Non Medical Prescribing Policy and Procedures

Non Medical Prescribing Policy and Procedures BCHC Policy Reference Number To be inserted by Library Services post approval If this is a paper copy of the document, please ensure that it is the most recent version. The most recent version is available on the Intranet/internet Page 1 of 37

Title: Version number: Version 4 BCHC Policy Reference Number Is this document new or a replacement for existing? Author/Document Lead Name of Executive Director Lead: Name of Approving Committee/Group & Date: Name of Ratifying Committee & Date: Review Date: May 2017 Date Issued: Date & Outcome of assessment for E&HRA Target Audience Subject category: Non Medical Prescribing Policy and Procedures To be inserted by Library Services post approval Replacement of Non medical prescribing policy and procedures CH 399 Melanie Hart - Non Medical Prescribing and Governance Lead Andy Wakeman Medical Director Medicines Management Committee 20/5/2014 Clinical Governance Committee 12/6/2014 Date that the document was placed on intranet and circulated to staff (to be added by Library). Equality Impact, Financial Assessment, Staffing Implications 27/4/2009- reviewed May 2014- no changes Compliance with regulation 20/5/2014 Impact on existing Policy-13/5/2014 All Non medical prescribers, both Nurses and Allied health professionals and their managers Please delete all that do not apply (you can select more than one if appropriate: Clinical Medicines Management Summary The aim of the policy and procedure guidance is to promote legal, safe and effective non medical prescribing. It encompasses all aspect of non medical prescribing, including legal and local requirements, and the administrative and procedural steps which appropriately trained non medical prescribers should follow. Commencement of Consultation Date 13/5/2014 Consultation History: The following Committees, groups or individuals have been consulted in the development of this policy: Name: Date: Non Medical Prescribing Sub-Committee members May 2014 Compliance & Assurance May 2014 Version History up to the previous 5 versions Version No. Lead Date Change Implemented Reason for Change 1 Melanie Hart 9/7/2009 New for BCHC 2 Melanie Hart 30/3/2010 Change in legislation 3 Melanie Hart 16/08/12 Change in legislation Page 2 of 37

Section Page 1. Introduction 5 2. Purpose 5 3. Scope 5 4. Objectives 5 5. Duties & Responsibilities 5.1 Chief Executive Officer 5.2 Clinical Governance Committee 5.3 Medicines Management Committee 5.4 Non medical prescribing Sub-committee 5.5 Service Directors 5.6 Clinical Managers 5.7 Clinical Staff 5.8 Non medical prescribing and governance team 6. Definitions 6.1 Community Practitioner Nurse Prescribers 6.2 Independent Prescribers 6.3 Supplementary prescribers 7. Procedures/Process 7.1 Controlled Drugs 7.2 Prescribing licensed medicines for use outside the terms of their licence 7.3 Prescribing medicines that are to be mixed 7.4 Unlicensed medicines (products without a UK marketing authorisation) 7.5 Borderline Substances 7.6 New Drugs on the market 7.7 Blood and blood products 7.8 Requests from patients and medical practitioners 7.9 Private Prescriptions 7.10 Appliances / Dressings in Part IX of the Drug Tariff 7.11 Drugs in Part XVIIIA and Part XVIIIB of the Drug Tariff 7.12 Prescribing for others 7.13. Good Practice, Ethics and Common Prescribing Issues 7.14 Completing a prescription form 7.15 Dispensing and Administration of prescribed items 7.16 Gifts/benefits and working with the Pharmaceutical Industry 7.17 Record Keeping 7.18 Adverse Reaction Reporting 7.19 Legal & Clinical Liability 7.20 Incident Reporting 5 6 6 6 6 6 6 7 7 7 8 8 8 9 9 9 9 10 10 10 10 10 10 11 11 13 14 14 15 16 16 17 Page 3 of 37

Section Page 8. Procedures 8.1 Process for application 8.2 Notification of qualification to prescribe 8.3 Prescription forms 8.4 Ordering, storage, issue and security of prescription pads 8.5 BNFs and NPFs 8.6 Maintaining Competence 8.7 Budget Setting and Monitoring 9. Implementation 24 10 Implications 25 11. Monitoring & Audit 27 18 19 19 20 23 23 24 12. References, Acknowledgements, Websites & Glossary of terms and abbreviations 28 Appendices A Eligibility Criteria for Designated Medical Practitioners (DMP) 30 B Non Medical Prescribers Details Form 32 C How to Order Prescription Pads 33 D Lost or Stolen Prescription Pad Flow Chart 34 E Non medical Prescribing Information Fax 35 F Process for Applying for Non Medical Prescribing (NMP) Course G Change of status for Non medical Prescribing Practitioner 37 36 Page 4 of 37

1. Introduction The aim of introducing Non medical prescribing was described by the Department of Health in 2006 to: 2. Purpose Increase and improve the management and access to medicines Improve the patient/carer experience without compromising safety Develop and utilise the knowledge and skills of health care professionals more effectively Contribute to the introduction of more flexible team working across the Trust Support the management of long term conditions The aim of this policy and procedure guidance is to promote legal, safe and effective non medical prescribing. It will encompass all aspects of non medical prescribing, including legal and local requirements, and the administrative and procedural steps that appropriately trained non medical prescribers should follow. It is supported by the Birmingham Community Healthcare Trust (BCHC) Medicines Management Policy. To ensure that only suitably qualified health care professionals access the relevant education it is essential that robust systems and policies are in place which meet the needs of the employing organisation and the individual, and reference to the BCHC Non Medical Prescribing Strategy should be made. 3. Scope All nurses, pharmacists and AHPs who are currently Non medical prescribers or who wish to undertake a course which would lead to a prescribing qualification. 4. Objectives This policy and procedural document will provide a comprehensive overview of all relevant legislation, documentation and procedures to ensure that all non medical prescribers and prospective non medical prescribing students are practising both legally and within Trust policies. 5. Duties & Responsibilities 5.1 Chief Executive Officer The Chief Executive Officer has overall responsibility for the strategic direction and operational management of Birmingham Community Health Care NHS Trust, including ensuring that Trust policies and guidelines comply with all legal, statutory and good practice guidance requirements. Page 5 of 37

5.2 Clinical Governance Committee The Clinical Governance Committee has responsibility for the ratification of this policy and procedures document and receives a monthly compliance report from the Medicines Management Committee 5.3 Medicines Management Committee The Medicines Management Committee has responsibility for the approval, monitoring the assurance framework for this policy and for reporting compliance to the Clinical Governance Committee via the monthly compliance report. 5.4 Non medical prescribing Sub-committee This sub-committee of the Medicines Management Committee has responsibility for ensuring this policy is up-to date and is being followed in practice. Any audits relating to non medical prescribing will be monitored through this committee. 5.5 Service Directors Service Directors are responsible for ensuring that the policy is implemented and adhered to in their services and training or education needs are identified and met (in conjunction with the Learning and Development team and managers of clinical services) as identified in training needs analysis. 5.6 Clinical Managers Clinical managers are responsible for ensuring that staff are adhering to this policy and that they report to the Non medical prescribing and governance team any changes in circumstances for non medical prescribers. 5.7 Clinical Staff Clinical staff are responsible for adherence to this policy Only qualified non medical prescribers employed by BCHC or working on behalf of it are authorised to prescribe. Prescribing may only be for patients registered with GPs in NHS South Birmingham, NHS BEN, or NHS HOB, or GPs in bordering Clinical Commissioning Groups (CCG s) with whom BCHC has a contractual agreement. All Prescribers must work within their own level of professional competence and expertise, and must seek advice and make appropriate referrals to other professionals with different expertise. Prescribers are accountable for their own actions, and must be aware of the limits of their skills, knowledge and competence. All non medical prescribers must act within their Professional body s code of conduct, standards or ethics. Page 6 of 37

5.8 Non medical prescribing and governance team The BCHC Non Medical Prescribing and governance team will maintain a register of non medical prescribers -all prescribers will be required to provide evidence of their eligibility to prescribe and provide management agreement of their competence and scope of practice. 6. Definitions 6.1 Community Practitioner Nurse Prescribers They may prescribe independently from a limited formulary of products designed to meet the needs of their patients (the Nurse Prescribers Formulary for Community Practitioners). This consists of appliances, dressings and some medicines, including a small number of Prescription Only Medicines (POM). Details of the Formulary are set out in both the British National Formulary and the Part XVIIB (i) of the Drug Tariff. The appropriate training for prescribing from this Formulary is incorporated into the basic training of all District Nurses (DN) and Health Visitors (HV) and can be undertaken by other nurses regardless of their speciality, if they meet the criteria for undertaking the course. 6.2 Independent Prescribers A Nurse Independent Prescriber (formerly Extended Formulary Nurse Prescriber) is a 1st level Registered Nurse, Registered Midwife or Registered Specialist Community Public Health Nurse whose name in each case is held on the Nursing and Midwifery Council professional register, with an annotation signifying that the nurse has successfully completed an approved programme of preparation and training for nurse independent prescribing. A Pharmacist Independent Prescriber is a registered pharmacist whose name is held on the membership register of the General Pharmaceutical Council (GPhC), with an annotation signifying that the pharmacist has successfully completed an education and training programme accredited by the GPhC and is qualified as an independent prescriber. An Optometrist Independent Prescriber is a registered optometrist whose name is held on the register of the General Optical Council and who has undertaken the appropriate accredited training and had their registration endorsed on the register. Independent Optometrist Prescribers are able to prescribe any licensed medicine for ocular conditions affecting the eye and the tissues surrounding the eye, except controlled drugs and/ or medicines for parenteral administration Podiatrist independent prescribers may only prescribe medications that are relevant to the treatments of disorders affecting the foot, ankle and associated structures in line with current practice and consistent with published professional guidance. A physiotherapist independent prescriber may prescribe any licensed medicine within national and local guidelines for any condition within their area of expertise and Page 7 of 37

competence within overarching framework for human movement, performance and function. Nurses, pharmacists, podiatrists and physiotherapists who have successfully completed an independent prescribing course can prescribe any medicine within the specific arrangements listed below. 6. 3 Supplementary prescribers Supplementary Prescribers (nurses, pharmacists, physiotherapists, radiographers, chiropodists/ podiatrists and optometrists) can prescribe by creating a voluntary partnership with a doctor (or dentist), to implement an agreed patient-specific clinical management plan (CMP). Supplementary prescribers are able to prescribe any medicine, including Controlled Drugs, unlicensed medicines and off-label medicines that are listed in the agreed CMP. The Plan will be drawn up, with the patient s agreement, following diagnosis of the patient by an Independent Medical Prescriber. Supplementary prescribing may well still be the most appropriate mechanism for prescribing, for instance where a nurse or pharmacist is newly qualified as a prescriber or where the nurse or pharmacist wishes to prescribe a new drug on the market. There are no legal restrictions on the conditions that may be treated under supplementary prescribing, but supplementary prescribers must still work within their professional competence. 7. Procedures and Process 7.1 Controlled Drugs Independent pharmacist prescribers and independent nurse prescribers are able to prescribe, administer and give directions for the administration of schedule 2, 3, 4 and 5 controlled drugs. However they are NOT able to prescribe diamorphine, dipipanone or cocaine for treating addiction but may prescribe these items for treating organic disease or injury. Compounding (mixing) any person acting in accordance with the written directions of a pharmacist, nurse, physiotherapist or podiatrist independent prescriber, dentist, or supplementary prescriber (working in accordance with a clinical management plan), are able to compound schedule 2, 3, 4 or 5 controlled drugs 7.2 Prescribing licensed medicines for use outside the terms of their licence Non- medical Independent Prescribers may prescribe medicines independently for uses outside their licensed indications/uk marketing authorisation ( off-label ). They must however, accept professional, clinical and legal responsibility for that prescribing, and should only prescribe off-label where it is accepted clinical practice and that it would better serve the patient s/clients needs than an appropriately licensed alternative. Furthermore the prescriber should be satisfied that there is sufficient body of evidence and/or experience to demonstrate its safety and efficacy. Prescribers should follow locally approved guidelines when prescribing off-licence medicines. The prescriber should explain the situation to the patient/guardian, where possible, but where a patient is Page 8 of 37

unable to agree to such treatment, the prescriber should act in accordance with best practice in the given situation and within the policies of BCHC. Community Practitioners Nurse Prescribers may not prescribe medicines independently for uses outside their licensed indications/uk marketing authorisation. except for nystatin off-label for neonates. Where Community Practitioner Nurse Prescribers are absolutely clear that the diagnosis is one of oral thrush, they may prescribe nystatin at the dose recommended in the Childrens BNF (100 000 units 4 times daily after feeds). An exception for nystatin is allowed on the basis that there is no systemic absorption of the product and the use of the product in treatment of oral thrush is long-established. Supplementary prescribers are able to prescribe any medicine, including unlicensed medicines and off-label that are listed in an agreed Clinical Management Plan. 7.3 Prescribing medicines that are to be mixed Independent Prescribers may prescribe medications that are to be mixed if the Summary of Product Characteristics (SPC) allows for this, as this is not rendering the product unlicensed. 7.4 Unlicensed medicines (products without a UK marketing authorisation) Independent Nurse, Pharmacist, Physiotherapist and Podiatrist prescribers are allowed to mix medicines to produce an unlicensed medicine, where the mixing of medicines means the combining of two or more medicinal products together for the purposes of administering them to meet the needs of the patients (e.g. in a syringe driver, or nebuliser). The mixing of medicinal products to produce an unlicensed medicine can also be undertaken by another person acting on the written directions of an Independent non medical prescriber, or by a supplementary prescriber where the mixing of the medicines forms part of the clinical management plan for an individual patient. The mixing of drugs should be avoided unless essential to meet the needs of the patient. Nurse and Pharmacist Independent Prescribers can prescribe unlicensed medicines for their patients, on the same basis as doctors and dentists. Physiotherapist and Podiatrist Independent prescribers are not permitted to prescribe unlicensed medicines. Community Practitioners Nurse Prescribers are not permitted to prescribe unlicensed medicines. 7.5 Borderline Substances Independent Prescribers should restrict their prescribing of borderline substances to items in the Local Formularies and on the Advisory Committee of Borderline Substances (ACBS) approved products and the circumstances under which they can be prescribed list (See BNF or part XV of the Drug tariff). The prescription should be endorsed with ACBS to avoid investigation. Page 9 of 37

7.6 New Drugs on the market It does not follow that non medical prescribers can automatically prescribe new medicines on the market even if they are licensed for use in the area of expertise practised by the prescriber. Competence to prescribe drugs that fall outside the group of drugs with which the practitioner has worked alongside the mentoring doctor will need to be considered very carefully by the prescriber and the manager. The non medical prescriber should ensure they are familiar with the Summary of Product Characteristics (SPC) of the drug and are competent to assess the patient for suitability to receive the medication and are competent to recognise and manage any side-effects. Specific training alongside a doctor and supplementary prescribing using a patient specific clinical management plan should be undertaken if the drug falls significantly outside of the prescribers current competence e.g. a drug that works in a different manner to the drugs with which the NMP is familiar. The BCHC Chief Pharmacist or another suitable pharmacist should be consulted if appropriate. 7.7 Blood and blood products Blood, including the cellular elements that are packaged for use as packed cells and platelets, is not considered to be a medicinal product and is therefore outside the ambit of the Medicines Act and its subsequent amending Regulations. The prescribing of blood for a patient is not therefore appropriate for Nurse or AHP independent prescribing. However, products derived from the plasma component of blood such as blood clotting factors, antibodies and albumin are considered to be medicinal products and are required to have marketing authorisations. These products may be prescribed by Nurse Independent Prescribers or as part of a supplementary prescribing arrangement. 7.8 Requests from patients and medical practitioners There may be times when it would be convenient for non medical prescribers to prescribe for patients when they are short of a drug supply or to prescribe at the request of a medical practitioner. NMPs must understand that the clinical responsibility for a drug lies with the person signing the prescription, and take this into consideration when such a request is made (see Section 7.13) 7.9 Private Prescriptions Prescribers must not provide private prescriptions for NHS patients unless the item is not prescribable on the NHS. There should be no situation for BCHC staff where this would occur. 7.10 Appliances / Dressings in Part IX of the Drug Tariff Independent Prescribers may also prescribe any appliances / dressings that are listed in Part IX of the Drug Tariff. 7.11 Drugs in Part XVIIIA and Part XVIIIB of the Drug Tariff No prescriber may prescribe on the NHS, drugs listed in part XVIIIA of the drug tariff so called black list. Drugs listed in part XVIIIB of the Drug Tariff, so called grey listed drugs Page 10 of 37

may not be prescribed at NHS expense except in the specified circumstances and prescriptions must be endorsed SLS. 7.12 Prescribing for others Qualified non medical prescribers cannot issue prescriptions on behalf of another professional who is not a prescriber. The prescriber must assess the need for the prescription themselves. However, non medical prescribers may prescribe medication for others to administer. This must be recorded on the patient prescription or administration chart. 7.13. Good Practice, Ethics and Common Prescribing Issues Prescribing decisions A non medical prescriber can only order a medicine for a patient whom he/she has assessed for care. They may issue a repeat prescription, but do so in the knowledge that they are responsible as the signatory of the prescription and are accountable for their practice. Before signing a repeat prescription they must be satisfied that it is safe and appropriate to do so and that secure procedures are in place to ensure that: a) The patient/client is issued with the correct prescription b) Each prescription is regularly reviewed and is only re-issued to meet clinical need c) A review must take place following a maximum of six prescriptions or six months elapsing d) The correct dose is prescribed e) Suitable provision for monitoring each patient/client s condition is in place and for ensuring that patient/clients who need a further examination or assessment do not receive repeat prescriptions without being seen by an appropriate prescriber A non medical prescriber should write a prescription for: Normally no more than one or two weeks supply for acute conditions, where applicable. For some infections, a short course of only 3-5 days is likely to be appropriate. Normally no more than 28 days supply of medicines for non-acute conditions. For some patients well stabilised on treatment and under regular review, the quantity should be limited to a maximum of 3 months supply. The non medical prescriber must ensure that the prescription is cost effective, meets the clinical needs of the patient and is within agreed protocols and procedures. Non medical prescribers should prescribe medicines according to locally agreed formularies, wherever possible, and this will be monitored. Prescribers qualified to prescribe must not issue initial prescriptions on behalf of others who are not qualified to prescribe. However, repeat prescriptions can be issued at the Page 11 of 37

request of those who are not prescribers, where the non medical prescriber was responsible for the initial prescription. Non medical prescribers may issue repeat prescriptions for patients on their own caseload on no more than six occasions or for a maximum period of six months without carrying out a reassessment. Who to write prescriptions for Non medical prescribers can only prescribe for patients who are registered with, or resident within, BCHC, as follows: or Non medical prescribers working for different GP practices in the community can use one prescription pad. There is one generic BCHC code on each prescription pad. They must prescribe only for patients on their caseload. Non medical prescribers working within a particular specialist service within the community will use a prescription pad with a specific cost centre code for that service. For example ADHD specialist nurses. They must prescribe only for patients on their caseload. Non medical prescribers can prescribe for travelling families provided that the appropriate residency forms have been completed. Hospital, prison or clinic based non medical prescribers should only prescribe for patients in the clinic, ward or prison in which they are working or for patients in their area of clinical responsibility (e.g. where nurses provide services in the community as part of an outreach team). Informing patients Non medical prescribers must ensure that patients and clients are aware of the scope and limits of their prescribing and how the patient or client can obtain other items necessary for their care. Information about treatment should be fully explained to ensure that there is no delay in obtaining supplies. Prescribing for self, family and friends Non medical prescribers will not prescribe for themselves. Non medical prescribers should never prescribe for anyone with whom they have a close personal or emotional relationship, other than in exceptional circumstances. They must be able to justify what is considered an exceptional circumstance and why, at the time, a prescription could not be issued by another Independent prescriber. Non medical prescribers may only prescribe Controlled drugs for someone close to them if: No other person with the legal right to prescribe is available and only then if that treatment is immediately necessary to: Save life Avoid significant deterioration in the patient/clients health Alleviate otherwise uncontrollable pain. Page 12 of 37

The non medical prescriber must be able to justify their actions and must document their relationship and the emergency circumstances that necessitated their prescribing a controlled drug for a person close to them. 7.14 Completing a prescription form FP10 Prescriptions must be written by non medical prescribers in accordance with prescription writing requirements laid down by the Prescription Pricing Division (PPD) of the NHS Business Services Authority as outlined in the Nurse Prescribers Formulary (NPF) and British National Formulary (BNF). The prescriber must complete all details on the prescription form by writing clearly and legibly using an indelible pen (preferably black). Only abbreviations as listed on the inside back cover of the current BNF are permissible. The details must include: - The patient s title, forename, surname and address (including postcode) and if available the patient s NHS number. Age and date of birth should preferably be stated- it is a legal requirement to write the patient s age on the prescription when prescribing a Prescription Only Medicine for a child under the age of 12 years. The name of the prescribed item(s), formulation, strength (if any), dose and frequency (in the case of preparations to be taken as required a minimum dose interval should be specified) and quantity to be dispensed. The quantity prescribed should be appropriate to the patient s treatment needs, bearing in mind the interval before the patient s condition is to be reviewed, the need to avoid waste, patient convenience and the avoidance of undue quantities of potentially poisonous substances in the home. It should also comply with the specified pack size in the NPF/BNF. The names of medicines should be written clearly, it is recommended to prescribe generically, except where this would not be clinically appropriate or where there is no approved generic name. Where there is more than one item on a form, a line should be inserted between each item for clarity. Unused space at the bottom of the prescription area should be blocked out with, for example, a diagonal line to prevent fraudulent addition of extra items. If any alterations are made, the prescriber must initial them In-patients and Intermediate Care Units When prescribing on an In-patient prescription sheet, the non-medical prescriber s registration number must be included with the signature. The information detailed above in 5.5.1 must be included, with a separate section completed for each individual drug. Page 13 of 37

The appropriate administration time must be ringed on the prescription chart and the times of administration for once only and drugs with frequent dose changes stated. (see also Medicines Management Policy and Standard Operating Procedure for Completion of Prescription Charts) 7.15 Dispensing and Administration of prescribed items Where a GP practice is a dispensing practice, non medical prescriptions can be dispensed by the practice, but only for the dispensing patients of that practice. Dispensing Doctors cannot dispense prescriptions written by non medical prescribers for patients of other practices. Pharmacists are a very useful source of help and advice to any prescriber. They can advise on pharmacology, drug dosages, product selection and side effects. They will also know the costs, availability and pack sizes of prescribed items. Non medical prescribers should be aware that pharmacists have legal and ethical obligations, which mean they may need to contact the prescriber sometimes urgently to confirm an aspect of the prescription, return it for amendment or even refrain from dispensing it. An up-to-date work (mobile or base) telephone number should be included (in the address box) on all prescriptions. When a non medical prescriber becomes aware that the patient intends to have a prescription dispensed by an appliance contractor, he/she must ensure that the prescription does not contain medical preparations. It is unethical for any prescriber to recommend a particular pharmacy to patients. This is a matter of patient choice unless this is in the best interests of patient care or in an emergency situation. There should, wherever possible, be separation of prescribing, administration and dispensing roles, in keeping with the principles of safety, clinical and corporate governance and The NMC Standards of Proficiency for Nurse and Midwife prescribers (2007) In exceptional circumstances, where a prescriber is both prescribing and dispensing a patient s medication, a second suitably competent person should normally be involved in the checking process. There must be clear accountability arrangements to ensure patient safety and probity, and audit arrangements must allow checking for clinical appropriateness to ensure patient safety and to track prescribing and dispensing by Nurse and Pharmacist Independent Prescribers. 7.16 Gifts/benefits and working with the Pharmaceutical Industry The choice of medicinal product for the patient/client must be based on clinical suitability and cost effectiveness. Personal gifts are prohibited and it is an offence to solicit or accept a gift or inducement. A register of interests must be maintained and kept within a personal portfolio. Companies may offer hospitality for a professional/scientific meeting, but such hospitality must be reasonable in level, and subordinate to the main purpose of the meeting. For further information please refer to the BCHC Business Conduct, Page 14 of 37

Hospitality & Commercial Sponsorship Policy, Guidelines on Sponsorship and Joint Working with the Pharmaceutical Industry and Medicines Management Policy. 7.17 Record Keeping All health professionals are required to keep accurate, legible, unambiguous and contemporaneous records of a patient s care. There is no single model or template for a patient record (although for guidance, staff should refer to the standards published by the relevant professional/regulatory body), but a good record is one that provides in a timely manner all professionals involved in a patient s treatment, with the information needed for them to care safely and effectively for that patient. It is a necessary way of promoting communication within the healthcare team and between practitioners and their patients/clients. Good record keeping is, therefore, both the product of effective team working and a pre-requisite for promoting safe and effective care for patients. The details of any prescription, together with other details of the consultation with the patient, should be entered onto the shared patient record immediately, or failing that, as soon as possible after the consultation. Only in very exceptional circumstances (e.g. the intervention of a weekend or public holiday) should this period exceed 48 hours from the time of writing the prescription. This information should also be entered at the same time onto the patient record and onto the nursing or pharmacy patient record (where a separate record exists). It is recommended that the record indicates clearly: Indication for the prescription The date of the prescription; The name of the prescriber (and that they are acting as a non medical prescriber); The name of the item prescribed, together with the quantity (or dose, frequency and treatment duration). To aid safe administration of medicines, the record should include: The name of the item prescribed, the strength (if any) of the preparation, the dosing schedule and route of administration, e.g. paracetamol oral suspension 120mg/5mls to be taken every four hours by mouth as required for pain, maximum of 20mls in any 24 hours. In the case of topical medicines the name of the prescribed item, the strength (if any), the quantity to be applied and the frequency of the application should be indicated. For dressings and appliances, details of how they are to be applied and how frequently changed, are useful. It is recommended that any advice given on General Sales List and Pharmacy medicines provided over the counter is also recorded. In some circumstances, in the clinical judgement of the prescriber, it may be necessary to advise the GP or consultant immediately about the prescription. This action should be recorded in the common patient record. Where a prescriber is acting in the absence of another, the original prescriber should be notified as soon as possible that a prescription has been issued. A sample fax form is included as Appendix E which could be used to send all the above information to the patients GP. Page 15 of 37

7.18 Adverse Reaction Reporting If a patient suffers a suspected adverse reaction to a prescribed, over-the-counter (Pharmacy or General Sales List) or herbal medicine, the adverse reaction should be reported via the Yellow Card Scheme. The Yellow Card Scheme is a voluntary scheme through which healthcare professionals notify the Medicines and Healthcare Products Regulatory Agency (MHRA)/ Committee on Safety of Medicines (CSM) of suspected adverse drug reactions. The MHRA/CSM encourage the reporting of all suspected adverse drug reactions to newly licensed medicines that are under intensive monitoring (identified by an inverted black triangle both on the product information for the drug and in the BNF and MIMS) and all serious suspected adverse drug reactions to all other established drugs. Serious reactions include those that are fatal; life threatening, disabling, incapacitating or which result in, or prolong hospitalisation and/or are medically significant. The electronic Yellow Card provides a simple and fast way to report suspected adverse reactions. The electronic Yellow Card, together with instructions on how to use it, is available on the MHRA website (www.mhra.gov.uk). Health professionals are encouraged to report all suspected adverse drug reactions using this method, although hard copy Yellow Cards are also acceptable. (Yellow forms can be found at the back of the British National Formulary and Nurse Prescribers Formulary). The adverse reaction should be reported to the GP or Consultant, and documented by the nurse prescriber, in red, on the patient records. A supplementary prescriber should also inform the independent prescriber of any reported ADRs. Should a health professional other than the non medical prescriber detect the adverse reaction, he/she should report the incident to the prescriber, make a record in the notes and the GP or Consultant must be informed. If a patient suffers harm due to an adverse incident involving medicines; or if harm could have been caused to the patient by the medicine (a near miss), the incident or near miss should be reported by the non medical prescriber via the DATIX system. This also encompasses a prescription or treatment sheet being incorrectly completed resulting in near miss/patient harm. 7.19 Legal & Clinical Liability Liability of Prescriber/Professional indemnity Prescribers are accountable for all aspects of their prescribing decisions. They should therefore only prescribe those medicines they know are safe and effective for the patient and the condition being treated. They must be able to recognise and deal with pressures (e.g. from the pharmaceutical industry, patients or colleagues) that might result in inappropriate prescribing. All prescribers must have professional indemnity insurance, for instance by means of membership of a professional organisation or trade union which provides this cover, and Page 16 of 37

must provide their employer a copy of this. This indemnity must be kept up to date and cover the areas they are prescribing for in order to prescribe for BCHC. Both the employer and employee (or contractor) should jointly agree the individual prescribing practice that includes a clear statement on scope of prescribing and areas of competence required as part of the duties of the prescriber (Appendix B) Liability of employer Where a nurse, midwife, pharmacist or therapist is appropriately trained and qualified and prescribes as part of their professional duties with the consent of their employer, the employer is held vicariously liable for their actions. In addition, non medical prescribers are individually professionally accountable to their own professional body for this aspect of their practice, as for any other, and must act at all times in accordance with Codes of Professional Conduct. 7.20 Incident Reporting What constitutes an incident? An incident is something adverse that has occurred. A near miss is something adverse that nearly occurred, and may occur in the future. The problem with some incidents with medicines is they can be unpredictable (such as some unexpected drug reactions) and therefore no fault can be attributable unless there is demonstrable negligence. Reporting depends on the nature of the incident and the following table gives an indication of when to report; it is not exhaustive and if there is uncertainty the incident should be reported: Reportable drug-related incidents Medicines which have been prescribed incorrectly E.g. dose too low or too high, when it results in a significant drug interaction, when it is contra-indicated or led to a significant adverse drug reaction or unnecessary allergic reaction, lack of instructions on the prescription Non-adherence to policy or procedure Loss or mislaid prescriptions and prescription pads Consent not given or obtained Note, this list is not exhaustive and advice can be sought from the Non-medical prescribing and governance team as to whether an incident should be reported or not. If there is a minor amendment to a prescription required, and the pharmacist has noted this and contacted the Non Medical Prescriber concerned for clarification before the drugs are dispensed, (e.g. capsules written instead of tablets) this will be classed as an intervention by the pharmacist, and unless a very serious error does not require reporting. Management, reporting and investigation BCHC operates an open culture for reporting incidents and near misses to facilitate learning from these in order to put in place remedial actions and procedures to prevent Page 17 of 37

future incidents. Reporting does not automatically mean a member of staff will be disciplined and the circumstances leading to any incident or near miss will be taken into consideration. Honest disclosure is in BCHC and patients/public best interest and concealment will be viewed as a potential disciplinary offence. Practitioners must at all times follow their own professional codes of conduct. Please refer to the BCHC Guideline for management of staff who have made a medication error Drugs or medicines related incidents, including lost prescription pads (actual events or near-misses) must be reported onto the Datix reporting system and to the immediate line manager/supervisor. Controlled drug incidents are automatically reported directly to the Trust Accountable Office for Controlled Drugs once a Datix is completed and the Standard Operating Procedure for Management of CD incidents must be followed. Reporting is in addition to, and not a substitute for, timely and appropriate action to manage the incident. Wherever practical a pharmacist should be involved in the investigation. Some incidents will need to be scaled up for appropriate investigation, depending on the circumstances, and may need to be dealt with through a root-cause-analysis or even treated as a serious untoward incident. Refer to the Trust Being Open Policy and the Management of Incidents Policy Informing patients and public If an error or incident has occurred that has involved a patient or member of the public then the following must be followed: 8.0 Procedures Tell the person what has happened Obtain advice from line manager and Non medical prescribing and governance team Arrange for any necessary immediate treatment or follow-up for the person Record all actions Submit a DATIX report 8.1 Process for application Once the eligibility criteria for undertaking non medical prescribing have all been met, and their line manager has agreed and notified the Non Medical Prescribing and Governance team that they require the funding, the potential prescriber must complete the application form, obtainable from the Non Medical Prescribing and Governance Team, and is also available on the intranet. The applicant must also contact the identified University for their application forms and dates of courses. The line manager will be notified by the Non Medical prescribing and governance team whether their application for funding has been approved- if it has then the application form needs to be signed by their line manager and an appointment made with the Non Medical Prescribing and Governance Team for final approval of the application. This is then submitted to the University, with their application from and details of the funding. Page 18 of 37

See Appendix F for a flowchart detailing the process, which is also available on the Non medical prescribing pages of the intranet. Once a place has been confirmed, the applicant must inform the Non Medical Prescribing and Governance Team of the start date and estimated completion date. 8.2 Notification of qualification to prescribe The Higher Education Institute will inform the relevant governing bodies of the non medical prescriber once the course has been successfully completed. The newly qualified non medical prescriber must inform the Non Medical Prescribing and Governance team when they receive confirmation from their regulatory body that their qualification has been recorded on to the professional register. A proforma (Appendix B) to declare their competence to prescribe and define their scope of prescribing practice including a sample signature must be completed by the prescriber and verified by their manager who must take copies for their personal file and then send back to the Non Medical Prescribing and Governance team. A Notification of Newly Qualified Non Medical Prescriber form will be completed by the Non Medical Prescribing and Governance team and submitted to the Prescription Pricing Division of the NHS Business Services Authority (NHS PPD). The PPD will inform the contracted NHS Secure Forms prescription printers of a non medical prescriber s inclusion on the list as eligible to prescribe. It is the responsibility of the new prescriber (either newly qualified or new to the organisation) to notify Pharmacists (both CCG employed and Independent Contractors) that they will be issuing prescriptions. Non medical prescribers issuing prescriptions within the hospital setting must also provide a sample signature to the Hospital Pharmacist and the wards. If working under a Clinical Management plan, or within limited formularies, these also should be provided to the pharmacists. 8.3 Prescription forms Birmingham Community Healthcare Trust Non Medical prescribers Non medical prescribers should usually hand write on FP10SS lilac prescriptions. These will be printed with their individual registration details and the type of prescribing qualification that they hold- for example: Pharmacist Prescriber, Nurse Independent/Supplementary Prescriber, Community Practitioner Nurse Prescriber. As non medical prescribers are able to use FP10SS forms for computerised prescribing, before it can commence, software must be configured to ensure the computer prescribing system correctly prints prescriber details as described above. Clear guidance on what should be included on a prescription is available at: http://www.nhsbsa.nhs.uk/prescriptionservices/811.aspx Non medical prescribers must inform the Non Medical Prescribing and Governance Lead if they are linked to more than one computer since the NHS PPD must be informed. Other BCHC employed/contracted Independent/ supplementary Prescribers Page 19 of 37

Hospital/clinic or prison based non medical prescribers may use three methods to prescribe. Hospital in-patient prescription form or sheet and discharge prescription sheet - to be used for inpatients and discharge supplies only. A prescription charge is not levied for in-patients. Internal hospital prescription form or sheet - to be used for out-patients but only in cases where the hospital pharmacy will dispense the prescription. A prescription charge may be payable, unless the patient is exempt from prescription charges. (NB: internal hospital forms cannot be accepted for dispensing by community pharmacies.) FPI0 HNC type prescription forms - where the medicine will be prescribed by a hospital/specialist prescriber (for example within the Learning Disability service) and dispensed by a community pharmacist. Hospital-based non-medical prescribers will normally have their prescriptions dispensed in the hospital pharmacy. A list of prescribers and signatures will be kept in the pharmacy for reference Hospital inpatient prescription forms and internal hospital prescription forms are to be signed by the non-medical prescriber indicating IP if prescribing independently and SP if Supplementary prescribing from a clinical management plan. The prescriber must also add their professional registration number and supply a contact number next to their signature. All non medical FP10HNC prescriptions should contain the following information: Nurse independent /supplementary prescriber NMC PIN Pharmacist Independent/Supplementary prescriber GPhC No Allied Health Professional Supplementary prescriber Registration No There will be occasions when a prescription needs to be written for patients not registered to local GPs. This is permissible only when there are appropriate Service Level Agreements or Contractual arrangements for the service being provided, for example Tissue Viability/Lymphoedema service. 8.4 Ordering, storage, issue and security of prescription pads The system for ordering, storage and issue of prescription pads will ensure that pads are stored securely and available to prescribers when needed. Ordering, receipt, storage, security and issue of the FP10SS forms will be managed centrally by the BCHC Non Medical Prescribing and Governance team. The FP10 forms arrive personalised with the prescribers details; they are serially numbered and produced on specially printed antifraud paper, in pads of 50. Page 20 of 37

When the prescription forms are received by NMP and governance team, the security of the forms become the responsibility of the Trust Prescription pads will be stored in a locked cabinet, Pads can only be issued to the person named on the prescription pad Issuing of Prescription Pads Initial prescription pads can only be issued to non medical prescribers after a recorded entry onto the Professional Register has been verified. An appointment is made with the Non Medical Prescribing and Governance team for the initial issue of prescribing pads, who will provide local information on pharmacies and other relevant information. The prescriber will need to bring evidence of current registration with their professional body and a form of identity, e.g. Trust ID badge. When subsequent pads are required, they need to be ordered through the Non Medical Prescribing and Governance team. A new order should be requested as the last current pad is started, as it takes approximately 2 weeks for new prescription pads to be delivered to the central base at Moseley Hall Hospital. an appointment needs to be made with the Non Medical Prescribing team for the issue of further supplies, and current ID and proof of current registration must be provided. The number of pads supplied at any one time will be dependent on the needs of the service and the individual prescriber and can be discussed at the time of ordering. The Non Medical Prescribing and Governance team will keep a list of all nurse and AHP prescribers, their professional registration numbers and specimen signatures that will be regularly updated and available to the Medicines Management Team. A register for each non medical prescriber, detailing the number of pads and date of supply and serial numbers of first and last prescription sheets will be maintained as a record of prescription pads issued. This will be signed by the issuer and the prescriber at the time of issue. The prescriber s signature will be checked against the specimen signature by the issuer. A flow chart detailing this process can be found at Appendix C When a non medical prescriber leaves, changes employment, or goes on long term sick/maternity leave within the organisation, it is the responsibility of the prescriber to ensure that prescription pads are returned to the Non medical prescribing team for recording of Serial numbers and storage or destruction. Failure of the prescriber to do this may result in disciplinary / legal action against them. Managers of non medical prescribers must inform the Non Medical Prescribing and Governance team of prescribers who are to leave the organisation, are suspended, or change role or change their name, e.g. in the event of a change in marital status, who will then inform the PPD to have the records amended accordingly. Managers must also Page 21 of 37