STANDARD OPERATING PROCEDURE Witnessing the Destruction of Stock Controlled Drugs within Wirral Community Trust Issue History Issue Version Purpose of Issue/Description of Change Planned Review Date One To ensure stocks of controlled drugs (CDs) in Trust are destroyed in the presence of an authorised witness in a safe and appropriate manner within current legislative requirements 2014 Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Accountable Officer for Controlled Drugs Section:- Medicines Management MMSOP: 27 Quality, Patient Experience, and Risk Group June 2012 Target Audience Witnesses authorised by the Controlled Drugs Accountable Officer to witness destruction of Controlled drugs and Clinical Leads and Senior Practitioners who are employed by services that stock Controlled Drugs UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTROL RECORD Title Standard Operating Procedure for Witnessing the Destruction of Stock Controlled Drugs Purpose To ensure stocks of controlled drugs (CDs) in Wirral Community Trust are destroyed in the presence of an authorised witness in a safe and appropriate manner within current legislative requirements Author Quality and Governance Service (QGS) and L Knight Impact Assessment Incorporated into procedure Yes No Subject Experts Medicines Governance Pharmacist Document Librarian QGS Groups consulted with :- N/A Infection Control Approved N/A Date formally approved by 7 th June 2012 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 L Knight New Status New / Revised / Trust Change 2/7
NAME OF DIS CIPLINE : TRUST WIDE OBJECTIVES To ensure stocks of controlled drugs (CDs) in Wirral Community Trust are destroyed in the presence of an authorised witness in a safe and appropriate manner within current legislative requirements SCOPE To cover all aspects of the destruction of stock controlled drugs from Wirral Community Trust This standard operating procedure does not cover the destruction of patient s own controlled drugs. See separate SOP for Destruction of Patients Controlled Drugs in the Community TARGET GROUP (Staff authorised to follow this SOP) This standard operating procedure (SOP) applies only to witnesses authorised by Wirral Community NHS Trust s Controlled Drugs Accountable Officer to witness the destruction of stock controlled drugs within the Trust and to Heads of and Senior Practitioners who are employed by Trust that have Controlled Drugs as stock EVIDENCE TO SUPPORT Amendment to Misuse of Drugs Regulations 2001 August 2007 Guidance for Pharmacists on the Safe Destruction of Controlled Drugs England, Scotland and Wales Royal Pharmaceutical Society September 2007 A Guide to Good Practice in the Management of Controlled Drugs in Primary Care (England) National Prescribing Centre Third Edition December 2009 Trust Policy GP11 Safe Handling and Administration of Medicines IT IS T HE R E S PONS IB ITITY OF ALL STAFF TO COMPLY WITH RELEVANT T R US T P OL IC IE S, PROCEDURES AND PROTOCOLS IN CONJUNCTION WITH THIS PROCEDURE PROCEDURE ACTIVITY RATIONALE RESPONSIBILITY 1. Trust Service to make an appointment with an authorised witness When stock controlled drugs (CDs) that are out of date or not required are identified, the Clinical Lead is responsible for making an appointment with an to supervise the destruction of the CDs (Contact the Quality and Governance Service on Telephone 0151 514 2202 or internally on 6015) A senior practitioner employed by the service will be present throughout the process and they are responsible for the physical destruction of To comply with Misuse of Drugs Regulations 2001 the drugs and for making the necessary entries 3/7 Clinical Lead in conjunction with a senior practitioner
in the register. Controlled Drugs Destruction Kits must be provided by the service themselves. Controlled drug destruction kits (DOOP kits) can be ordered from NHS Supply Chain code for 250ml kit is KYA003 2. Ensure selection of appropriate authorised witness Quality and Governance Team members that are authorised to witness the destruction of CDs are directly accountable to the Accountable Officer (AO) and must individually read and sign this SOP before undertaking this role. To comply with Misuse of Drugs Regulations 2001 The must ensure that they do not have day to day responsibility for the handling of Controlled Drugs within their job role. Refer to individual authorisation for full details 3. Destruction of Controlled Drugs Destruction of CDs should take place in a room with a sink and at a time when no patients, or members of the public need to use the room The CDs to be destroyed should have been appropriately recorded, marked and segregated (within the CD Cupboard) prior to the visit. The AO should be informed of any concerns. The senior practitioner must be requested to complete a list of the items to be destroyed The CDs segregated for destruction should be removed from the CD cupboard and reconciled with the CD Register The senior practitioner must destroy the CDs using the Controlled Drugs Destruction Kit, by following the instructions on the kit. All stages of this process must be in the presence of the It is advisable for the senior practitioner destroying the CDs to wear a facemask and gloves if available To ensure no distraction and to maintain security To ensure there are no discrepancies To ensure appropriate destruction For protection against particles Senior Practitioner and Authorised Witness 4/7
1. Shake container to loosen granules 2. Add CDs to container, ensuring no more than half full/or to the manufacturer s fill mark 3. Crush tablets before adding (the addition of a small amount of water will minimise any dust) 4. Add powders and liquids directly into kit (adding the liquids last) 5. Break open ampoules before adding, putting both the contents and the glass into the kit 6. For patches remove backing, fold over and place in kit 7. Fill to capacity with water 8. Replace lid securely 9. Shake thoroughly 10. Contents will congeal in 3 to 5 minutes 11. Sealed container to be placed in the CD cupboard whilst the inactivation process is taking place of CD dust The CDs are now considered irretrievable and the responsibility of the authorised witness is complete After 24 hours the kit should be added to a standard clinical waste sharps bin/pharmaceutical waste bin for disposal by secure incineration 4. Records When stock CDs are destroyed the following details must be entered into the register on the relevant pages: The drug name, form and strength The quantity of drug being destroyed The date of destruction The signature of the Senior Practitioner employed by the service The signature of authorised witness together with printed name, and full job title stating their authority to witness, e.g. authorised by AO The must make a Trust record of the controlled drugs destroyed. The Quality and Governance Controlled Drug Stock Destruction Record Book, held in the Quality and Governance Office should To comply with legislation This is considered good practice Senior Practitioner in conjunction with the 5/7
be taken on the visit and the full details of destructions should be recorded. If the record book is not available, the record should be made on the same day or next working day. 5. Discrepancies If any discrepancies are noted in the Controlled Drug Register, the authorised witness should make a detailed note of the discrepancy and report to the AO within 1 working day and complete an incident report. The presence of a discrepancy does not necessarily prevent the destruction taking place. The should consider the risks (if any) of not destroying the CDs during the visit, recording what has, or has not, been destroyed and include any relevant information 6. 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 prevent the unnecessary destruction of evidence To maintain patient safety and comply with Trust Incident Reporting system for effective clinical governance 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 clinical evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care, this must be documented using the Trust s incident reporting system and an appropriate action plan put in place TR AINING SPECIALIST COMPETENCIES OR QUAL IF IC AT IONS C ONT INUING E DUC AT ION & T R AINING As per Trust s Training Matrix for each service Training if necessitated by changes in legislation 1. Staff must comply with the Trust s Training Matrix which specifies mandatory training requirements. 2.In addition staff must comply with their service level training matrix for training and competencies as required for role 6/7
3. All staff to have an annual appraisal ORGANISATION DEPARTMENT (IF APPLICABLE) Wirral Community NHS Trust Quality and Governance Service STANDARD OPERATING PROCEDURE APPROVED BY: Peer Review Forum Trust Formal Approval Medicines Management Group Quality, Patient Experience and Risk Group 7/7