to the clinic of bulk FP10s Distribution: process of distributing FP10s to individual staff members Issuing: process of printing individual prescriptions for/and handing to the client 6. rdering by pharmacist FP10 prescription pads are ordered from the suppliers by pharmacy on receipt of an email request from the SMS pharmacist. he request must include the following details: ype of prescription (FP10 MDA-SS) Quantity (number of boxes of 500) Specify delivery details ( name and address of service) Requests should be emailed to HMHCpharmacy@candi.nhs.uk he prescription forms will then be delivered directly to the Margarete Centre or IDASS. 7. Supply When the order of FP10 (MDA) prescription forms arrives at the clinic the pharmacist must be informed, who will then arrange for immediate secure storage. Prescription forms must never be left unattended. he pharmacist will sign for and record the delivery. Records must include the box numbers, serial numbers, order number and date received. A suggested table can be found in Appendix 4 to expedite the recording and reconciliation process. he prescription forms are now the responsibility of the clinic pharmacist. 8. Distribution n receipt or when practical the clinic pharmacist prepares accountability lists (List Sheets) for each box of 500 prescription forms received. Instructions for the preparation of list sheets: 2
a) he Serial umber Spread sheet is opened b) he first number of the box of 500 without the check digit is entered in the first box on the prescription numbers page which can be accessed via the tag at the bottom of the spreadsheet. Upon entering the entire sequence of 500 should be generated. c) Sequential check digits are then entered in spaces B2, B3, B4 until the correct sequence is generated for the rest of the 500 prescriptions. It will usually be necessary to enter 3-4 of these for the program to respond correctly. d) he printable sheets page is then accessed via the tag at the bottom of the spreadsheet. he list sheets may then be printed. here will be 10 sheets each containing the serial numbers of 50 prescription forms. It is advisable to check the numbers are correct by choosing one or two random numbers and checking the corresponding number on the prescription form prior to printing. e) he prescription numbers on each LIS SHEE are recorded by the pharmacist in a record book or using the suggested table. he prescription forms are then ready to be issued. In order to expedite reconciliation it is suggested that a unique number be assigned to each List Sheet of 50 prescriptions. his can be done by writing a number on the top right hand corner of the sheet. hese numbers should begin with the year and a sequential number. herefore it will begin at 20161, followed by 20162 etc. When a key worker, prescriber, or other authorised person (referred to as keyworker hereafter) requires prescriptions they approach the pharmacist. Prescriptions may be issued in bundles of any multiple of 50, and then as a general rule enough should be supplied to last the keyworker approximately one month, however 200 should be seen as a maximum. he pharmacist then fills in a Cover Sheet, and staples it to the required number of prescription List Sheet. If 50 prescriptions are required then there will be one sheet, for 100 prescriptions 2 sheets and so on. his along with the corresponding prescription forms is personally handed to the keyworker. he pharmacist must record the name of keyworker, the date, the serial numbers of the prescriptions issued (or the sequential numbers, see above) alongside the supply record, see section 7 and the suggested table. he keyworker must sign to acknowledge receipt he prescription forms are now the responsibility of the keyworker who must store them safely and be able to account for each prescription form. hey must be locked up when not in use in such a way that only the person to whom they are issued has access to them. 9. Issuing Prescription forms are then used by the person to whom they are issued in accordance with the rust Prescription Handling Policy and the Guidance for Prescribing in Substance Misuse Services. For every prescription issued the name of the client to whom it is issued must be recorded on the List Sheet, other details of the prescription are recorded in the client specific Prescription Record Sheet. hese must include the serial number, drug prescribed, daily 3
dose, start/end dates, number of days and total quantity. nce transferred to an individual client s Prescription Record Sheet they become the responsibility of the person keyworking that client and remain so until the client has signed receipt. 10. Voids Prescriptions may be erroneously printed, or otherwise soiled or determined unusable: 10.1 During printing/writing stage While in the possession of the keyworker and before the details have been entered on the Prescription Record Sheet for an individual client In this case they must be immediately and indelibly marked with 2 lines and the words void or cancelled by the staff member who discovers the need to do this. he staff member must also sign (initials) in the Void (signature1) column of the List Sheet A second person, registered professional (pharmacist, nurse, doctor), must then destroy the voided prescriptions using an approved cross cut shredder and sign in the Destroyed (signature 2) box on the List Sheet. his should be done at earliest possible convenience. he prescription form remains the responsibility of the person to whom it was issued until two signatures are entered on the List Sheet documenting their destruction. 10.2 After transfer to the Prescription Record Sheet for an individual client. In this case they must be immediately and indelibly marked with 2 lines and the words void or cancelled by the staff member who discovers the need to do this. he staff member must also sign (initials) in the Client sign receipt R void/destroyed (2 signatures) column of the Prescription Record Sheet. A second person, registered professional (pharmacist, nurse, doctor) must then destroy the voided prescriptions using an approved cross cut shredder and countersign (initials) in the Client sign receipt R void/destroyed (2 signatures) column of the Prescription Record Sheet. his should be done at earliest possible convenience. he prescription form remains the responsibility of the keyworker of the client, named on the Prescription Record Sheet and prescription, until two signatures are entered on the Prescription Record Sheet documenting the destruction (or until issued to a client as discussed in 9. above). 11. Accountability When the keyworker has finished all the prescriptions in the issue then the Cover Sheet and accompanying List Sheets must be returned to the pharmacist who will check that all prescriptions are accounted for (see below) and record the return in the record book or using the suggested table with a signature and the date 4
n return the List Sheets should have either a client name or two signatures documenting destruction by every serial number. he person to whom the prescriptions are issued is responsible for this. When transferred to an individual client s Prescription Record Sheet each prescription entered should have either a client signature documenting receipt or two signatures documenting destruction. he person keyworking the client is responsible for this. Spoilt prescriptions should not be returned to the pharmacist having been destroyed as discussed in section 10 above. In the event of unforeseen circumstances where a voided prescription needs to be returned it should be returned with the List Sheet with which it was issued. If this is not possible it can be returned with another List Sheet. In this case the serial number must be written on the back of the List Sheet it is returned with. 12. Dissemination and implementation arrangements hese procedures will be circulated to the relevant SMS teams and pharmacy. It will be introduced and explained at team meetings by the pharmacist. It will be available on rust Intranet. 13. raining requirements Staff training will be by way of an introductory session at the team meeting of the MC and IDASS. ew staff will be introduced to the system by the pharmacist on induction. Designated registered nurses working at the MC or IDASS will receive training from the pharmacist to perform the functions described in sections 7 and 8 in the case of pharmacist absence. 14. Monitoring and audit arrangements Safe and secure handling of prescription forms will be monitored by the clinic pharmacist to ensure there is a complete audit trail for every prescription issued. his will be achieved by: he pharmacist will ensure that on return the List Sheets have either a client name R two signatures documenting their destruction by every serial number. he pharmacist will carry out an audit of 5 (five) randomly selected Prescription Record Sheets checking to ensure that for each prescription entered there is either a client signature R two signatures documenting their destruction. his will be reported to the chief pharmacist along with the CD and FP10 (HC) audits on a 3 monthly basis. 5
Elements to be monitored Lead How trust will monitor compliance Frequency Reporting arrangemen ts Acting on recommendations and Lead(s) Change in practice and lessons to be shared Safe and secure handling of forms FP10 prescribing Incidents Chief Pharmacis t Chief Pharmacis t Chief Pharmacis t Audit Quarterly DC Required actions will be identified and completed in a epac data Monthly DC Datix ngoing DC specified timeframe Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 15. Review of the procedure his SP shall be reviewed every 2 years or earlier should a change of practice is introduced. 16. References HS Security Management Service: Security of Prescription forms Guidance, HS Protect, Updated July 2015. RPSGB Medicines, ethics and practice: a guide for pharmacists : 39 th edition July 2015 www.nhsbsa.nhs.uk 17. Associated documents FP10 HC Prescription policy Prescribing guidance for prescribing in substance misuse services Prescription Handling for Key Workers policy Medicines management policy Controlled Drug policy 6
Appendix 1 Example list sheet SERIAL UMBER CLIE AME VIDED SIGAURE 1 DESRED SIGAURE 2 7
Appendix 2 Cover sheet FP10 (MDA) (BLUE) PRESCRIPI ISSUE FRM CVER SHEE Serial numbers Date issued : Issued to Date returned: hese prescriptions are now your responsibility. hey are controlled stationary and must be stored safely and securely and returned to secure storage immediately after use. Any loss or theft must be reported to the pharmacist, service director or a member of medical staff immediately when noticed. ou are advised to check that all are present each time you use them. Every prescription must be accounted for. For prescriptions issued the name of the client to whom they are issued must be recorded (other details are recorded on the individual clients prescription record sheet) Prescriptions to be voided must witnessed by a second person. he first signature is for the person voiding it by marking with 2 lines and the words voided or cancelled. he second for shredding. n return there should be by every prescription number either client name or two signatures documenting destruction. 8
Appendix 3 Client ame : Address : Prescription Record Sheet Pharmacy ame and address Detoxification Plan otes he Margarete Centre 108 Hampstead Road London W1 2LS 02033176000 Keyworker DB Phone Date Current Pharmacy phone IDASS 592, Holloway Road London 7 6LB 02033176240 Prescription number Drug and form Daily dose 9 Start date End date D A S otal quantity Pick-up days (circle) M W F S S M W F S S M W F S S M W F S S M W F S S M W F S S M W F S S M W F S S M W F S S M W FP10 (MDA) PRESCRIPI FRM SP FR F SMS_PHA48_JUL S S 2016 SS A Signed by (prescriber) Dose being titrated () or optimis ed () Detox plan in place? Issued by Date Client sign receipt R void/destroyed (two signatures)
Appendix 4 able SEE BELW 10
Box number Serial numbers rder number Date received Serial numbers r sheet number Issued to Date issued Sign receipt Returned and complete pharmacist initial and date Box number Serial numbers rder number Date received Box number Serial numbers rder number Date received 11
Appendix 5 Equality Impact Assessment ool es/o 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) ationality 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, 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? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? /A o /A /A /A 12