NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDICINES CODE OF PRACTICE MEDICINES MANAGEMENT WHEN PATIENTS ARE DISCHARGED FROM HOSPITAL

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDICINES CODE OF PRACTICE MEDICINES MANAGEMENT WHEN PATIENTS ARE DISCHARGED FROM HOSPITAL Reference CL/MM/024 Date approved 13 Approving Body Directors Group Implementation date 13 Supersedes version 3 (Sep 2010) Consultation undertaken Medicines Code of Practice Review Group Date of Completion of 28 th March 2011 Equality Impact Assessment Date of completion of We are 28 th March 2011 Here For You assessment Target audience All members of NUH staff who deal with medicines Supporting procedure(s) Discharge and Transfer Policy and Procedure (CL/CGP/036) NotIS Electronic Discharge / TTO -Standard Operating Process -Doctor Reference Guide -Pharmacist/Technician Reference Guide -Guidance notes for Prescribing via the etto system Information for doctors -Guidance notes for endorsing supply details via the etto system Information for ward pharmacists and ward technicians Review Date May 2014 Lead Executive Medical Director, NUH Author/Lead Manager MMC NUH Further Guidance/Information Pharmacy Medicines Information Page 1 of 16

Contents Section Title Page number Here For You standards 3 24.1 Prescribing of discharge medicines 4 24.2 Supply of medicines from Pharmacy 6 24.3 Storage of TTO Medicines 8 24.4 Checking of the TTO discharge prescription 8 and medicines before discharge 24.5 Issuing of medicines to the patient or carer 9 24.6 Provision of Out of Hours TTOs 10 24.7 Adult acute medical patients admitted to the 11 Trust for less than 24 hours, Adult short-stay elective surgical patients admitted for less than 48 hours, and all paediatric patients admitted for less than 48 hours Appendix 1 Equality Impact Assessment Report outline 13 Equality statement 15 Environmental impact assessment 15 Appendix 2 Certification of employee awareness 16 Page 2 of 16

The Here for You standards have been introduced to ensure that employees are aware of the acceptable standards of behaviour that are expected and in doing so we have made a pledge to each other. We pledge that all day, everyday we will all do our very best to ensure: You are appreciated, with a polite and respectful attitude, from kind and helpful colleagues, who value everyone who takes responsibility for doing a good job You are supported to make the best use of your time, by simplifying processes, eliminating waste, and streamlining communication to ensure everyone can be focused on high quality care for patients You are encouraged to improve the quality of our service to patients, by listening to patients needs and through evidenceled improvement, team working, training and personal development Page 3 of 16

24.1 PRESCRIBING OF DISCHARGE MEDICINES All discharge prescription documentation must be ratified by the Medicines Management Committee and the Medical Records Committee. All patients must have a TTO discharge prescription written or NotIS electronic discharge prepared on discharge from NUH. The only exceptions are patients transferred to Lings Bar and Highbury Hospitals and those described in section 24.7. An independent prescriber must complete the TTO discharge prescription. Transcription by a nurse or pharmacist for subsequent signature by a doctor is not permitted unless there is a local agreement in place approved by the MMC. Discharge prescriptions should not be written too far in advance of discharge as medication changes often take place. Whenever possible, discharge prescriptions should be written at least 24 hours in advance in order to prevent delayed discharges. If a patient s discharge is delayed and their prescription changes, a new TTO discharge prescription must be written. The prescriber must review all medicines that are currently prescribed on the in-patient chart. All medicines that are to be continued after discharge must be prescribed on the TTO discharge prescription, including any medicines that the patient was taking before admission which are to be continued. 24.1.1 Completing the TTO discharge prescription As a minimum requirement to identify the patient the following must be written onto all copies of the TTO discharge prescription before the rest of the form is completed: the patient s name date of birth hospital or other unique identifying number If a patient addressograph sticker is used for the patient name, one sticker must be placed onto each coloured sheet of the TTO Page 4 of 16

discharge prescription. The prescriber must check that the correct patient addressographs have been used and that they match the inpatient prescription card. Prescribing of medicines onto the TTO discharge prescription or NotIS electronic discharge must comply with the guidance for all prescriptions in section CLMM006 of this Medicines Code of Practice. Only one medicine may be prescribed per line of the form. Prescriptions for controlled drugs must also comply with the legal requirements for the handwritten content of such prescriptions. (See section CLMM012 of this Medicines Code of Practice.) If more than one form is used this must be indicated i.e. 1 of 2, 2 of 2 etc. Prescribers must ensure that they state on the TTO discharge prescription: The reason for medication change during admission and any requirement for monitoring. The reason for taking the medicine in terms that the patient can understand in the appropriate box on the TTO discharge prescription. The duration of medications which are to be taken for a finite time. The specific dosage details and duration of any medicines with a variable dose, e.g. steroid reducing courses. If the patient is prescribed an oral anticoagulant, this must be written onto the TTO discharge prescription stating the name and strength of tablets required e.g. Warfarin 3mg tablets, with the dosage directions as directed. Refer to anticoagulant guidelines. Medication for discharge can be prescribed using the electronic NotIS discharge summary system. 24.1.2 Prescribing The prescriber will be required to follow the NotIS Electronic Discharge / TTO -Standard Operating Process. The system will automatically record the patient s date of birth and hospital or other Page 5 of 16

unique identifying number, once the relevant patient s name has been selected. The prescribing process must involve the completion of the following mandatory fields: -name of drug -status (whether New, Amended or Unchanged) -dose -route -frequency -treatment duration -medicines stopped to state whether no medicines stopped intentionally or where stopped, specify the drug, reason for stopping and restarting instructions if relevant. An optional field to include additional instructions / reason for medication may be completed. Prescriptions which include a controlled drug will be printed out on the ward and signed by hand by the prescriber. The electronic form will be submitted and the signed paper copy sent to pharmacy for dispensing. 24.2 SUPPLY OF MEDICINES FROM PHARMACY Pharmacy will provide a supply of medicines to a patient in line with the Service Level Agreement between the PCT and the Trust. The quantity supplied will vary depending on an individual patient s needs. A reduced supply will be made if a specific course length is clinically indicated (for example, a course of antibiotics) or a longer supply may be provided if the medicine is designated as hospital only. If it is possible for pharmacy to confirm that the patient has an adequate and suitable supply of a medicine at home, then a supply may not be made, and an appropriate endorsement will be made on the TTO discharge prescription. The supply will include reuse of Patients Own Drugs (PODs) if they are in a suitable condition (refer to section CLMM018 of this Medicines Code of Practice). Loose blister strips of PODs brought into hospital will be re-packaged and labelled, unless the patient has been in hospital for less than 48 hours and a pharmacist or technician can confirm that the patient knows how to take the medication. Loose Page 6 of 16

blister strips of PODs being transported between wards or pharmacy must be identifiable as belonging to the patient. The only exception to this is for short stay elective surgical patients and medical admissions unit patients (see sections 24.7 and 24.8). 24.2.1 Pharmacy Professional Checking A Pharmacist must professionally check all TTO discharge prescriptions that are processed through Pharmacy. The professional check will take place either on the ward or in the dispensary. The pharmacist will check the TTO discharge prescription against the inpatient chart, supplementary prescription charts and PODs for accuracy and appropriateness of therapy, and will initial the Pharmacy professional check box when they have completed this. Pharmacists are authorised to screen NotIS electronic discharge prescriptions either at ward or dispensary level. This can only be done if the Medicine Prescription and Administration Record is available at the time of screening whether on the ward or in the dispensary. All prescriptions if suitable will be passed by the pharmacist. Any prescriptions that require amendment will be either failed or amended by the pharmacist using a verbal order. If the prescription is failed, the prescriber will then amend and resubmit. TTO discharge prescriptions sent to a Pharmacy dispensary must be accompanied by all PODs, any medicines previously supplied by Pharmacy, and all drug charts, including supplementary charts. Loose blister strips being transported to pharmacy must be identifiable as belonging to the patient. When professionally checking TTO discharge prescriptions on the ward, the pharmacist or technician will leave appropriate medicines in the patient s drug locker. Additional medicines to complete the supply will be sent separately from Pharmacy. When medicines for the discharge have been assembled and checked by Pharmacy, they will sign the final check box in the bottom right hand corner of the TTO discharge prescription. Page 7 of 16

24.3 STORAGE OF TTO MEDICINES TTO medication supplies must be stored in a locked location on the ward, usually the patient s own medicines locker. Storage of controlled drugs supplied as TTOs must be as described in section CLMM012 of this Medicines Code of Practice. Any medication requiring refrigeration must be stored in the designated locked drugs fridge. Storage of the TTO discharge prescription should be according to local ward procedure. 24.4 CHECKING OF THE TTO DISCHARGE PRESCRIPTION AND MEDICINES BEFORE DISCHARGE Before giving the TTO discharge prescription and medicines to the patient or carer, the nurse must check: The TTO discharge prescription has been signed by a doctor Pharmacy signatures are present in both the professional check box and final check box on all copies of the TTO discharge prescription. The TTO discharge prescription corresponds to the in-patient prescription and supplementary charts, and any discrepancies brought to the attention of the prescribing doctor. The medicines supplied by pharmacy and any prescribed PODs correspond with the TTO discharge prescription to confirm: Patient name Drug name Doses Directions Sufficient quantity (either supplied or endorsed as available at home) Any discrepancies must be brought to the attention of pharmacy. Page 8 of 16

The patient identifiers on the medicines correspond with the prescriptions and the patient. Any discrepancies must be brought to the attention of pharmacy and the drugs not supplied to the patient. The nurse must ensure that no stock containers, unlabelled medicines or labelled medicines without any directions are supplied to the patient. Nurses must ensure that all patients discharged on oral anticoagulants have an Anticoagulant clinic discharge card and that a date for the next INR appointment has been arranged. Refer to the anticoagulant guidelines. Medication must not be transferred from an original box or container into any other container in order to provide the patient with medication. For patients whose medication has been prepared against a NotIS electronic discharge prescription, the nurse must print out a copy of the patient document when it is at stage 7 and the medication is all available on the ward. The nurse must check all of the above except the doctor s signature and the pharmacist s final check box. 24.5 ISSUING OF MEDICINES TO THE PATIENT OR CARER On issuing the medicines to the patient or carer, the nurse must check: That the medication supply and the TTO discharge prescription are for the correct patient, by confirming the name and hospital number against the patient s wristband. That the patient or carer understands the purpose of medication and how to obtain further supplies if necessary. The nurse may then replace the medicines in the pharmacy bag and issue them to the patient or carer. The nurse must give copies of the TTO discharge prescription to the appropriate people (GP copy, patient copy and the copy to be filed in the patient s notes). For the electronic system, a NotIS discharge prescription is transmitted to the GP electronically or printed and sent Page 9 of 16

by post. A patient copy is printed and given to the patient and a copy is printed and put into the notes. Once the medicines have been issued to the patient or their carer, the security of the medicines is the responsibility of the patient or carer. If the patient or carer does not have sufficient understanding to take responsibility for the medicines (for example a patient being discharged via the ambulance service to a nursing home) the medicines must be placed in a pharmacy bag, then this bag put into the patient's property bag. The ambulance service are then responsible for transporting the patient's property bag safely to their place of discharge. 24.5.1 Patients who are unable to wait for their medication The patient or their representative must return to collect the TTO discharge prescription and medicines whenever possible. These may only be issued to them by an appropriately trained member of staff as described in section 24.4. Only in exceptional circumstances may a taxi be used to deliver medicines to a patient s home address. In this situation the nurse must contact the Pharmacy for advice. 24.6 PROVISION OF OUT OF HOURS TTOs At the Queens Medical Campus designated wards are designated as being permitted to have discharge medicines dispensed by pharmacy until 2300h. (Refer to the Pharmacy Out of Hours policy). On ali other wards, including all wards at City campus, if a patient is discharged outside Pharmacy opening hours and discharge medication has not been prepared in advance, the nurse must contact the doctor to check if medicines can be administered early on the ward, or if any can be omitted for that night. If this is the case, the discharge medication will be dispensed as a priority the next morning by Pharmacy. If patients have any of their own medicines and there have been no changes to these, they may be returned to the patient if requested or needed for that evening. Two nurses must check the PODs and write Page 10 of 16

against each medicine re-issued on the TTO discharge prescription own checked and both nurses must sign the chart. Where possible however, the PODs should be kept with the TTO discharge prescription in a secure locked location on the ward for checking by Pharmacy the next morning. If any other medicines are required, the nurse must contact the oncall pharmacist for advice. 24.7 ADULT ACUTE MEDICAL PATIENTS ADMITTED TO THE TRUST FOR LESS THAN 24 HOURS, ADULT SHORT STAY ELECTIVE SURGICAL PATIENTS ADMITTED FOR LESS THAN 48 HOURS AND ALL PAEDIATRIC PATIENTS ADMITTED FOR LESS THAN 48 HOURS 24.7.1 If any of these groups of patients have no changes to their regular medicines and sufficient supplies of their own medicines at home The prescriber may write on the TTO discharge prescription No change in medication. The pharmacist, technician or nurse does not need to check the PODs. They will endorse the chart, own returned not checked or own at home. No medicines dispensed during this admission may be given to the patient. Sufficient clinical details of the admission must still be completed on the TTO discharge prescription for the GP A pharmacist does not need to perform a professional check and the patient can be discharged by the nurse. 24.7.2 If any of these groups of patients have new medicine(s) prescribed or have run out of any of their usual regular medicines The prescriber must prescribe the medicines required on the TTO discharge prescription and then also write on the prescription (if appropriate) No other medication changes. A pharmacist must then complete a professional check as stated in 24.2.1. The pharmacist, pharmacy technician or nurse does not need to check the PODs. They will endorse the chart, own returned not checked or own at home Page 11 of 16

Sufficient clinical details of the admission must still be completed on the TTO discharge prescription. On the NotIS Electronic Discharge the prescriber can tick the box No change to regular medicine. If no new items are required the prescription will not be screened by a pharmacist. The prescriber may tick the box No change to regular medicine and list only the new medicines on NotIS Electronic Discharge if the patient has been in for less than 24 hours in medicine or 48 hours in surgery. 24.7.3 If any of these groups of patients have a change in dosage made to any of their regular medicines or have a medicine discontinued The prescriber must prescribe all the drugs on the TTO discharge prescription or NotIS Electronic Discharge in the normal way (see section 24.1.1) and a pharmacist must complete a professional check as stated in 24.2.1 and supply or remove the medicines If a supply of medication has been dispensed by the hospital to the patient during their inpatient stay (identified by the pharmacy address on the label) and it is required for home, the supply may not be given to the patient unless the medicine has been prescribed on a TTO discharge prescription. The pharmacist or nurse must ask the prescriber to prescribe the dispensed items on the TTO discharge prescription, and these will be checked by pharmacy as described in section 24.2. Page 12 of 16

EQUALITY IMPACT ASSESSMENT REPORT OUTLINE 1. Name of Policy or Service MEDICINES MANAGEMENT WHEN PATIENTS ARE DISCHARGED FROM HOSPITAL 2. Responsible Manager Medical Director, NUH 3. Name of Person Completing Assessment Sonia Gilmore 4. Date EIA Completed Updated 28 th March 2011 5. Description and Aims of Policy/Service This chapter of the Medicines Code of Practice has been modified to permit prescribing and supply of medications at discharge using a paper triplicate prescription or an electronic prescription generated by enotis. 6. Brief Summary of Research and Relevant Data 7. Methods and Outcome of Consultation Medicines Code of Practice Review Group 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Assessment of Impact Page 13 of 16

Gender Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Social Deprivation 9. Decisions and/or Recommendations Following the initial impact assessment, it is my recommendation that this document does not require a full impact assessment. This policy relates to the standards required for NUH compliance with Government Policy as listed above and does not discriminate against any of the strands of equality listed above. 10. Equality Action Plan N/A 11. Monitoring and Review Arrangements It is recommended that once implemented, this chapter is reviewed in line with NUH guidelines. Page 14 of 16

Equality Statement All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social and employment status, HIV status, or gender re-assignment. Environmental Impact Assessment This policy has no detrimental environmental impact Page 15 of 16

Appendix 2 CERTIFICATION OF EMPLOYEE AWARENESS Document Title Medicines management when patients are discharged from hospital Version (number) 4 Version (date) I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - general manager Non clinical directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilise this form in a similar way, but this would always be an additional (not replacement) action. Page 16 of 16