Medicines Policy v3 PDF

DOCUMENT CONTROL PAGE
Title: Medicines Policy
Version Number as from December

2004: THREE
Document Type: Policy

Scope: Trust-wide
Classification: Policy
Author: Medicines Policy Task & Finish Group

Groups Consulted: Professional Advisory Group,
Validated By:
Drugs and Therapeutics Committee
Equality Impact Assessed:

Suzanne Schneider
Date:
October 2012
(If appropriate) Replaces:

Version two
Description of amendments:
Major amendments to all sections. Incorporation of community services
medicines policy. Addition of self-medication policy. Removal of nil-by-mouth
policy (now separate guideline). Policy updates to incorporate admission and
discharge process
Authorising Body:
Date of Authorisation:
Risk Assurance Committee
Nov 12
Master Document Controller:
Review Key Words:
Suzanne Schneider
Date:
Medicines policy, medicine,
Medicines Information Pharmacist
Nov 15
prescrib, administ, selfmedication, storage,
controlled drug, illicit,
accountability, delegation,
check, medicines
reconciliation, unlicensed,
competencies, wardex, drug
history, error, disposal,
delay, key, MAR
Medicines Policy, version 3
Page 1 of 119
Introduction .............................................................................................................. 4
Key Staff and Staff Groups Involved in Medicines Management ............................. 7
Monitoring Arrangements ......................................................................................... 9
Prescribing of Medicines ........................................................................................ 11
Patient Group Directions (PGDs) ........................................................................... 26
Administration of Medicines ................................................................................... 28
Controlled Drugs .................................................................................................... 38
Use of Methadone .................................................................................................. 42
Guidelines for the Handling of Illicit Substances .................................................... 47
10
Admission to bed based services and medicines reconciliation .......................... 50
11
Medicines on discharge ....................................................................................... 53
12
Mental capacity and Covert Administration of Medicines .................................... 56
13
Self Administration of Medicines ......................................................................... 57
14
Unlicensed medicines.......................................................................................... 59
15
Storage of Medicines ........................................................................................... 62
16
Use of Patients Own Drugs (PODs) and Supply of Named Patient Medicines .... 67
17
General rules for supply of medicines to Community Services ............................ 71
18
Carriage of Medicines.......................................................................................... 73
19
Disposal and Return of Medicines ....................................................................... 74
20
Management of Medication Errors and Near Misses ........................................... 76
21
Medicines Management Training ........................................................................ 78
Appendix 1- Protocol for safe and secure handling of medicines in Community Services
...................................................................................................................................... 79
Appendix 2 Patient Group Direction Template ........................................................... 85
Appendix 3 - Guidance for Unregistered Staff in the Administration of Medicines ........ 90
Appendix 4 - Standard Operating Procedure for Controlled Drugs for Royal Bolton
Hospital and Bolton Community Unit ............................................................................. 95
Appendix 5 - Storage and Recording Requirements for Controlled Drugs .................. 100
Appendix 6 - Protocol for the Use of Controlled Drug Denaturing Kits in Community
Services ...................................................................................................................... 101
Appendix 7 - Form for the removal or destruction of unauthorised drugs or other
suspicious substances ................................................................................................ 103
Appendix 8 - Self Administration of Medicines Assessment Algorithm ........................ 104
Appendix 9 - Self Administration of Medicines Assessment Record ........................... 105
Appendix 10 - Self Administration Consent Form ........................................................ 106
Page 2 of 119
Appendix 11 - Information for Patients about Self Administration of their Medicines .. 107
Appendix 12a Disclaimer for the Prescribing of Unlicensed Medication Single
Consultant ................................................................................................................... 109
Appendix 12b Disclaimer for the Prescribing of Unlicensed Medication Multiple
Consultants ................................................................................................................. 110
Appendix 13 List of Unlicensed Medicines that do not require a disclaimer ............. 111
Appendix 14 - Fridge Monitoring Sheet ....................................................................... 112
Appendix 15 - Algorithm for the use of patients own drugs (PODs) ........................... 113
Appendix 16 - Protocol to remove discontinued and out of date medication from patients
home ........................................................................................................................... 114
Appendix 17 Medicines Policy Monitoring Grid ........................................................ 117
Page 3 of 119
1 Introduction
1.1
This Medicines Policy is intended to be read by all individuals who deal with
medicines within the Trust.
1.2
The policy provides guidance on all aspects of medicines handling and

management, including prescribing, ordering, storage and administration and, as
such, constitutes an important element of the Trusts risk management strategy.
1.3
This is the first edition of the Bolton NHS Foundation Trust Medicines Policy; this
policy is based on the Royal Bolton Hospital and the Bolton Primary Care Trust
(PCT) Medicines Policies. It supercedes these two previous policies and
encompasses relevant pharmacy and nursing policies relating to drug
administration.
1.4
The Nil by Mouth Chapter has been removed and is now a separate guideline.
1.5
The policy will be subject to biennial revision and may be modified by local
protocols, which must be agreed by the Drugs & Therapeutics Committee.
Comments and suggestions should be directed to the Chief Pharmacist on
extension 5555.
1.6
This policy should be read in conjunction with the Foundation Trust (FT)
Formulary, the FT Guidelines for Antimicrobial Therapy and other relevant local
policies and procedures.
Objectives of the Policy

The objectives of the Medicines Policy are to:
Ensure that all Trust staff follow standard policies when dealing with
medicines.
Provide a standard for the handling of medicines, which can be audited.
Page 4 of 119
Page 5 of 119
Medicines Trail
Prescribing / initiation of
treatment
Influenced
by
pharmacists,
Trust
Formulary, Evidence
Based Practice, D+T
Procurement / acquisition of
medicines
Manufacture / manipulation
of medicines
Receipt of
medicines
Issue to point of use /

dispensing or supply
Preparation / manipulation of
medicines for administration
Use of medicines /
administration
Influenced
by
pharmacy procedures,
contracting issues, risk
management, financial
considerations
Influenced by pharmacy
procedures,
nursing
procedures,
risk
management, IV Guide,
Clinical Skills / Training
Influenced by trust
waste policy, COSHH
and
environmental
issues
Removal / disposal of waste

from wards and departments
Removal of waste from the

hospital/service
Page 6 of 119
2 Key Staff and Staff Groups Involved in Medicines Management
The Chief Pharmacist

Responsible for the provision, management and development of all pharmacy
services throughout the trust.
Holds statutory responsibility for ensuring safe systems are in operation for the
prescription, dispensing and administration of medicines.
Holds corporate responsibility for Medicines Management within the Trust.
Provides strategic leadership in Medicines Management both within the Trust and
across the Health economy to promote safe, clinically effective and cost-effective
use of medicines and control of drug expenditure.
Responsible person under the Medicines Act for Bolton NHS Foundation Trust
pharmacy services
Accountable Officer for the safe management of Controlled Drugs throughout the
Trust.
Co-ordinates and implements research and development activity in Medicine
Management.
The Trust Drug and Therapeutics Committee.
Reports to the Clinical Standards and Quality Improvement Committee
Chaired by the Medical Director with representation from senior medical and
Pharmacy staff.
Considers applications for additions to the Bolton NHS Foundation Trust
Formulary and the purchase / supply of new drugs.
The Clinical Standards Board
Forecasts developments in healthcare which involve the use of medicines and
provides effective advice on the local implications of such developments and their
management.
Reaches a consensus, based on the available evidence, regarding the place in
treatment locally of relevant new drugs and formulations, or of existing drugs with
new indications, and works to ensure that such advice is disseminated to all
stakeholder organisations.
Responds promptly to local, regional and national changes to NHS policy that will
affect prescribing and medicines management locally, including NICE guidance
and NSFs.
Membership from the Trust (Chief Pharmacist, Medical Director and Head of
Professional Practice), Commissioners (General Practitioners and Head of
Medicines Management) and cross sector finance department representation.
Page 7 of 119
The Foundation Trust Clinical Governance and Assurance Committee

Co-ordination of divisional audit programmes and forward plans
Facilitation of audit reports
Facilitate dissemination of audit results
Ensuring multidisciplinary involvement in clinical audit
Co-ordinate and approve the development of appropriate clinical guidelines and
care pathways in response to NICE Guidance, NSFs and other relevant national
guidance.
This group will receive the quarterly audit reports from pharmacy and a senior
pharmacist is a member of this committee.
All Staff
All staff have a personal and professional responsibility to act within their own scope
of practice / professional standards / training with respect to the handling,
distribution, prescription, storage and administration of medicines.
Staff responsible for the safe and effective use of medicines include:
Pharmacy Staff.
Medical Staff.
Nursing Staff.
Other professional groups (AHPs, ODPs)
All Other Staff (Transport, Security, Management)
Page 8 of 119
3 Monitoring Arrangements
Adherence to this policy will be monitored as a key part of the pharmacy service
delivery. Specific audits are detailed in the Pharmacy Department Audit Calendar.
Pharmacy staff visit trust wards daily (Monday Friday) and monitor prescribing for
clinical efficacy, safety, appropriateness and compliance with Bolton NHS Foundation
Trust Formulary (including Trust Antibiotic Guidelines).
Additional monitoring is as stated below.
Prescribing in the Royal Bolton Hospital
Prescribing is monitored by the pharmacy department. All outpatient prescriptions
(with the exception of a very small number of FP10s(HP) prescriptions written in
emergency situations outside pharmacy hours) are monitored and checked in the
dispensary. This monitoring by a pharmacist is a legal and professional
requirement. The dispensary is a Registered Pharmacy and as such is subject to
inspection and audit by the General Pharmaceutical Council Inspectorate and
Enforcement Division.
Quality of Medicines
This is a professional requirement for pharmacists. External support is provided
by Quality Control North West (QCNW) and the Regional Tendering Process for
Pharmaceuticals. Any defects are reported through the pharmacy to QCNW who
hold a database of defects and cascade any MHRA Safety Alerts. Action on
these defects and alerts is stored in pharmacy.
Storage of Medicines
Pharmacy Technicians carry out a three monthly audit on the storage of
medicines in hospital clinical areas. Any discrepancies are reported through
senior nursing staff.
Administration of Medicines
Training is provided as part of Mandatory Training Programme and update events
on responsibilities of staff regarding the administration of medicines (Safe
Medicines Awareness, Level 1). It is the responsibility of Ward Managers and
individual staff to ensure competency in administration of medicines.
Controlled Drugs (including the use of Methadone and Illicit Substances)
Pharmacy staff carry out a three monthly audit on the use and storage of
controlled drugs. This is reported through the Trust Accountable Officer for
Page 9 of 119
Controlled Drugs and further reported to the Controlled Drugs Local Information
Network. This Network produces an annual report to the PCT Executive Board.
Pharmacy and a Divisional Manager audit any returned controlled drugs / illicit
substances (or substances believed to be illicit) twice a year.
The Exemplar Programme
In bed based services, the Exemplar Programme has been developed as a tool to
raise standards in patient care. This programme utilises a regionally developed
audit tool (North West Care Indicators), localised where required, which measures
compliance over nine different domains on a monthly basis including:
Medicines Prescribing and Administration
Pain Management
Venous Thrombo Embolism (VTE) assessment
Further information on the Exemplar Programme is available on the Bolton NHS
Foundation Trust Website.
Community Services
In Community Services, all areas that handle medicines carry out an annual audit
to ensure that medicines are stored safely and securely.
A sample audit is included in Appendix 1 and each team should use this as a
template to complete the audit.
It should be completed and returned to the line manager with an action plan, if
appropriate.
See also Appendix 17 for Medicines Policy Monitoring Grid.
Page 10 of 119
4 Prescribing of Medicines
4.1
PRESCRIBING OF MEDICINES (IN-PATIENTS)
All prescriptions must be written by a medical or dental practitioner or an approved NonMedical Prescriber. Medical students, physician assistants or nursing staff not
registered as Non-Medical Prescribers are not allowed to sign prescriptions or to
prepare prescriptions for signature by medical staff.
The patients name, hospital number, date of birth, ward, allergy status and the name of
the consultant must be clearly visible on the prescription sheet. This may be handwritten
or preferably a combination of handwritten and ID label.
For paediatric patients, date of birth and weight should also be entered.
The patients weight must also be entered if prescribing drugs with dose dependant on
weight e.g. LMWH, animoglycosides, aminophylline infusion. The weight should be
documented in the weight box on the front of the prescription.
The use of drugs in patients with reduced renal function should be considered when
prescribing.
The date on which treatment is to commence must be entered on the prescription sheet.
Dates where treatment is not intended must be crossed out on the chart (eg treatment
to start the next day or post op or treatment to be stopped after a number of days)
The name of the medicine should be written legibly in black ink using approved names.
Proprietary names (i.e. brand names) must not be used. The only exceptions to this rule
are multi-ingredient preparations with no approved names or products whose
proprietary names define a specific formulation (e.g. slow-release theophylline
preparations). Prescribe solid oral dose forms of morphine and oxycodone preparations
using both approved and proprietary names.
Prescribers should consider the contraindications and interactions with other medicines
and arrange for appropriate monitoring of medication & its effects If the drug being
prescribed requires the patients renal function to be confirmed before the drugs is
commenced, U&Es should be taken as a base line before the drug is prescribed e.g.
LMWH and aminoglycosides. Liver function should be monitored in the same way for
eg amiodarone, methotrexate
The dose must be expressed in S.I. Units. Quantities less than 1 gram must be written
as milligrams. Decimal points should be avoided, for example 500mg not 0.5g to avoid
confusion. Whenever a decimal point is necessary, great care must be exercised by
both the prescriber and the nurse administering the drug. The terms MICROGRAM and
Page 11 of 119
NANOGRAM must not be abbreviated but must be printed in full and used for quantities
less than one milligram. When prescribing drugs expressed as Units, the full word must
be used and not abbreviated to U. Only the following abbreviations are acceptable:Quantity
Approved Abbreviation
milligram
mg
gram
g
kilogram
kg
litre
L
millilitre
ml
millimole
mmol
The dose required must not be expressed in terms of the dosage form for
single ingredient preparations e.g. ATENOLOL 2 tablets is not acceptable.
It should be written as e.g. ATENOLOL 100mg.
4.1.2 ROUTE OF ADMINISTRATION
Only the following abbreviations are acceptable:
Route
Intramuscular
Inhalation
Intravenous
Nebulised
Oral
Rectal
Vaginal
Subcutaneous
Sublingual
Topical
Nasogastric
Percutaneous Endoscopic
Gastrostomy
Approved Abbreviation
IM
INH
IV
NEB
PO
PR
PV
SC
SL
TOP
NG
PEG
All other routes must be written in full.

Only one route of administration may be specified for each medicine e.g.
METOCLOPRAMIDE PO/IV is not acceptable.
4.1.3 DOSAGE FREQUENCY
For As required medicines the frequency of administration must be written by the
prescriber. A maximum dose in 24 hours must be stated.
Pre-medication (before surgical procedures) should be given in accordance with a
locally agreed protocol.
Page 12 of 119
For regular medicines prescribing times should be in accordance with regular

medicine rounds wherever possible. A 6am dose should only be ordered if there is a
good therapeutic reason.
4.1.4 PRESCRIBERS SIGNATURE
All items on the in patient prescription sheet must bear the full signature of the
prescriber. The prescriber must print their name clearly on the first entry of the
prescription.
For controlled drugs, the prescribers full signature is always necessary (see Section 6).
The signature of a medical student or non registered prescriber is not acceptable.
Prescribers must complete the full prescription personally.
4.1.5 DISCONTINUING MEDICINES
The date when a medicine is discontinued must be entered into the stop date box.
The entry must be initialled by the prescriber discontinuing the medicine.
A diagonal line should be drawn through the prescription so that its cancellation is
obvious, but the prescription should not be obliterated. A vertical line should be used to
indicate the time at which the prescription is to stop.
Incorrect entries must have a line drawn through and the word cancel written against
them by the prescriber and signed.
Medicines prescribed on separate charts (see 4.6) must be discontinued on both
documents.
4.1.6 All medicines must be written on the prescription sheet, including details of
oxygen therapy, irrigations, gentamicin, parenteral nutrition and dressings
supplied by pharmacy, all of which are prescription only medicines. Dieticians will
add dietary supplements to the prescription sheet. Cross reference must be
made on the front of the prescription chart (using the spaces provided) to other
drugs prescribed on separate charts e.g.
Anticoagulants.
I.V. fluids and additives (including TPN, blood and blood products).
Insulin.
Dialysis fluids.
Cytotoxics.
Bladder instillations.
Page 13 of 119
4.1.7 PRESCRIBING BY TELEPHONE VERBAL ORDERS

4.1.7.1
Bed Based Services
In the interests of patient safety, prescriptions in bed based services must not be given
or accepted over the telephone or verbally, except in an emergency. An emergency in
this case is defined as a life threatening situation. Telephone / verbal orders will not be
accepted by pharmacy.
4.1.7.2
Community Services
In Community Services instructions may be accepted by fax as long as they are dated
and signed by the prescriber and it is clear who the signing prescriber is. Any changes
in drug regime must also be dated and recorded by the prescriber.
Under exceptional circumstances where a medicine has already been prescribed for
that patient, and with agreement of both parties, a registered nurse may accept a
telephone message from a prescriber for an alteration (e.g., dose alteration) to a
prescription to be administered in the patients home under following conditions:
Two persons must acknowledge the message, one of which must be a registered
nurse. The second person will be selected at the discretion of the registered
nurse.
The nurse receiving the call must repeat the prescription to the prescriber to
ensure accuracy.
A record must be made of the nature of the message, date, time; name of the
prescriber and both parties receiving the instruction must witness the record.
The alteration must be confirmed in writing by the prescriber on the next normal
working day.
Verbal alteration cannot be accepted for Controlled Drugs.
4.1.8 VALIDITY OF PRESCRIPTIONS
Unless the course of treatment is clearly specified, the prescription will be considered
valid until cancelled by the prescriber (see 4.1.5 and 4.1.11) except in the case of
antibiotics which are issued for 7 days, unless the prescriber indicates a specific
duration of treatment. This should be done by using the stop date box, all IV
antibiotics should be reviewed daily, with the exception of deep seated/high risk
infections (e.g. meningitis, endocarditis, bone and joint infection) which MUST have a
stop or review date. See the Trust Guide Antibiotic Policy for further information on
prescribing antibiotics.
Prescriptions must be re-written if the patient is re-admitted or transferred from another
hospital.
Page 14 of 119
Medicines Charts are only valid in the organisation where originally written. This
includes patients transferred between sites within Royal Bolton Hospital NHS
Foundation Trust and Community Services. This does not include Greater Manchester
West Mental Health Trust wards.
Only Bolton NHS Foundation Trust Medicines Charts can be used in any FT service.
4.1.9 PRESCRIBING BY STAFF FOR THEMSELVES AND THEIR FAMILIES

It has been agreed within the Bolton NHS Foundation Trust that:
a) Medical staff / Non-Medical Prescribers may not prescribe for themselves or
their families, in line with current General Medical Council (GMC)
recommendations.
b) Medical staff / Non-Medical Prescribers may not prescribe for any other staff
members. Staff may be treated only when they have been referred for
treatment to the Trust as a registered patient and they are formally registered
as an outpatient, inpatient, AED patient, daycase or Occupational Health
patient.
c) In emergencies, staff should attend existing facilities in out-patients, the
Accident & Emergency Department or Occupational Health, where a senior
doctor will prescribe according to the formulary as necessary. The current
prescription charge will be payable if applicable.
d) Green FP10 (HP) prescription forms should never be used by medical staff /
Non-Medical Prescribers to prescribe for themselves or their families. Green
FP10 (HP)s must not be used to order food or toilet articles and other
prescriptions which are not drugs or appliances other than those specified in
the drug tariff. They should not be used for unlicensed creams / ointments as
substantial extra charges are imposed on the Trust. The use of these forms
is routinely audited.
Invoices will be raised and disciplinary proceedings considered if any
unauthorised use is found.
4.1.10
RE-WRITING OF PRESCRIPTIONS
If a change in dose, frequency or route of administration is required, the whole

prescription (for the drug affected) must be re-written and the original entry
discontinued. Prescription charts should also be re-written when they become untidy
especially after medications have been stopped and / or changed or the prescription
form has been contaminated in any way (eg spillage etc). When re-writing prescriptions,
the prescriber must ensure that the date entered is the date when the therapy
commenced and not the date of re-writing. It should be indicated on the prescription
sheet that the treatment has been reviewed. The date of re-writing the prescription
should be recorded in the rewrite box on the front of the prescription sheet
Page 15 of 119
4.1.11 OTHER ENTRIES

Any information relating to drug hypersensitivity, renal or liver impairment, pregnancy or
special diet should be recorded by the prescriber in the special instructions box on the
front of the prescription chart. This must also be recorded on any subsequent
prescription chart.
The prescriber may indicate the length of treatment e.g. for 5 days. This may be
confirmed by completing the stop date box in advance.
4.1.12 BOLTON NHS FOUNDATION TRUST AND GREATER MANCHESTER
MEDICINE MANAGEMENT GROUP FORMULARIES
The FT Formulary is the approved list of medicines for use within the Trust. Products
are selected by the Drugs & Therapeutics Committee in consultation with Trust
Consultants, local GPs and PCTs.
The joint formulary across Greater Manchester has been produced under the direction
of the Greater Manchester Medicines Management Group (GMMMG). The aim of the
formulary is to maximise safe, effective and economic prescribing. It ensures that
patients receive seamless care across the primary-secondary care interface and
reduces the need for switching programmes. Adherence to the formulary is strongly
recommended by GMMMG and this formulary supersedes all local formularies. The
formulary is applicable to new initiations and treatments in approximately 80% of
patients.
http://www.nyrdtc.nhs.uk/GMMMG/Groups/formulary/html/formulary.html
When prescribing medications, the prescriber should refer to the Trust guidelines to
determine the availability of drugs. Newly prescribed items which are not in the
formulary will need Consultant approval (with reasons for the choice of non-formulary
therapy) before they can be ordered. Forms for this purpose can be requested from the
relevant senior pharmacist for the specialty- via the pharmacy office -5555.
When using the patients own drugs during their stay and at discharge, they need to be
transferred to the patients locker and administered in the usual manner. These drugs
remain the property of the patient and permission must be sought from the patient to
dispose of any discontinued or out of date medicines prior to discharge. They must not
be administered to any other patient.
If the patient is transferred, the drugs must be sent with the patient. See Section on
Controlled Drugs.
Page 16 of 119
If a patient is admitted on a non-formulary preparation which is not stocked by

pharmacy and the medication is being continued with the patients own supply not
available (or suitable) for use, then the pharmacy department will order a small supply
to cover .This is only if there is no suitable trust drug suitable substitution is the first
line eg one NSAID for another and will be arranged by the pharmacist.
4.2
SUPPLY OF PRESCRIBED MEDICINES

PURCHASING, STORAGE AND DISTRIBUTION OF MEDICINES
Medicines are unlike any other items of commerce and for this reason the purchase,
storage and distribution must be under the control of a pharmacist. The Trust Standing
Financial Instructions delegates the financial responsibility, within pre-set limits, for
tenders and the signing of orders for medicines to the Chief Pharmacist and authorised
deputy, who have procedures to ensure that legal and ethical requirements are met.
Medical, nursing, technical and other staff are not permitted to undertake contracting or
tendering for, or purchasing of, medicinal products intended for administration to
patients within the Trust.
They must also not accept free samples of any medication for use within the Trust.
4.3
OUT-PATIENT PRESCRIPTIONS
The requirements for out-patient prescriptions are generally as indicated in for inpatient
prescription but see also prescriptions for controlled drugs. Drugs may only be
prescribed when there is an urgent clinical need and referral for GP prescribing is
deemed detrimental to the patients treatment. Hypnotics will not normally be supplied,
unless the patient was admitted on them. A maximum of 28 days supply (prn
analgesics only small packs supplies unless they are being taken regularly when two
packs will be supplied, and an original pack for inhalers and topical preparations) will be
dispensed unless circumstances dictate that a different supply is necessary. This
includes:
1. Hospital only medicines - these cannot be prescribed by General Practitioners.
2. Clinical trial medicines.
3. Pulsed / cyclical treatment.
4. Reducing doses of drugs e.g. steroids will be supplied for up to 4 weeks, then
passed on to GP
5. Drugs for tuberculosis treatment.
6. Haematology treatment.
7. Chemotherapy treatment
8. Drugs to ensure sufficient supply over public / bank holidays.
Page 17 of 119
4.4.
Prescribing Using the Inpatient Chart
Page 18 of 119
The front page of

the Royal Bolton
Hospital
NHS
Foundation Trust
In
Patient
Prescription Chart
4.4.1
Patient Demographics and Individual Information
Page 19 of 119
All sections must be completed. Known allergies and intolerances as well as the record
of completion of the VTE Risk Assessment must be completed and signed by the
prescriber. A patient sticker should be used but if none are available the patient name
must be clearly written together with their RBH Unit Number.
4.4.2 Medication at Admission
Page 20 of 119
This section is generally completed by pharmacy staff. When pharmacy staff are not
available at admission it is acceptable to complete the medication history section and
the remainder will be completed by pharmacy staff.
4.4.3 Intravenous Antibiotics
When prescribing intravenous anti-infectives (antibiotics, antifungals and

antivirals), the indication for treatment must be included Generalised use of
the term Infection is not acceptable. All prescriptions for antibiotics must
state on that prescription chart and in the case notes the clinical indication and
intended treatment duration (or review date) of the antibiotic prescribed. The
indication should be as specific as is known at the time (e.g. sepsis? cause) and
must be updated as more information is available.
With the exception of high risk or deep seated infections (e.g. empyema,
endocarditis, liver abscess, bone and joint infection) requiring prolonged
intravenous therapy, all IV antibiotics must be reviewed every 24 hours.
High risk or deep seated infections must have either a stop or review date
documented both in the medical notes and on the prescription chart. This will
allow the prescribing team to assess clinical progress, microbiology results and
continued appropriateness of therapy, including choice of agent(s), route, dose
and frequency (including any necessary adjustments for worsening or improving
organ function).
Refer to the Trust Antibiotic Policy.
Page 21 of 119
A stop date or a review by date must be added at the time of prescribing. All
prescriptions for intravenous antibiotics turn Red after two days. This means that
nursing staff will question the validity of the prescription if it has not been reviewed. The
P section in all parts of the chart is for pharmacy annotation. Pharmacy staff may also
provide additional information / instruction in the Additional Instructions box.
Pharmacists write in green pen to distinguish their entries from the prescriber.
4.4.4 Oral Anti- Infectives (Antibiotics, Antifungals and Antivirals)
The same requirement for indication, stop or review date and extended duration apply
for oral anti-infectives as for intravenous anti-infectives. The IV antibiotic section does
not have a stop date or extended duration box as the prescribing should be reviewed
daily.
4.4.5 As Required Medication
The indication must be completed as well as the maximum dose in 24 hours (should this
be applicable).
Page 22 of 119
4.4.6 Regular Injections (not antibiotics)
Dalteparin is preprinted with the thromboprophylaxis dose. It must be competed and

signed if it is to be used. The VTE assessment must be done
Any other injections can be prescribed below this
4.4.7 Regular Prescriptions (all other routes)
Page 23 of 119
This includes topical, inhaled, rectal etc as well as oral. It is NOT for IVs.
As with all other prescriptions, each entry must be signed and dated. Once stopped, the
date and the reason for stopping the prescription must be added. The prescription
requires bleep number, signature and printed name of the prescriber.
4.4.8 Once Only Medications
This section is intended for pre-operative medications or medications that will only
normally be administered once, such as prophylactic antibiotics, sedation vaccines, etc.
4.4.9 Insulin
This section is intended to be used for patients who are prescribed insulin by injection.
Page 24 of 119
4.4.10 Venous Thromboembolism (VTE) Risk Assessment

All patients should be risk assessed on admission and when there is a significant
change in their condition as to whether they are at risk of a VTE and prophylactic
treatment should be initiated if indicated.
Page 25 of 119
5 Patient Group Directions (PGDs)

5.1
A Patient Group Direction (PGD) is a written instruction for the supply or

administration of medicine (or medicines) where the patient may not be
individually identified before presenting for treatment.
5.2
All PGDs have to be drawn up locally and must meet legal, ethical and trust
criteria. The following should be referred to when developing or updating PGDs:
Pharmacy Department - NHS Bolton Foundation Trust. SOP for the
Introduction of a new Patient Group Direction (PGD) and Review Process for
Existing PGDs. (2012).
The template for development of a local PGD is contained as Appendix of this
Policy.
National Prescribing Centre (NPC) Patient Group Directions guide and
competency
framework
(2009)
http://www.npc.nhs.uk/non_medical/resources/patient_group_directions.pdf
5.3
Only the following registered healthcare professionals, acting as named

individuals, can use PGDs:
nurses
nidwives
health visitors
paramedics
optometrists
podiatrists
radiographers
orthoptists
physiotherapists
pharmacists
dieticians
occupational
therapists&prosthetists
speech
&
language
therapists.
Page 26 of 119
5.4
A record or list of the individuals named as competent to use PGDs will be

kept by a senior person in each service only these staff will be able to
operate within a PGD. The PGD is a legal document and every healthcare
professional must read and sign the PGDs prior to use, sending a copy of
the signature sheet to their manager.
5.5
The healthcare professional should refer to the relevant PGD at all times
when operating within them i.e. a copy of the relevant PGD should be
readily available.
5.6
All staff operating within PGDs are expected to participate in audit of the
use of PGDs, if necessary/appropriate.
5.7
A PGD can include flexible dose ranges so that staff can select the most
appropriate dose for the patient.
5.8
The majority of clinical care should be provided on an individual, patient

specific basis.
The supply and administration of medicines under PGD should be
reserved for the limited number of situations where this offers an
advantage for patient care (without compromising patient safety).
5.9
5.10
The use of PGDs must also be consistent with appropriate professional

relationships and accountability, i.e. the nurse or allied health professional
(AHP) must act within their own expertise and competence.
Page 27 of 119
6 Administration of Medicines
6.1
PURPOSE AND SCOPE OF THE SECTION
The administration of medicines is an integral and essential entry criterion for the
Professional registration (NMC, 2009). Medicines administration is not solely a
mechanistic task but a task that requires thought and the application of
professional judgments. Registered practitioners must have the knowledge and
skills required for the safe administration of medicines and keep those skills up to
date (NMC, 2008).
This section of the policy sets out guidance for practitioners and their
responsibilities in the safe and effective administration of medicines to a correctly
identified patient.
This applies to all Practitioners who are required to administer medicines in the
course of their work, including temporary staff
See policy introduction (Section Introduction) which outlines staff group
roles and responsibilities in relation to medicines.
Refer to relevant statutory and professional guidance alongside this policy.
Please see Appendix 3 to this Policy for GUIDANCE FOR THE ASSISTANT
PRACTITIONER (AP) IN THE ADMINISTRATION OF MEDICINES
6.2
DEFINITIONS
For the purpose of this policy, a Practitioner is a person who is registered with a
recognised professional body and where the administration of medicines is within
their agreed scope of professional practice e.g. Nursing and Midwifery Council
(NMC).
A Wardex is the term used for the patient prescription chart used in inpatient
bed areas.
Medicine Administration Record Sheet (MARS) is the term used for the patient
prescription chart used in community areas.
An FP10 is the term used for prescriptions issued by GPs, non-medical
prescribers or hospital doctors in a clinic setting.
Bed based services is the term used to refer to services that provide in-patient
care e.g. wards in Hospital, Intermediate Care (Darley Court) and Bolton
Community Unit.
Page 28 of 119
6.3
POLICY STATEMENT - Administration of Medicines
The safe and reliable administration of medicines is at the heart of patient safety.
Patients require the correct drug, in the correct dose, at the correct time. The
policy supports this through setting out the processes to support staff in the safe
administration of medicines.
6.4
GUIDELINES/ PROCEDURES/METHODS
6.4.1
The Prescription Chart (Wardex / MARS)
Do not administer medicines to a patient if a prescription chart is illegible, or not

completed fully, or if there is any doubt about the appropriateness or dose of any
drug.
In the event that a chart is incomplete, the practitioner should highlight this and
ask for this to be corrected before administering any medicines that are not
correctly prescribed.
In most circumstances, the Wardex / MARS are used to prescribe any
medications or indicate where a Patient Group Direction applies (section 6.4.5).
A medical, dental practitioner or an approved non-medical prescriber (NMP) can
prescribe. The NMP will indicate this status by adding the code V300 on the
prescription chart (see Non medical Prescribing Policy). A register of signatures
of all current NMPs is held in the Pharmacy Department.
6.4.2
Calculations, Checking and Preparation
Avoiding Interruptions and Distractions

Avoid distractions and interruptions whilst making up or administering any
medicines.
Before starting the procedure gather what equipment you may need, and carry out
any preliminary checks and observations if necessary prior to administration.
Attention should be paid to reduce the incidence of unnecessary interruptions, such
as organising breaks to ensure that the ward has a full compliment of staff during
these periods.
Delegate responsibility to another member of staff to answer the phone or queries
or deal with patient requests to minimize interruptions.
Checking of Medications in Both Bed Based & Community Settings
Recommendations on safe administration of medicines state that in the majority of
cases a first or second level registered nurse, should be able to administer
Page 29 of 119
medicines without involving a second person check.

Full accountability for the correct administration of the medicine lies with the
administering practitioner, unless checking with another registered practitioner and
in this case, both are equally accountable. In no circumstances can accountability
be delegated to a student or support staff.
Second Person Check in Bed Based Services
A second person check is required for the following:
The administration of medicines (including intravenous) to children aged 16
years or less.
Controlled drugs with the exception of Oramorph solution 10mg/5ml.
Intravenous injections whether bolus or infusion.
Where a need for a calculation of fractional dose or dilution is necessary,
e.g. Heparin that is not a standard dose and requires a calculation to
determine the correct dose, mixing of oral antibiotic solutions
All Chemotherapy or Cytotoxic preparations (refer to Policy for
chemotherapy administration).
Insulin
Second Person Check in Community
In the majority of circumstances, one-person medicines administration as opposed
to two is acceptable, unless it is deemed appropriate by the practitioner or requires
two people in the Standard Operating Procedure.
Exceptions to the Second Check Rule

There are certain situations where a second check is impracticable, such as during
a cardiac arrest, or where the administration of the medicine is an integral part of a
defined therapeutic clinical procedure or intervention, e.g. the anaesthetising of
patients during surgery.
When carrying out calculations consider the following;

Take time to work out calculations
Recheck answers
Do not be rushed
Answers or quantities that look wrong probably are, have an initial mental estimate
of the dose.
It is acceptable to use calculators as part of the checking process.
If using a medical device 2 staff should calculate the rate and check that this
corresponds to the rate set on infusion pump.
Page 30 of 119
6.4.3
Preparing Substances for Injection:
Intravenous solutions must not be prepared for injection in advance of their

immediate use, or to administer medication drawn into a syringe or container by
another practitioner when not in their presence. An exception to this is an already
established infusion or medication prepared under the direction of a pharmacist
from a central intravenous additive service and labeled for that patient.
For specific information regarding the preparation and administration of
Chemotherapy please refer to:
Policy and Procedure for the Management of Cytotoxic Chemotherapy
Spillage and Contamination of Personnel
Policy and Procedure for Chemotherapy Administration.
6.4.4 Patient Group Direction (PGD)

Named Practitioners may administer and supply medicines in the absence of a
prescription in accordance with the PGD guidance.
In accordance with PGD guidance, the relevant PGD must be read and signed by
each practitioner who will be administering. Please refer to PGD section of this
Policy or contact Pharmacy Department for further information.
Responsibility lies with the Named Practitioner to ensure that they have an
understanding of the use of these preparations and they are administered in
accordance with the principles of safe administration.
6.4.5 Medicines Administered without a Prescription

The agreed range of medicines that can be administered at the discretion of
registered practitioner without a prescription is printed on the back page of the
wardex (only applicable to bed based services using a wardex). If any of the
agreed medicines are administered this must be recorded on the prescription
chart.
6.4.6 Administration of Liquid Medicines and Crushed medication via Oral

and Enteral Routes
Oral/ Enteral Syringes and Tablet Crushing Pots
Never use Intravenous (IV) syringes for the measuring of, or administration of
oral and enteral medicines.
Page 31 of 119
An appropriate oral/enteral syringe must be used to administer and

measure oral liquid medicines when a medicine spoon or measuring pot
cannot be used.
Oral/enteral syringes are colour coded purple and labeled ORAL/ENTERAL
Tablets/capsules should only be crushed/opened under medical or pharmacy
advice. Tablet Crushing Pots are used only under the direction of a Pharmacist
or Prescriber.
They are obtained via the ward pharmacist or technician. They should be
marked indelibly with the patients name as they are for single patient use only.
The tablet crusher may be used for different tablets, although they should be
crushed separately. Pots can be reused indefinitely for a named patient if
cleaned.
If the prescription is endorsed as DISSOLVE or DISPERSE in water then please
do not crush the tablets first; crushing is a last resort.
Modified Release (MR) tablets MUST NEVER be crushed and administered.
For further information please refer to:
Clinical Practice Guidance for the Management of Feeding Gastrostomies
for Adults in a Primary Care Setting
NPSA/2007/19.
r the Administration and recording of Medicines

6.5
PROCEDURE FOR THE ADMINISTRATION AND RECORDING OF
MEDICINES
Check the following before administration:
Page 32 of 119
Identify the patient: Check the name, date of birth and hospital number on
the Wardex/MARS with the patient and check the details correspond with
the wristband (bed based services only). Where possible ask the patient to
state their name and date of birth. Refer to Positive Identification Policy.
Always check the Wardex/MARs that the patient has no known allergies or
contra indications to the prescribed medicine - even if none are recorded
check allergy status with patient.
Note any instructions from pharmacy indicating potential interactions
between prescribed medicines.
Inform the prescribing practitioner immediately where allergies are found or
contra-indications to any prescribed medicine are identified/observed.
Ensure the prescribed medicine has not already been given.
Review all parts of the Wardex /MARS, so no drugs are missed or
duplicated. Community teams should also check the record of visit sheet.
Medicines dispensed for a named patient should only be administered to
that patient.
Check expiry date for all medications and the date when solutions opened
discard if dates not found.
Administration:
Select the medicine required and follow the 5Rs for each;
Right Patient
Right medicine
Right date and time
Right dose
Right route
Discuss the medications being administered with the patient and or carer
and check there is an understanding of the purpose of the drug and any
common side effects.
The person administering the drugs can assign another person to support
the patient to take their medicine, but this remains under their direct
supervision.
Initial, date and time as indicated on the Wardex/MARs, that the medicine
has been given and taken by the patient.
Record any adverse effects or variables using your clinical and professional
judgement to determine any necessary follow up actions.
The overall responsibility for the administration of the drugs lies with the
registered practitioner. Under no circumstances should medicines be left on
a patients locker or at the bedside, unless otherwise specified in this Policy.
Refusal of Medication and Covert Administration of Medicines
Where the patient refuses a medicine:
Ensure they are aware of the risks of omitting these.
Document this clearly in the patient record and where appropriate inform the
medical staff.
If the patient is not capable of consenting to take their medication:
Page 33 of 119
It is still possible to administer the medication if it is considered to be in their

best interests.
The use of administration of covert medication is likely to be appropriate
only in patients with severe dementia, acute deliriums or a profound learning
disability.
Covert is the term used when medicines are administered in a disguised
format, for example in food or in a drink, without the knowledge or consent
of the person receiving them.
The practice of offering medication in food or drink is only allowable in
particular circumstances and could be open to abuse. The Covert
Administration Policy provides guidance as to when this practice is lawful,
and to ensure that if it happens it has been properly considered, thorough
consultations have been made and that the practice is transparent and open
to public scrutiny and audit.
The decision to administer medicines covertly must not be routine practice
and must be a contingency/emergency measure.
For further guidance please read in conjunction with the Trust Policy on
Mental Capacity Act 2005, Consent to Examination or Treatment Policy and
the Covert Administration of Medicines Policy).
Safe administration of insulin

Always measure and administer single insulin (bolus) doses using an insulin
syringe or commercial insulin pen device (never using intravenous syringes).
An insulin syringe must always be used to measure and prepare insulin for
any intravenous infusion.
The term units should be used at all times and abbreviations, such as U or
IU, are never used.
For further information please refer to NPSA/2010/RRR013
6.6
OMISSIONS AND DELAYED MEDICINES
Most medicines can be given plus or minus one to two hours from the time
prescribed on the Wardex/MARS with the exception of Critical Medicines (see
section 5.2 below)
Reasons for any omissions or delays of medicines must be recorded using the
appropriate codes on the Wardex/MARs.and also in the collaborative/patient
records.
If there is no identifiable clinical reason/justification for omitting the dose, this
MUST be reported as a clinical incident. Any omissions based on a clinical need
are exempt from reporting as a clinical incident.
6.7
CRITICAL MEDICINES
Page 34 of 119
Critical Medicines
The following set out the critical medicines where it is crucial that these are
administered at the stated time:
Critical Medicines
Resuscitation medicines including colloid or crystalloid intravenous fluids
First doses of injected:
o Antibiotics
o anticoagulants or thrombolytics.
o anticonvulsants including bendodiazepines.
Parkinsons disease medicines
Stat doses of any medicine.
Insulin or oral hypoglycaemics - linked to when food will be eaten
Strong analgesia
Bronchodilators
Glyceryl Trinitrate
If 1 dose is missed this MUST be reported as a Clinical Incident.
All staff should be aware that omission or delay of critical medicines are patient
safety incidents and should be reported (NPSA, 2010 / RRR 009).
6.8
RECORD KEEPING
Record keeping
The administering practitioner must make an indelible record of administration in
the patients records by completing the Wardex/MARS and in the Controlled Drug
Register/ Home Controlled Drug Register Card.
Any errors in the recording of administration must be clearly cancelled with a single
line in indelible ink through the initials. The reasons for this must be explained and
captured in the collaborative record/nursing record.
6.9
NIL BY MOUTH AND OR DIFFICULTY SWALLOWING
Seek Advice
If a patient has swallowing difficulties or is nil by mouth the practitioner must contact the
prescriber or seek advice directly from Pharmacy Department.
6.10
VERBAL MESSAGES
Taking a verbal message:

A verbal instruction by a Doctor to administer an unprescribed medicine is only acceptable
Page 35 of 119
where failure to administer would result in serious harm to the patient. In this case, the
Practitioner must fully justify and be accountable for his or her actions.
In the community setting a registered nurse may accept a telephone message from a
prescriber for an alteration (e.g., dose alteration) to a prescription to be administered in the
patients home:
When taking a verbal message the Practitioner must provide the Doctor with full details of
the symptoms, relevant medical history, current medication record and any known allergies
or contra-indications to drugs.
In the community setting, the registered nurse and where possible a second practitioner will
be selected for the receiving of verbal messages. In bed based services two registered
nurses must acknowledge the message. All verbal messages must be documented in the
Wardex/MARs and collaborative records.
The following should be confirmed with the Doctor:
Patient's identity
Name and form of medicine
Route of administration
Dose prescribed
Date and time for administration
Name of Practitioner
Name of Doctor.
A record of the message must be made in the patient's Health Record and in the once only
section of the prescription sheet and both parties receiving the instruction must witness the
record. The Doctor must confirm and sign the prescription before going off duty. The
alteration must be confirmed in writing by the prescriber within 24hours in community
setting.
Verbal alteration cannot be accepted for Controlled Drugs.
6.11
TRANSCRIBING
Transcribing (for community services only)

This is the transferring of direction to supply or administer from one source to another e.g.
copying from a prescription (FP10) to a Medication Administration Chart or prescription
sheet, (with the exception of Controlled Drugs, which should be completed by a prescriber).
This process should:
Be completed by a registered nurse and checked by a second registrant at time of
completion or at the next visit.
Use the most up to date prescribing information
In Darley Court, when a registered nurse completes the wardex then a registered
prescriber must confirm that the medication is still appropriate on the next normal working
day.
Page 36 of 119
6.12
MEDICINES FOR PERSONAL USE:
Medicines, which are provided by the Trust for the use of patients, must never be
taken or given for personal use by hospital/community staff.
Staff who become ill on duty should be referred to either Occupational Health,
Accident and Emergency or their General Practitioner (GP).
The Hospital Pharmacy Department has a small stock of over the counter
medicines available to purchase within Pharmacy working hours.
6.13
REFERENCES
Department of Health (2003) Building a safer NHS for patients: Improving medication
safety. A report by the Chief Pharmaceutical Officer, London, department of Health.
Medicines Act and ensuing statutory instruments 1968
Mental Health Act Commission Guidance Note, Nurses, the Administration of Medicines
for the Mental Health Act 1983 ref GN 2/2001
Misuse of Drugs Act and ensuing statutory instruments 1971
Nursing Midwifery Council Midwives Rules & Standards August 2004. NMC
Nursing Midwifery Council The Code April 2008. Standards of conduct, performance and
ethics for nurses and midwives. NMC
Nursing Midwifery Council. (February 2008) Standards for Medicines Management. NMC
(reprinted Aug. 2008)
Nursing Midwifery Council. April 2006. Standards of proficiency for nurse and midwife
prescribers NMC
National Patient Safety Agency (June 2010) Rapid response report
NPSA/2010/RRP013. safer administration of insulin.
National Patient Safety Agency (February 2010) Rapid response report
NPSA/2010/RRP0009: Reducing harm from omitted and delayed medicines and delayed
medicines in hospitals.
National Patient Safety Agency (March 2007) Promoting safer measurement and
administration of liquid medicines via oral and other enteral routes

Rathaman, KL; Meadows et al. (2007). Creation of a patient safety zone to reduce
pharmacy and nursing distractions and improve patient care. Asph Midyear Clinical
Meeting 42 (Dec).
Page 37 of 119
7 Controlled Drugs
7.1
DEFINITIONS
7.1.1 Controlled Drugs are those drugs covered by the Misuse of Drugs Act
1971 and associated Regulations. Medicines classed as controlled drugs
can be found in the current Misuse of Drugs Regulations at
www.homeoffice.gov.uk or in the current issue of the BNF
7.1.2 Under the Health Act 2006, the Trust has appointed an Accountable
Officer for the safe and effective use of Controlled Drugs. This
Accountable Officer is the Chief Pharmacist, who will audit the use of
controlled drugs at regular periods and report the results to the Trust
Board and the Local Information Network.
7.1.3 Medical, Pharmacy, Nursing and other staff still retain their own
professional and legal responsibilities around the use of Controlled Drugs.
7.1.4 The ward / department managers are responsible for the safe and secure
storage and the use of Controlled Drugs within their own areas.
7.1.5 All areas that handle Controlled Drugs should have Standard Operating
Procedures (SOPs). These SOPs should cover all aspects of risk
management and audit trails for ordering, storing, prescribing, dispensing,
recording, supplying, administration, and destruction of CDs appropriate to
the setting and the team. Each team should have clear written SOPs in
place that are known, understood and followed by practitioners and staff.
Standard Operating Procedure for Royal Bolton Hospital and Bolton
Community Unit (wards and also other areas) constitutes part of this
Policy (Appendix 4)
7.2
PRESCRIBING OF CONTROLLED DRUGS
7.2.1 All medical staff (not students and unregistered locums) may prescribe
Controlled Drugs, but may not prescribe diamorphine or cocaine for the
treatment of addiction unless licensed by the Home Office to do so.
Prescribing of diamorphine for pain control (including for addicts if clinically
appropriate) is allowed under Home Office guidelines.
7.2.2 Non-Medical Prescribers are limited by the type of prescribing being used.
Under the Supplementary Prescribing regulations, Controlled Drugs may
be prescribed if included in an approved Clinical Management Plan.
7.2.3 On 23rd April 2012, the Misuse of Drugs Regulations 2001 was amended
to enable independent nurse and pharmacist prescribers to prescribe
controlled drugs listed in Schedule 2 to 5, except diamorphine, cocaine
Page 38 of 119
and dipipanone for the treatment of addiction,within their scope of practice,

competence and experience.
7.2.4 The amendment also regulates the mixing of medicines that include
controlled drugs, enables morphine and diamorphine to be supplied by
independent nurses and pharmacists where administration of such drugs
is required for the immediate, necessary treatment of sick or injured
persons. The Trust leads on NMP, the Head of Professional Practice and
the Chief Pharmacist are available for further advice and guidance.
7.2.5 The National Patient Safety Agency document Reducing Dosing Errors
with Opioid Medicines published in July 2008 states that any practitioner
who is involved in the prescribing, dispensing or administering of
Controlled Drugs should:
- Confirm any recent opioid dose, formulation, frequency of
administration and any other analgesics prescribed for the patient.
- Ensure any intended dose increase is safe (not normally more than
50% higher than previous dose).
- Ensure they are familiar with the medicines e.g. starting dose,
frequency, dosing increments, overdose and side effects.
7.2.6 Controlled drugs prescriptions for out-patients or discharges frequently

present problems due to non-compliance with the regulations. Medical
staff should ensure that all legal requirements are fulfilled (see table
below).
Controlled drugs prescriptions for out-patients or discharge patients must
by law have the:
a) Full name and address of the patient (unless a barcoded label is used).
b) Full name of the controlled drug.
c) Form of the drug, e.g. tablets.
d) Strength of the preparation, if several exist.
e) Dose.
f) Total quantity of the preparation, or the total number of specified dose units,
in both words and figures.
g) Hospital Number or patients NHS Number.
and, in addition,
h) The prescription must be signed and dated by the doctor
i) Controlled Drug Prescriptions are only valid for 28 days. The quantity of
Schedule 2, 3, and 4 CDs to be prescribed at any one time must not exceed
30 days.
7.2.7 Prescribers must not prescribe or administer CDs for themselves, family or
friends
Page 39 of 119
7.2.8 Prescribe solid oral dose forms of morphine and oxycodone by both
approved and proprietary name
7.3
STORAGE OF CONTROLLED DRUGS
7.3.1 All Controlled Drugs must be received into the area by a designated
person.
7.3.2 All Controlled Drugs must be stored in a locked safe, cabinet or room,
which is so constructed and maintained as to prevent unauthorized access
to the drugs. A purpose built CD cabinet is recommended. The designated
person(s) must at all times be responsible for carrying the keys to allow
access to the CD cupboard.
7.3.3 For list of medicines to be stored in the CD cupboard, see Appendix 5
(Storage Requirements for Controlled Drugs).
7.3.4 No medicines other than Controlled Drugs should be stored in a CD
cupboard unless specified by a Trust policy or agreed with Pharmacy (e.g.
storage of concentrated IV potassium solutions, Propess or mifepristone).
7.4
RECORD KEEPING
7.4.1 Record of supplies received and administered must be made in a

Controlled Drugs Register.
7.4.2 Daily stock count of stocks of Controlled Drugs is recorded in Controlled
Drugs Daily Drug Count Book.
7.4.3 A record of controlled drugs received from patients, their administration
and returns back to patients or relatives acting on their behalf is
maintained in Patients Own Controlled Drugs Book.
7.4.4 All orders of stocks of Controlled Drugs should be made using Controlled
Drugs Order Book, unless ordering performed by pharmacists
(community services).
7.4.5 Stationery listed in 7.4.1, 7.4.2, 7.4.3 and 7.4.4 will be issued by
Pharmacy. Area, name of person ordering stationery, type of stationery
issued, quantity, serial numbers of the stationery will be recorded. A
receipt will be filled upon collection stating the name of the person
collecting and type of stationery collected.
7.4.6 Erroneous entries should be corrected by scoring through with one line
and the correct entry made underneath or elsewhere on the same page as
practicable.
Page 40 of 119
7.4.7 In a patients own home, CDs that are administered by a registered nurse
must be recorded on the Home Controlled Drug Register Card (CH226)
and if possible verified by a second member of staff, who will also provide
advice on safe storage.
7.6
DESTRUCTION OF CONTROLLED DRUGS
7.6.1 Any out of date stock of Controlled Drugs (i.e. any controlled drugs not
dispensed for individual patients) must be destroyed by a person
specifically authorized by the Trust Accountable Officer.
7.6.2 Any out of date Controlled Drugs that have been dispensed for a particular
patient must be destroyed by a pharmacist in the presence of an
appropriate witness.
7.6.3 Patients own Controlled Drugs may be destroyed in patients own homes
if deemed appropriate. Such destruction may only be performed by a
registered healthcare professional using a controlled drug denaturing kit in
the presence of a suitable witness. The denaturing kit should subsequently
be returned to the licensed waste carrier. (See Appendix 6)
7.7
DISCREPANCIES
7.7.1 If there is a discrepancy of stocks of Controlled Drugs, the person

discovering such discrepancy must notify their manager. An incident form
must be completed and the Trust Accountable Officer must be notified.
7.8
MONITORING
See Section 3 (Monitoring Arrangements).

.
Page 41 of 119
8 Use of Methadone
GUIDELINES FOR PRESCRIBING METHADONE FOR PATIENTS ADMITTED
FOR AN UNRELATED MEDICAL / SURGICAL REASON
8.1
INTRODUCTION
8.1.1 Opioid withdrawal symptoms are unpleasant but not life threatening. In
contrast, methadone overdose, or its administration to the opioid naive,
can be fatal. Opioid withdrawal is not a medical emergency, so methadone
does not need to be prescribed in the Accident and Emergency
Department.
8.1.2 In pregnancy, opioid or benzodiazepine withdrawal can precipitate serious
foetal problems. Rapid stabilisation of symptoms is essential.
8.1.3 For a comprehensive review, see the Dept of Health publication Drug
Misuse & Dependence Guidelines on Clinical Management, 1999.
8.2
WHO CAN PRESCRIBE METHADONE
8.2.1 Doctors do not need a special licence to prescribe methadone in the

management of drug addiction.
8.2.2 Oral methadone should be prescribed as Methadone Mixture 1mg per ml.
8.2.3 Parenteral methadone dosage is equivalent mg for mg to oral but should
not routinely be prescribed. If the parenteral route is unavoidable,
methadone should be given intramuscularly, not intravenously. The
injection is only licensed for intramuscular use. Patients must not
self-inject whilst in hospital.
8.3
CAUTION: WHEN NOT TO GIVE METHADONE
8.3.1 The doctor must write on the prescription chart Do not give if drowsy.
8.3.2 The nurse must monitor the patient every time.
8.3.3 Do not give methadone to a patient who is drowsy, sedated, ataxic, with
slurred speech or asleep. Never wake a patient up to give methadone. If
any of these applies, the nurse must ask for a medical review. Do not give
methadone if the patient has been absent from the ward and you suspect
illegal drug use.
8.4
TAKING THE DRUG HISTORY
Page 42 of 119
In addition to taking a full drug history, the doctor must find out whether
the patient is:
(a) Established on a methadone programme with the Community drugs
team or a GP.
Or
(b) Using street drugs or on an unconfirmed dose of methadone.
8.5
MANAGING PATIENTS ESTABLISHED ON A METHADONE

PROGRAMME
In pregnancy, opioid or benzodiazepine withdrawal can precipitate serious
The doctor should confirm the dose with the clinic or GP, who should liaise
with the community pharmacy where the patient is registered, to cancel
outstanding prescriptions
Establish the total daily dose from clinic and prescribe as as advised by
them. Do not increase the established dose without relevant Community
Drug Team advice. If the patient is in for a while, consider getting
community teams advice on possible reduction
Methadone should be prescribed in milligrams, not by volume alone. Use
Methadone Mixture 1milligram per ml. Do not prescribe on a when
required basis and write on prescription Do not give if drowsy
Do not give methadone if patient is drowsy, sedated, ataxic, has slurred
speech or is asleep.
Never wake a patient to give them methadone.
The nurse must monitor the patient, observing the Cautions in Section 3
above, on When not to give methadone.
If the patient brings in their own prescribed medication, they must give
permission for its use or destruction. Ward staff must record receipt in the
Controlled Drugs Register or green log book, store it in the CD cupboard,
and arrange for a pharmacist to transfer back to pharmacy for destruction.
8.6
MANAGING PATIENTS ON STREET HEROIN OR UNCONFIRMED

PRESCRIBED METHADONE DOSE
Do not start methadone unless there is objective evidence of withdrawal
symptoms
Then prescribe as per Trust guidelines PATHWAY FOR THE
MANAGEMENT OF ADULT ILLICIT DRUG USERS and write on
prescription Do not give if drowsy
Patients must be advised that in-patient methadone is prescribed to cover
their hospital medical/surgical treatment.
It is not the start of a
programme.
Page 43 of 119
Use the admission as an opportunity to see if the patient requires referral

to the appropriate Community Drug Team, who work to defined catchment
areas and refer if agreed - document in notes and on front of wardex in
drug history section
Do not give methadone if patient is drowsy, sedated, ataxic, has slurred
speech or is asleep.
Never wake a patient to give them methadone.
The nurse must monitor the patient every time, observing the Cautions in
Section 3 above, on when not to give methadone.
8.7
MANAGING PATIENTS ON METHADONE WHO ARE ALSO USING

STREET OPIATES
There are those patients who are established on methadone or have been
established on it since admission (Categories 8.5 & 8.6 above), who continue
to use street opiates. In these situations, seek advice from the relevant
Community Drug Team.
8.8
OBJECTIVE WITHDRAWAL SYMPTOMS
Occur
When an opioid-dependent individual is without their usual source of opioid
for a period of time.
Severity
Is variable and depends on:
The amount of opioid usually taken.
Route of administration - usually made more severe in intravenous
users.
Psychological factors, e.g. coping strategies/anxiety.
Time of onset
Depends on the opioid used.
Short-acting opioids: 6 - 8 hours after last use e.g. Heroin, morphine,
dihydrocodeine.
Long-acting opioids: 16-24 hours after last use e.g. Methadone.
Symptoms
Subjective
Craving for opioids
Anxiety symptoms
Pains and cramps in muscles, particularly stomach, back and legs
Page 44 of 119
Unable to sleep
Feeling hot and cold
Objective
Cold, sweating, clammy and goose flesh
Yawning
Nausea, vomiting and diarrhoea
Restlessness and insomnia
Tremor
Lachrymation and rhinorrhea
BP and tachycardia
Note:
These symptoms may occur in other medical conditions or co-exist with
other conditions.
Seizures or fits do not occur in pure opioid withdrawal.
Drowsiness, sedation, disorientation or confusional states do not occur in
pure opioid withdrawal.
Pyrexia is not a symptom of opioid withdrawal.
Opioid withdrawal may be masked or attenuated by other drugs or
substances, e.g. benzodiazepines, barbiturates, alcohol, phenothiazines
8.9
RESPONDING TO REQUESTS FOR ABUSABLE DRUGS
Analgesics
Patients in hospital may require treatment for painful conditions. Their usual
daily dose of methadone may not control additional pain, so they may
require pain relief as in any other patient. Non-steroidal anti-inflammatory
drugs may be used as appropriate. Opioids may be necessary, but should
be dictated by clinical need for analgesia.
Benzodiazepines
Where possible, these should be avoided. If night sedation is required, do
not initiate temazepam. Patients who are prescribed benzodiazepines by
their GP or CDT should continue to receive them.
Cyclizine
Avoid cyclizine because of its abuse potential.
Others
The BNF lists drugs with abuse potential (see under Misuse of Drugs Act).
If in doubt, check with a pharmacist.
8.10
DISCHARGE PRESCRIBING OF METHADONE
The patient should go back to their usual prescriber. For patients in an

established programme, the clinic must be notified of discharge at least one day
beforehand.and the details of who will supply the methadone prescription needs
to be agreed and documented . Methadone is only allowed on discharge if there
are exceptional circumstances, with a maximum supply of two days
Page 45 of 119
8.11
SOURCES OF ADVICE
The Community Drugs Team and pharmacy are available for advice
Page 46 of 119
9 Guidelines for the Handling of Illicit Substances
9.1
Introduction
9.1.1 Many patients who misuse drugs are admitted, treated or visit the Trust,
either as a direct result of drug misuse or for other reasons. In some
cases, the fact that a patient misuses drugs is already known to the
medical and nursing staff. In others, it is not.
9.1.2 There is a risk of illicit substances being used on Trust premises so all
staff are expected to be vigilant and act accordingly should any illicit
substance be located or they are suspicious of substances being brought
into the Trust by visitors or patients.
9.1.3 When a member of staff takes possession of the substance, he or she is
placed in a vulnerable position unless it can be demonstrated that the
substance was taken for the purpose of delivering it into the safe custody
of a person lawfully entitled to possess it or destroy it. It is therefore
important that all actions relating to the taking into safe custody or
destruction of suspected substances are fully and correctly documented
and witnessed and the procedures below followed. The senior nurse in
charge and the senior doctor on duty must be consulted. If the senior
doctor is not a consultant, he/she should discuss it with the duty
consultant. Unless large quantities of drugs are involved, the main aim is
to ensure that the drugs are handled and destroyed in a safe and legal
manner.
9.1.4 Where large quantities of unauthorised drugs or other substances are
found on a patients person, i.e. greater than that considered to be for
personal use the police should always be informed and fully assisted in
their enquiries. An officer will attend the ward / department and initiate
enquiries. The legal position is that the public interest overrides that of
confidentiality.
9.1.5 The discovery of quantities of unauthorised drugs consistent with the
patients own personal use rarely leads to a successful prosecution.
Furthermore, a heavy handed response can compromise patient care and
cause considerable disruption of ward routines and the waste of much
time and effort. The police are aware of this and do not wish to
compromise patient care. Consequently, following discussions with
Greater Manchester Police, it is recommended that the decision to contact
the police or dispose lawfully of the substance should be taken jointly by
the ward manager in conjunction with the consultant with clinical
responsibility for the patient.
Page 47 of 119
9.1.6 Under no circumstances can a Schedule 1 (Class A, B or C) drug

(includes cannabis and lysergide which are not used medicinally) be
handed back to a patient at discharge, as the person doing so could
be guilty of an offence of unlawful supply of a Controlled Drug.
9.2
Procedure to be followed when a patient is found to be in possession

of unauthorised drugs or othersuspicious substances:
1. The member of staff finding the substance should immediately inform the
nurse in managerial charge of the ward or department.
2. The ward or department nurse manager should place the substance in a
suitable secure container with a label identifying the source (patients
initials and hospital number) and a brief description of the contents
(brownish powder or brown resinous material, not what the contents
are believed to be). The label should be over the seal and signed by the
nurse in charge and a witness.
3. The container should then be placed in a locked controlled drugs
cupboard.
4. The ward or department nurse manager should contact the consultant in
charge of the patient.
5. The ward manager should complete Part A of the Form for removal and
destruction of unauthorised drugs or other suspicious substances
(Appendix 7 of this Policy). An entry should also be made in the back of
the controlled drug register.
6. Where the ward manager and the patients consultant agree that the
quantity of the substance found is consistent with the patients own
personal use, then the ward pharmacist should be contacted to remove
the substance for destruction. In this case, Parts B and C should be
completed as indicated, by the ward manager, the consultant and the
pharmacist. One copy of the form should be filed in the patients medical
record and one copy retained by the pharmacy department. If the patient
objects to this course of action, contact the Police Incident Management
Unit.
7. Where either the ward manager or the consultant in charge, or both,
consider that the quantity of the substance found is greater than is
consistent with the patients own personal use, Part B must be completed.
The ward manager / consultant should then contact the Police Incident
Management Unit.
8. If the police officer attends, the ward staff should co-operate fully with the
officer. In some cases, the officer may not need to know the identity of the
source patient. However, if he or she does, this should be provided by the
doctor. In the investigation of an alleged criminal offence, confidentiality is
unlikely to be a sufficient defence in law against disclosure.
Page 48 of 119
9. Each case will be treated on its own merits and it is therefore not possible
to indicate the precise action the police will take. However, the patient will
never be questioned or removed from the ward or department if it is
considered by the consultant in charge to be inappropriate on clinical
grounds.
10. Following his enquiries, the police officer will remove the suspicious
substance from the ward. Part D should be signed by the police officer and
the nurse witnessing the transfer. One copy should be given to the police
officer, and one copy filed in the patients medical record.
Page 49 of 119
10 Admission to bed based services and medicines reconciliation

10.1
Introduction
10.1.1 Effective medicines reconciliation is an essential component of clinical

governance, ensuring patient safety through the safe and appropriate use
of medicines in each individual patient. It is also a basic principle of good
medicines management and is underpinned by good prescribing practice
and communication at the interfaces of care.
10.2
Definition
10.2.1 An accurate list of the patients medicines needs to be maintained and

documented on the prescription chart during patients stay along with
details of any changes made and the reason(s) for stopping a medicine.
This should be reliably communicated between the teams when care is
transferred to another ward or hospital and at discharge to the GP or other
relevant primary care providers.The whole process is called medicines
reconciliation.
10.2.2 This process should only be undertaken by a member of the pharmacy
team, nursing or medical staff.
10.2.3 It is the responsibility of medical staff to ensure that any changes in a
patients medication during their in-patient stay is documented clearly in
the patients notes and on the patients prescription chart. This information
must also be documented on the discharge summary.
10.3
Admission
10.3.1 When patients are admitted to bed based services, it is important to

ensure that the medicines prescribed on admission correspond to those
that the patient was taking before admission.
10.3.2 This involves taking a careful medication history from the patient, using the
most recently available information sources, resolving any discrepancies
and documenting which medicines are to be continued, stopped, withheld
or changed. Medicines to be continued should be prescribed on the
prescription chart, along with any new medicines started on admission.
10.3.3 Process in bed based services
Patients should have their medicines reconciled within 24 hours of
admission.
A minimum of 2 information sources should be used to obtain a list of
medicines taken by the patient prior to admission. These sources include:Medicines Policy, version 3
Page 50 of 119
1.
2.
3.
4.
Verbal information from the patient/carer.

Patients own medicines
G.P. medication summary/ fax.
Medicines Administration Record Sheet (MARS) from care
providers
5. Medical notes/Discharge Summary from recent hospital admission.
6. Summary Care Record
Over the counter medication, herbal remedies/alternative medicines,
recreational drugs should be documented.
Known/suspected allergies and intolerance to drugs should be recorded
with details of reactions.
Medicines which have been discontinued/withheld on admission should
be documented with details in the patients notes.
10.4
Taking Medication Histories in Community Services
10.4.1 As part of their duties, some staff may on occasion take a patients
medication history; any practitioner should consider why they need to take
this history if purely for recording purposes.
10.4.2 If it is felt that a medication history is needed, then the information should
come from a recognised source, such as:
The latest recent repeat medication slip provided by the GP
practice which should be confirmed with the prescriber, patient or
carer as appropriate
the patients medication containers, (ensuring that the medication is
current by contacting the appropriate community pharmacy),
A recent hospital discharge summary. The dates of the last
admission should be checked wherever possible.
10.4.3 Wherever possible confirmation should be sought from the patient/carer
that the information matches the medication that they are actually taking
and any discrepancies are recorded along with the source of the
information.
10.4.4 If a practitioner is concerned about the effects of a medicine on a patient,
they should refer to the prescriber or to a pharmacist and if necessary
contact the patients doctor themselves.
10.4.5 Some practitioners may be competent to give general information on the
effects of medicines e.g. general side effects of non-steroidal antiinflammatory drugs (NSAIDs). It is inappropriate for staff who are not
prescribers to change any parameter of a Prescription Only Medicine
without first discussing it with the GP, doctor, or other independent
prescriber, unless working within the remit of a Patient Group Direction or
Supplementary Prescribing framework.
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10.4.6 Prescribed treatments that are not licensed medicines, e.g. nutritional
supplements, should not be amended unless the practitioner is working
within their own professional competence and accountable for their
actions. Professionals should contact the dietician for guidance if there are
concerns regarding nutritional products prescribed. Any advice given, in
relation to the medication, must be recorded in the patients notes and any
concerns referred back to the prescriber.
Page 52 of 119
11 Medicines on discharge
11.1
Introduction
11.1.1
This section should be read in conjuction with the Adult Hospital

Discharge and Transfer of Care Policy.
11.1.2
All clinical correspondence for outpatients should be forwarded to

the patients GP within 5 working days of attendance as detailed in the
Commissioning for Quality and Innovation scheme (CQUINs).
11.1.3
Discharge summaries for in patient and day cases should be issued

to GPs within 24/48 hours of discharge.
11.2
Royal Bolton Hospital
11.2.1
Medical, Nursing and Pharmacy staff involved in the discharge

process are expected to refer to and follow this policy and procedures
outlined via training provided on the use of Ascribe system and standard
work.
11.2.2
Discharge medication (TTOs) should be prescribed as soon as a

patient is identified as medically fit for discharge and plans are agreed for
a safe discharge. It is in the interests of patients and staff alike that every
effort be made to ensure discharge prescriptions are written at least 24
hours in advance of the planned discharge date. Good discharge planning
will facilitate the processing of discharge prescriptions during normal
Pharmacy opening hours.
11.2.3
Medical staff (and Non-medical prescribers involved in writing

Electronic Discharge Summaries) should review patients medication
before discharge and complete all relevant sections of Electronic
Discharge Summary (see also Admission to bed based services and
medicines reconciliation section).
11.2.4
If injectable medicines or Controlled Drugs are to be administered

by District Nurses at patients home, written request for such
administration has to be completed by the prescriber stating the medicine
to be administered, dose, route and timing of administration. The
prescriber has to sign such request and also print their name.
11.2.5
Patients discharge medication needs to be clinically checked by a

pharmacist and will be dispensed by Pharmacy Department except
medicines of which the patient has got a sufficient own supply. Every
patient should have a minimum of 7 days supply of each medicine for
Page 53 of 119
discharge, unless less is required to finish a course of treatment or for any

other clinical reason.
11.2.6
For discharges when Pharmacy is closed, please refer to

Procedure to be followed for dispensing medication for urgent discharge
when Pharmacy is closed on Trust Intranet Pharmacy homepage.
11.2.7
When the prescription has been dispensed the discharge

medication must be stored in the patients bedside locker, unless items
need to be stored in the fridge, Controlled Drugs cupboard or for larger
bulk items in a designated area.
11.2.8
Immediately prior to discharge the TTO list must be printed off and
the nurse must check all the medicines against the TTO list adhering to
the principles set out on the Assembly of Discharge Medicines
competency.
11.2.9
Medicines not listed on the TTO list should not be supplied to the
patient on discharge, they must be removed, labels crossed through and
returned to Pharmacy. Medicines brought to hospital by the patient
however constitute patients property and can only be removed with
patients consent. If such consent is declined, medicines need to be clearly
marked as stopped by crossing through the label and writing STOPPED
on it. This should also be documented in patients notes.
11.2.10
The nurse discharging patient must check that the patient
understands how to take their medications at home, including changes
and discontinued medicines and record it on the discharge checklist (at
the end of the Patient Assessment & Care Document (R276).
11.2.11
The patient must be given a printed copy of their Electronic
Discharge Summary.
11.2.12
On discharge the nurse must leave the empty locker open ready for
cleaning prior to the next patient allocated to the bed.
11.2.13
Staff are encouraged to complete the Assembly of Discharge
Medicines competency.
11.3
Community Services
11.3.1 Bolton Community Unit

11.3.1.1
It is the responsibility of the nursing staff to ensure patients are
discharged or transferred from the unit with all current medication as
prescribed, ensuring the patient has a minimum of seven days supply.
11.3.1.2
If the medication is unavailable, a FP10 prescription should be
supplied for all medicines needed on discharge.
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11.3.1.3
The FP10 should be dispensed by a Community Pharmacy prior to
the patient being discharged from the unit, the out of hours taxi service
may be used if necessary. If this is not possible, the patient or their carer
should be supplied with the FP10 and advised to obtain a supply of the
prescribed medicine(s) from a community pharmacy at the earliest
opportunity.
11.3.1.4
It is the responsibility of the Medical Prescriber on the unit to
complete the discharge letter detailing any medication changes. This
information should be faxed to the patients GP within 24/48 hours of
discharge.
11.3.2 Darley Court
11.3.2.1
The Pharmacy team should be informed of any planned discharges
to enable them to work with the Prescribers to obtain a supply of
medication necessary for discharge.
11.3.2.2
The Pharmacy team, when available, will assemble the discharge
medication, ensuring the patient has a minimum of seven days supply,
reconciling the medication against the current medication chart.
11.3.2.3
A Discharge Medication Letter will be generated; detailing all
current medication and any items discontinued or amended during the
patients stay and where appropriate a Medication Administration Record
Sheet (MARS) for carers use.
11.3.2.4
The Pharmacy team ensures the discharge medication letter is
faxed to the patients GP within 24/48 hours of the patients discharge.
11.3.2.5
When Pharmacy staff, are unavailable, it is the nurses
responsibility to ensure medication is assembled against the current
medication chart and discharged with the patient.
11.3.2.6
If the medication is unavailable an FP10 prescription should be
requested from the Medical Prescriber and obtained from the community
Pharmacy using the out of hours taxi service if necessary.
11.3.2.7
It is the responsibility of the nursing staff to inform the Pharmacy
team of any discharges they have not been involved in to enable them to
forward a Discharge Medication Letter to the patients GP.
11.3.3 Controlled Drugs

If the patient is being discharged on Controlled Drugs that will be administered by
District Nurses, the medicines administration chart should be completed and
signed
by
the
prescriber
prior
to
discharge
Page 55 of 119
12 Mental capacity and Covert Administration of Medicines

12.1 If a patient is not capable of consenting to take their medication, it is still
possible to administer the medication if it is considered to be in their best
interests.
12.2 The use of administration of covert medication is likely to be appropriate
only in patients with severe dementia, acute deliriums or a profound learning
disability.
12.3 Covert administration is the term used for administration of medicines are
administered in a disguised format, for example in food or in a drink, without the
knowledge or consent of the person receiving them.
12.4 The practice of offering medication in food or drink is only allowable in
particular circumstances and could be open to abuse. The Covert Administration
Policy provides guidance as to when this practice is lawful, and to ensure that if it
happens it has been properly considered, thorough consultations have been
made and that the practice is transparent and open to public scrutiny and audit.
12.5 The decision to administer medicines covertly must not be routine practice
and must be a contingency/emergency measure.
12.6 For further guidance please read in conjunction with the Trust Policy on
Mental Capacity Act 2005, Consent to Examination or Treatment Policy and the
Covert Administration of Medicines Policy).
Page 56 of 119
13 Self Administration of Medicines

13.1
Patient Self Administration
13.1.1
Self administration of medicines should be considered where a

patient may benefit from such a process. Examples of this would be those
patients using medicines such as inhalers or GTN sprays, or patients who
have long standing conditions such as Parkinsons disease if the timingof
their medicines is crucial.
13.1.2
Registered nurses, midwives and the pharmacy team are

responsible for the initial and continued assessment of patients who are
self administering and have continuing responsibility for recognising and
acting upon changes in a patients condition with regards to safety of the
patient and others.
13.1.3
In the case of medicines that require specific storage

arrangements, a patient may need to self administer under the supervision
of a registered nurse.
13.1.4
Paediatric patients are excluded from self administration as two

registered nurse checks are used for all medicines administration to
paediatric patient to ensure patient safety.
13.1.5
Controlled Drugs are excluded from self administration.
13.2
Patient Assessment and Consent
13.2.1
Where patients consent to self-administration of their medicines,

the following points should be considered:
The nurse, the pharmacist and the doctor retain professional and legal
responsibility for the patients medication whilst they are in hospital.
Patients take the responsibility for their actions relating to selfadministration of their medicines.
Patients can withdraw consent at any time.
The medicines should be fully labelled, with directions for use to every
patient who is involved in self administration.
Information given and supervision should be tailored to meet individual
patient need.
Page 57 of 119
13.2.2
Patients should be assessed for suitability for the following:

Level 0a: Full self administration following documented
assessment, patient in possession of the locker key. Under no
circumstances should the patient be given the master key.
Level 0b: Full self administration of selected medicines only,
following documented assessment, patient not in possession of
the locker key
Level 1: Patient needs supervision with their medicines. The
locker key is in possession of the nurse. As a minimum the
nurse and patient must together check the medicine dose to be
taken. The nurse will if appropriate educate the patient on how
the medicines are to be administered and why they are
prescribed.
Level 2: Full Nurse administration of all types of medication
Level 3: Not applicable, Community Services/ Domiciliary
settings only.
13.2.3
Self Administration of Medicines Algorithm can be found in

Appendix 8, Self Administration of Medicines Assessment Record in
Appendix 9, Self Administration Consent Form in Appendix 10 and Self
Administration Patient Information Leaflet in Appendix 11 of this Policy
13.2.4
Please note: Individual medicines may require a different level of

support.
13.3
Other requirements
13.3.1 Medicines will be kept in the medicines locker with the exceptions of
specified medicines such as GTN spray or asthma reliever inhalers which
may be kept with the patient and self administered as required, however
these medicines must not be left unattended.
13.3.2 At each medicine round the nurse must check with the patient if the
medicine has been taken and must document the date, time taken and
confirm self-administration with the relevant code on the Wardex. The
code to be used is S. Any change in the patients condition that affect the
level of self medicating ability needs to be picked up and acted on
immediately and the self-medicating status reassessed.
13.3.3 Please seek advice from a senior pharmacist within the Pharmacy
Department if an individual patient is assessed as able to and benefitting
from self-administration.
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14 Unlicensed medicines
14.1
Definitions
14.1.1 Unlicensed prescribing is defined as:

1. Prescribing of a medicine, which does not have a valid UK product license
and therefore cannot be marketed in the UK.(unlicensed medicine)
2. Prescribing of a drug with a valid UK product license at a dose, via a route
or for an indication that is not listed in the product license (unlicensed
use). This is also known as prescribing off-label.
14.1.2 Unlicensed medicine is defined as a:
1. Product that has a license in another country.-These can be imported
into the UK for a named patient, but are then considered unlicensed as
they do not have a UK license.
2. Product that no longer has a product license. - Either because the
licence has been suspended, revoked or not renewed. These are
sometimes still manufactured, but only in an unlicensed capacity for a
named patient.
3. Special -These are bespoke products, prepared for the needs of a specific
patient for when a licensed preparation is unsuitable. For example: a
liquid, preservative-free, or additive-free preparation. The active ingredient
is often, but not always, taken from the licensed drug.
4. Product being used in clinical trials - unless the product has a UK
product license and is being used in accordance with its license in a
clinical trial.
14.1.3 Clinical trial drugs are treated differently by the Trust, and do not fall under
this section of Medicines Policy. They are subject to strict clinical trials
regulations. For advice on clinical trials drugs please contact the Research
and Development Department on ext 3848 or the Clinical Trials
Pharmacist, via the Pharmacy office, ext 5555.
14.2
Unlicensed medicines and PGDs
14.2.1 An unlicensed medicine should only be administered to a patient against a

prescription and not against a patient group direction.
14.2.2 Medication which is being used off-label may be administered under a
patient group direction if such use is exceptional, justified by best practice
and the status of the product is clearly described
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14.3
Prescribers responsibility
14.3.1 Unlicensed drugs or off-label uses should only be prescribed where a

licensed alternative is not available or not suitable for the necessary
clinical management of the patient.
14.3.2 The Trust requires that unlicensed prescribing should be undertaken by or
under the direction of a consultant or a registrar with experience in that
clinical area.
14.3.3 Prescribers are free to prescribe unlicensed drugs or off-label, however, in
doing so, they hold responsibility and therefore liability and may be called
upon to justify their actions in the event of an adverse reaction. The
manufacturer will only be held responsible or strictly liable if the
misadventure occurred as a result of a defect in the product. The Trust will
accept liability for the use of medicines for indications not included in the
product license provided such use would be considered standard practice
by their peer group, and the above requirements have been undertaken.
14.3.4 For unlicensed medicines, the consultant is required to sign a disclaimer
(Appendix 12 ), stating the intended use and whether other prescribers in
their team can prescribe the named medicine on their behalf. Disclaimers
are valid for 2 years and only apply to the specific conditions laid out by
the prescriber.
14.3.5 Where a prescriber has been invited to prescribe a drug that has been
initiated by a consultant, a shared care arrangement should be secured.
This would involve the prescriber:
o Familiarising themselves with the drug, including the side effect
profile.
o Satisfying themselves that the rationale for the use of the drug in
that patient is clinically appropriate.
o Taking responsibility for adequate monitoring or being satisfied that
this is being done effectively by a third party.
o Having access to consultant support if a problem arises.
14.3.6 The prescriber should, where possible, inform the patient of the unlicensed
status, and obtain patient consent. A written record should be kept of
these discussions.
14.4
Pharmacists responsibility
To obtain unlicensed medicines only on the written authority of a
consultant.
To ensure a disclaimer has been completed for an unlicensed medicine
before dispensing the prescription.
To explain to healthcare staff the practical implications of using unlicensed
medicines or medicines for unlicensed uses.
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To raise awareness to prescribers who have prescribed an unlicensed use

of a medicine.
To assess the quality of an unlicensed product prior to releasing the
product for use, in accordance with pharmacy procedures regarding
procurement. Note that the final responsibility of a faulty product lies with
the supplier, even in the case of unlicensed medicines.
To follow pharmacy procedures regarding procurement and dispensing of
unlicensed medicines.
14.5
Nurses responsibility
14.5.1 It is nurses responsibility to question the doctor or pharmacist if an

instruction to administer a medicine is thought to be outside the terms of a
product licence.
14.5.2 A nurse may refuse to administer medicines being used outside the terms
of their product licence if that is judged to be in the best interests of the
patient. Refusal to administer should not occur solely because a medicine
is unlicensed.
14.6
Unlicensed medicines not requiring a disclaimer
14.6.1 A list of such unlicensed medicines is in Appendix 13 of this Policy.

14.6.2 Drugs on this list do not require a clinical disclaimer to be completed by
the prescriber. That is, a specific consultant does not need to take
overarching responsibility. The trust will take responsibility as laid out
above, if all other responsibilities are fulfilled as above.
Page 61 of 119
15 Storage of Medicines
15.1
STORAGE OF MEDICINES IN BED BASED SERVICES
Responsibilities of ward / department managers

The Ward / Department Manager is responsible for ensuring that all medicines
are stored securely in locked metal cupboards to which only authorised staff
have access, and that keys are passed only to authorised staff as appropriate.
Particular attention should be paid to medicines stored in non-designated
locations, for example resuscitation trolleys and treatment rooms. Those wards
using bedside lockers must pay particular attention to the security of these
lockers.
The keys to the cupboard(s), fridge(s), trolley(s), etc. are to be held by the Team
Leaders on each ward / department. While a nurse is in charge of a ward or
department, he or she is responsible for all the medicines on it. In the event of
any discrepancies or apparent loss, the ward or senior pharmacist must be
informed as soon as the pharmacy is next open. If there appears to have been a
loss, the Incident Management Procedure should be followed.
At quarterly intervals, pharmacy technicians are required to visit wards and
departments to check storage, security and safety of medicines. In addition CD
registers and requisition books will be inspected and stocks checked by
designated pharmacy staff. Ward / Department Managers must ensure that CD
stocks are checked daily.Technicians will also audit the storage conditions of
other medicines.
Medicines should be stored securely in the appropriate location on wards /
departments. All medicines should be kept in their original pack, including any
information leaflet. This does not apply to an insulin pen in use out of the fridge or
to bulk IV fluids. Bulk IV fluids removed from original box must be stored in
clearly labelled containers fit for purpose. These locations should only be used
for the storage of medicines and for no other purpose. All the storage areas
should be locked, but the Emergency Drugs (CPR) Box should be accessible
without difficulty at all times.
These cupboards include:
Main cupboards
For the storage of internal and external medicines which are not kept in
the medicines patients locker, disinfectant or reagent cupboards,
Controlled Drugs cupboard, medicines refrigerator, or sterile fluids area.
Internal and external preparations should be segregated, either in
separate cupboards or at least on different shelves.
Epidural infusion fluids should be stored in a separate area to IV fluids,
those containing controlled drugs can be stored in the standard Controlled
Drug Cupboard providing IV infusions are not stored in the same
Page 62 of 119
cupboard.
Stock checks should be carried out on controlled drugs held on wards and
departments by the ward manager or designated deputy at agreed regular
intervals and this check recorded in the designated log book.
Discrepancies should be reported immediately to the appropriate
Divisional Nurse. and to Pharmacy in working hours
Medicines refrigerator
For the storage of medicines marked Store in Refrigerator store between
2-8 C e.g. TPN, CIVAS, stock insulins etc. The fridge should be defrosted
regularly ensuring build up of frost does not occur, kept locked and reported
for repair if the temperature dial indicates a fault. The temperature dial should
be checked each time the fridge is accessed and at least daily if not in regular
use. No food or drink for staff, visitors or patients should be stored in the
medicines fridge. The fridge monitoring sheet should be completed daily
(Appendix 14).
Disinfectant cupboard
For preparations which are not used for patients. eg for Haztabs
Reagents cupboard
Contains urine testing and blood testing strips.
Sterile fluids for infusion and irrigation
Fluids are normally stored in a designated area on wards / departments; it is
usually impractical to store them in cupboards. Stock should be rotated to
ensure use within expiry dates.
Epidural infusion fluids should be stored in a separate area to IV fluids, those
containing controlled drugs can be stored in the standard Controlled Drug
Cupboard providing IV infusions are not stored in the same cupboard.
Patients own drugs / bedside lockers and patient transfer
When a new patient is admitted, a check that the locker is empty must be
performed. When a bed is empty, the locker must be empty and kept
unlocked with the door open to ensure no medicines remain unchecked.
All patients own drugs or drugs dispensed for discharge for that patient
must be supplied only against the discharge prescription as per protocol to
that patient. All the patients drugs in the locker- either own or dispensed
whilst in- must be transferred with the patient to any new bed based
service.
Part of the discharge or transfer procedure must include checking that the
patients drugs have been removed from the locker and are with the
patient. When a new patient is admitted, a check that the locker is empty
must be performed. When a bed is empty, the locker must be empty and
kept unlocked with the door open to ensure no medicines remain
unchecked.
For all patients transferred during an in-patient stay, the receiving nurse
must amend the prescription chart with the new ward and consultant and
confirm with the transferring nurse that all drugs have been transferred
Page 63 of 119
with the patient

15.2
RECEIPT AND STORAGE OF MEDICINES IN COMMUNITY SERVICES
15.2.1 Receipt of medicines

15.2.1.1
When medications are delivered to community premises the driver
will hand over the transit container to a clinic administrator or clerk and will
obtain a signature if required for the receipt of delivery. Medicines
delivered from supplier to the clinics will be checked by designated FT
staff against the copy order form/requisition and delivery note to ensure
accuracy for:
Correct drug
Correct formulation
Correct strength
Correct quantity
Shelf-life of products
Storage requirements
Good condition of the products
Requirements for safe handling
15.2.1.2
After checking, the delivery note will be retained for a period of 2
years. The name(s) and quantities of medicines received are then entered
in the stock sheets, which should also be stored securely.
15.2.1.3
Items for refrigeration must be checked and placed in the correct
refrigerator immediately.
15.2.1.4
Any queries related to the supply of medicines should be directed to
the supplier.
15.2.2 Storage of medicines
15.2.2.1
In clinic sites and medical rooms within special schools, the
responsibility for the safe keeping of medicines lies with the designated
person(s) who controls access by keys to the medicines. When not in use,
sets of keys should be stored in a locked key cupboard or other secure
place. A second set of keys should be kept in an appropriate, secure
location.
15.2.2.2
All medicinal products should be stored in a locked cupboard or a
locked refrigerator reserved for the storage of medicinal products.
Premises should be alarmed when not in use.
15.2.2.3
Medicines should ideally be segregated as follows:

Medicines for internal use.
Medicines for external use (including disinfectants).
Refrigerator medicines.
Diagnostic reagents cupboard.
Page 64 of 119
Area for flammable liquids.

Area for sterile topical fluids.
Medical gasses stored in appropriate storage facility.
15.2.2.4
Where premises are shared by a number of clinics, each clinic
should be responsible for its own stock of medicines, which should be
stored separately (ideally in a separate cupboard but at least in a separate
area of a communal locked cupboard).
15.2.2.5
Urgent medicines for clinical emergencies should be available in
each clinic (refer to hospital intranet for guidance). They should not be
kept in a locked cupboard, but should be held at strategic and accessible
sites. They should be secured when the clinic is not running sessions.
Once a pack has been opened, it should be returned to the supplier and a
replacement provided. These medications should be checked and
maintained as detailed in the FT resuscitation policy.
15.2.2.6
In the patients home, staff must encourage patients to store all
medicines (including gases such as oxygen) in a safe place away from
children and according to the manufacturers instructions. Patients should
also be encouraged not to hoard drugs but instead return any unwanted
medicines to the local pharmacy for safe destruction and to inform the GP
if they are not taking their medicines.
15.2.2.7
Medicines must never be transferred from the container in which
they are dispensed into another container.
15.2.2.8
Oxygen and nitrous oxide cylinders should be stored in a secure
area free of grease within clinics. Safety chains or a stand should be used
to ensure that non-portable cylinders are physically stable. Store away
from flames and heat sources. A designated person must ensure that they
are in working order, are correctly stored, have not exceeded any stated
expiry dates and should check the cylinders once a month. A log of checks
must be kept up to date.
15.2.2.8
In Foundation Trust Community Services premises, refrigerated
items such as vaccines must be stored in a locked drugs refrigerator and a
daily log kept of temperatures using a maximum and minimum
thermometer (Appendix 14).The refrigerator must be designed for vaccine
storage. Domestic fridges are NOT appropriate. The person monitoring the
temperature should sign the log entries. In the event of a breakdown in the
refrigerator, the RBH FT Pharmacy or the Health Protection Specialist at
St Peters Houses (telephone 462154) should be contacted to ascertain
whether any of the affected medicines could be saved.
15.2.2.9
A log should be kept of the time at which items are removed from
the refrigerator to ensure that items returned to the refrigerator have not
been out for more than three hours (good practice).
Page 65 of 119
15.2.2.10
Vaccines should be stored in a cool box with an ice pack prefrozen, (which is not touching the vaccines), for 5 hours when not
refrigerated and ideally individual vaccines should not be returned to the
fridge on more than one occasion. Any that are returned should be marked
as such with the date and used first on the next occasion that the vaccine
is required.
Page 66 of 119
16 Use of Patients Own Drugs (PODs) and Supply of Named Patient

Medicines
16.1
BACKGROUND
The NHS Plan for Pharmacy England and Wales advocates the more costeffective use of medicines, the re-use of patients own drugs (PODs) is one way
of reducing unnecessary duplication of supply and waste. Patients are
encouraged to bring their medicines into hospital / community services so that
they may be administered to them during their stay. Named patient drugs are
medicines supplied and labelled by a Hospital / Community Pharmacy.
16.2
SUPPLY OF MEDICINES TO NAMED PATIENTS
16.2.1 QUANTITY SUPPLIED

16.2.1.1
All supplies for named patients will be for one month for hospital
wards and as appropriate for individual patients in community services,
using the manufacturers original pack wherever possible.
16.2.1.2
Exceptions to this general rule include:

Antibiotics: the appropriate course length will be supplied.
Inhalers, creams and ointments, suppositories, pessaries, eye
drops and ointments: the smallest appropriate manufacturers
original pack will be supplied.
Unusually bulky items that could not practically be
accommodated on the ward: a quantity will be supplied after
consideration of available storage space.
Short expiry medications: an appropriate quantity will be
supplied after consideration of the expiry date.
Controlled Drugs, short term hypnotics, some laxatives,
analgesics and when required (PRN) medicines
Drugs with frequently varying dosage, for example oral
corticosteroids (e.g. Prednisolone, dexamethasone), and
potassium supplements.
Oral
anticoagulants
(e.g.
warfarin,
phenindione,
nicoumalone), will be supplied as a named patients, but
labelled as directed to allow for flexibility in dosage.
Injections, infusions, Nebules and dressings
16.2.1.3 Exceptions to the rule will be dispensed for named patients use at
the discretion of the pharmacist/pharmacy technician where there is a
reasonable likelihood that the patient will be discharged on the medication.
Otherwise, stock should be used during the patients stay. Items will be
dispensed on discharge if necessary.
Page 67 of 119
16.2.2 CRITERIA FOR SUPPLY

Medicines will be supplied to patients:
Whose PODs are found to be unsuitable for re-use.
Who fail to bring in, or refuse re-use of, their PODs
Where patients state they have their medicines at home.
Who have less than seven days supply of their medicines
Who have had a new medication started during their stay
16.2.3 PRE-PACKS
A small range of commonly used medicines may be available pre- labelled (pre
packs). Examples include analgesics, antibiotics, and laxatives. Pharmacy staff
may issue these to patients (once checked by another approved pharmacy staff
member). The patients name, the date dispensed, and the dose details must be
entered in the relevant spaces on the pre-pack. A hospital address sticker should
also be added.
16.2.4 SUPPLY OF MEDICINES OUTSIDE NORMAL PHARMACY WORKING
HOURS (OUT OF HOURS )
16.2.4.1
Medicines need to obtained from the emergency drugs cupboard (night

store).These medicines may be used in the usual way until labelled for a named
patient by Pharmacy on the next working day. The on call pharmacist may be
contacted via the switchboard by long range pager, for advice if necessary. Calls
will be filtered during the night.
16.2.4.2
Community Services
The out of hours (OOH) service should be accessed. OOH GPs will provide an
FP10 prescription which can be obtained from a Community Pharmacy.
16.2.4.3
Darley Court and Bolton Community Unit.
The Pharmacy out of Hours/Emergency Delivery Service procedure should be

used for supply of Urgent medication only.
16.2.5 TRANSFER OF MEDICINES

PODs and named patient medicines must be transferred with the patient via the
transfer bag for medicines.
16.2.5.1
Page 68 of 119
The nurse transferring the patient must ensure the locker is empty and all
appropriate medicines are with the patient before the transfer can be completed.
If the bed is empty, the locker must be open.
16.2.5.2
Community Services
It is the responsibility of the nurse/ health care professional to ensure all

appropriate medicines are transferred with the patient. If the medication is
unavailable a FP10 prescription should be supplied for all current items
16.2.6 DISCONTINUED MEDICINES
16.2.6.1
These should be removed from the patients locker by the nursing staff or
Pharmacy staff as soon as they are crossed off the prescription. The change
must be brought to the attention of the ward pharmacy team.
16.2.6.2
Community Services
Discontinued items should NOT be transferred with the patient. The patients
verbal permission should be obtained before removing the discontinued items
which should be disposed of in the green PHS waste bin.
16.2.7 RE-LABELLING OF MEDICINES
16.2.7.1
16.2.7.1.1
PODs and named patient medicines should only be re-labelled by
Pharmacy staff.
16.2.7.1.2
Medicines must be in packaging with a clearly visible expiry date.
Other medicines may be re-labelled at the discretion of a pharmacist.
Following a dose adjustment to an existing medication, a POD or named
patient medicine can continue to be used for the patient, but following the
new prescribed dose instructions. The nursing staff must alert the
pharmacy staff to the change on the next working day.
16.2.7.1.3
Pharmacy staff will then re-label the medicine with the new dose
instructions at the earliest convenience. Re-labelling may be delayed if it is
likely that the dose will be changed again before discharge. It is essential
that this be done before the medicine is issued on a discharge
prescription.
16.2.7.2
Community Services
Medicines should not be relabelled. For any changes in doses a new supply
should be requested via the medical prescriber and obtained via a community
pharmacy
Page 69 of 119
16.2.8 RESUPPLY OF MEDICINES

16.2.8.1
Pharmacy will resupply medicines to patients when their own supply, or those
issued by Pharmacy, has diminished to less than 7 days worth. New supplies
should be locked in the patients locker for use when the original supply runs out
completely. Do not start the new pack until the previous pack is finished.
16.2.8.2
Community Services
Further supplies of medicines for individual patients may be re-ordered by Trust

staff through patients GP depending on individual patient needs.
Note: ordering medication may need to be included in the patients care plan to
enable carers to complete this task on behalf of the patient.
In Darley Court the Pharmacy team will ensure patients medication is re-ordered
throughout the patients stay. Any newly commenced items or dose changes
should be brought to the attention of the Pharmacy Team.
16.3
PATIENTS OWN DRUGS (PODS)
16.3.1 PODs can only be administered to the patient they belong to. These drugs
remain the property of the patient and permission must be sought from the
patient to dispose of any discontinued or out of date medicines prior to
discharge. They must not be administered to any other patient.
16.3.2 PODs must be assessed for suitability to re-use. See Appendix 15 for the
procedure.
16.3.3 During normal pharmacy working hours, this process will be carried out by
pharmacy staff.
16.3.4 Outside pharmacy hours, the ward nurse or admitting doctor may assess
and authorise the use of PODs until pharmacy authorisation can be given
on the next working day.
16.3.5 All suitable PODs must be stored in the individual patients locker, which
must be kept locked.
16.3.6 Any PODs found to be unsuitable for re-use should be ordered from the
Pharmacy Department when they are next open. Should the pharmacy be
closed and the medications are required urgently, they may be obtained
from the emergency cupboard, or other wards, in the usual way for shortterm use. The pharmacy will re-label or supply a patient labelled pack
(described previously), on the next working day.
Page 70 of 119
17 General rules for supply of medicines to Community Services

17.1
The usual route of medicine procurement is by a patient specific

prescription written by a Doctor, Dentist, or other Non Medical Prescriber.
17.2
Medicines should be prescribed only when they are necessary, and in all
cases the benefits of administering the medicine should be considered to
the risk involved. (BNF 63, 2012 www.bnf.org.uk).
17.3
Medicines shall be obtained only from bona fide suppliers. These will be:
Pharmacy Department at the Royal Bolton Hospital
Farillon (usual national supplier of vaccines)
Directly from the manufacturer
National Pharmaceutical Wholesalers
Community Pharmacies
17.4
A list of stock medicines specific to the various services will be held in

clinics and health centres.
17.5
The list and the quantity of stock to be held in each clinic shall be decided
by consultation between the Pharmacy Team, staff working in the clinics
and appropriate senior medical, nursing or other professional staff.
17.6
The lists will be subject to regular review as required by those staff.

Urgently required items, not on the list, will only be provided after
submitting a separate request, authorised by the appropriate line
manager.
17.7
Stock control will be undertaken by a designated person(s) on regular

basis but at least monthly to maintain agreed stock levels. This will include
reconciliation of existing stock with the records in stock sheets.
17.8
The designated person must be from the appropriate staff group listed in
the paragraph 17.9. The responsible lead/manager must be notified of any
discrepancies between stock records and levels.
17.9
The following personnel may request the supply of medicines identified on

the list for their service subject to their name being included on a list of
authorised signatories:
Registered Nurses
Dental Nurse
Dental Practitioner
Community Paediatrician
Page 71 of 119
Registered Podiatrist
Registered Physiotherapist
Registered Pharmacist
Registered Orthoptist
Registered Pharmacy Technician
Other designated FT staff
17.10 Specimen signatures of the above must be provided to the supplier (if
necessary) to confirm authorisation for supply and should be updated on
an annual basis or when a designated manager wishes to amend the
register.
17.11 Medicines to be ordered from a supplier will be ordered on an official order
form or on-line. A copy of an order form will be retained to check against
the goods received. N.B. Telephone orders will not be accepted.
17.12 Order forms/prescription pads must be kept in a secure area at all times
i.e. in a locked cupboard/drawer within a locked room.
17.13 When available, sugar-free medicines
patients/clients, especially children.
should
be
requested
Page 72 of 119
for
18 Carriage of Medicines
18.1
COMMUNITY SERVICES
18.1.1 Bolton NHS FT Community Services staff may carry Prescription Only
Medicines that have been prescribed for named patients. The drugs must
be transported out of sight in a locked car from the dispensing pharmacy
direct to the patient. Alternatively, the dispensing pharmacy may be
prepared to deliver directly to the patient.
18.1.2 Registered nurses should carry adrenaline 1 in 1000, ideally in the form of
a pre-assembled syringe and needle in approved anaphylaxis packs.
Suitably trained professionals should have access to adrenaline 1 in 1000
in clinics where local anesthetics are administered. Staff will then be able
to respond to anaphylactic reactions in patients and administer the drug
according to the Patient Group Direction. Staff should ensure that they are
up to date with training requirements for the treatment of anaphylaxis.
18.2
ROYAL BOLTON HOSPITAL
18.2.1 Bolton NHS FT Hospital Services staff, wearing a valid trust ID badge,
may transfer medicines from the Pharmacy Department to clinical areas.
18.2.2 If the drugs are not transported by Pharmacy staff then they must be
transported in a sealed container from the pharmacy direct to the end
user.
18.2.3 When transferring a patient, their drugs should be transported in a green
transfer bag.
18.2.4 A Standard Operating Procedure exists in Pharmacy Department for the
transfer of medicines to and from Bolton Hospice.
Page 73 of 119
19 Disposal and Return of Medicines

19.1
COMMUNITY SERVICES
19.1.1.Please refer to Bolton NHS FT Healthcare Waste Management Policy and

the DH document Safe Management of Healthcare Waste.
19.1.2 The following principles should be adopted when disposing of medicines:
Witnessed accountability
Secure transit
Adequate documentation
Legally authorised persons to carry out and, where necessary,
witness destruction
19.1.3 No medication, however small in quantity, should be disposed of in
domestic or commercial refuse or via the sewerage system.
19.1.4 Part-used multi-dose vials of vaccine will be destroyed in the clinic at the
end of each session in the special waste sharps bin. Expired/unwanted
vaccines may also be disposed of in the same way. A record is to be
made in the stock book. Service managers must ensure appropriate
procedures are in place at all premises from the service for which they are
responsible is provided.
19.1.5 All sharps and syringes must be safely disposed of in Sharps Bins in
accordance with the organisations Clinical Waste policy. For disposal of
cytotoxic drugs and waste, see the organisations Healthcare Waste
Policy.
19.1.6 Prescribed medicines are the property of the patient and remain so when
no longer needed. The patient (or their representative) should, be
encouraged to return the medication to a community pharmacy.
19.1.7 In exceptional circumstances, where every other option to remove unused
medication has been explored, a professionally qualified member of staff
may return medication to a community pharmacy. A record of the
medicines and quantities removed must be made and signed by the nurse
or healthcare professional and the patient (or their representative).
Medicines must be returned to a community pharmacy for safe disposal.
See Appendix 16 Protocol to remove discontinued and out of date
medication from patients home for further guidance.
19.1.8 Oxygen or nitrous oxide cylinders any empty or unwanted oxygen or
nitrous oxide cylinders will be replaced or collected by the supplier.
Equipment for the delivery of oxygen belongs to the supplying contractor
(usually Air Products, telephone 0800 373580).
Page 74 of 119
19.2
Please refer to Bolton NHS FT Healthcare Waste Management Policy and the
DH document Safe Management of Healthcare Waste
Page 75 of 119
20 Management of Medication Errors and Near Misses

20.1
INTRODUCTION AND BACKGROUND
Be Safe, be Honest - Report

20.1.1 See Trust Clinical Incident Policy and Management of Medication Error
Policy.
20.1.2 All Drug Incidents / Near Misses are classed as Clinical Incidents and
must be reported using the usual incident reporting procedure.
20.1.3 The ward pharmacist / on-call pharmacist or a senior pharmacy manager
is available for advice and guidance and will be able to assist with any
remedial action, advice regarding patient treatment, policy development
and root cause investigations.
20.1.4 If a practitioner realises that an error has been made eg a drug has been
omitted, given incorrectly or the procedure has failed, the following steps
should be taken:
Check the patients well-being, explain to them what has happened
and reassure them
Obtain advice if necessary eg from line manager, prescriber,
Medicines Management Team, Medicines Information in Pharmacy
Department at Royal Bolton Hospital or the Out of hours service.
Arrange any necessary immediate treatment or follow-up for the
patient.
Document the error in the nursing records (community staff) or
patient records (hospital staff).
If a serious error occurs resulting in harm to the patient, the
manager or director on call must be notified immediately.
Any errors involving Controlled Drugs must be reported to the
Accountable officer for the Foundation Trust (The chief
pharmacist).
Midwives should also inform their Supervisor of Midwives.
Report the incident using the incident reporting procedure and
inform the line manager and prescriber at the first opportunity
20.1.5 In addition to this policy, health care professionals should, at all times,
follow their own professional code of conduct. For registered nurses, the
Nursing and Midwifery Council has guidelines for the administration of
medicines which is available at www.nmc-uk.org.
20.1.6 Local policies and guidelines should be followed and advice sought if
necessary.
Page 76 of 119
20.2
ADVERSE DRUG REACTION (ADR) REPORTING AND MANAGEMENT
20.2.1 What is an Adverse Drug Reaction?

An unwanted or harmful reaction experienced following the administration of a
drug or combination of drugs under normal conditions of use and suspected to be
related to the drug
Ref. MCA/CSM Suspected adverse drug reaction (ADR) reporting and the
Yellow Card Scheme, Guidance notes
20.2.2 Suspected adverse drug reactions should be reported through the Yellow
Card Scheme. Yellow cards help identify trends in adverse drug reactions
and so improve medicines safety in the long-term. Reporting is a
professional responsibility and can be done by any healthcare
professional. Patients can also report adverse reactions independently to
the Yellow Card Scheme.
20.2.3 Yellow cards can be found online at www.yellowcard.gov.uk and at the
back of the BNF. You only need a suspicion to report, you do not have to
be certain. Please include as much information as possible but do not be
put off reporting just because some details are not known.
20.2.4 Please report all suspected adverse drug reactions for new medicines
(identified by the black triangle symbol in the BNF and all serious
suspected ADRs for established vaccines and medicines, including
unlicensed medicines, herbal remedies, and medicines used off-label. If
you are unsure whether or not to report, please report anyway.
20.2.2 Areas of special interest:
Please report all suspected adverse reactions involving:
children
elderly
delayed drug effects
congenital anomalies
herbal remedies
20.2.3 Pharmacy involvement
The ward pharmacist or Medicines Information team must be informed of any
suspected adverse drug reaction and can provide essential advice in the
management of any ADR. The on-call pharmacist is available for advice outside
normal
pharmacy
hours.
Page 77 of 119
21 Medicines Management Training

The management of medicines (prescribing, storing, administering
etc) within the clinical areas plays an ever increasing part in the roles
of many registered practitioners. It is therefore important that the
staff involved in aspects related to medicines management are
trained appropriately to reduce the significant number of adverse
patient events relating to medicines management.
Clinical staff whose role involves administration of medicines should
access training as outlined in the Training Needs Analysis section of
the Mandatory Training Policy or by their respective professional
bodies.
Please find Guidance on the Role of Unregistered Staff in Appendix 3
of this Policy.
Please note :
All staff who encounter medication errors will require additional
training, supervision and competencies.
Please refer to Management of Medication Errors Policy.
References:
Greater Manchester Strategic Health Authority (2005) Medicine
Matters Assistant Practioner Guidance GMSHA.
Nursing and Midwifery Council (2004) Standards for Medicine
Administration NMC (Section 5 Delegation)
Page 78 of 119
Appendix 1- Protocol for safe and secure handling of medicines in

Community Services
Annual review
Area or Department of Employment
Year .
These standards apply to all Bolton NHS Foundation Trust employed staff
working in community services
It should be available for inspection as necessary.
Page 79 of 119
1. Ordering of medicines. A list of all medicines to be used by or supplied to

community clinics and health centres shall be determined for each professional
group. These medicines should only be ordered by authorised staff, using an
electronic or order book system.
The authorised member/s of staff to order
and sign requisitions for medicines are:If medicines are ordered manually, the order
book is kept in a locked drawer in:2. Receipt of medicines. Medicines may be received onto the premises by nominated
staff/staff groups. They should then be handed to a member of staff who is
authorised reconcile the medicines received with those ordered. This member of
staff should
Ensure any discrepancies are recorded and resolved
Ensure the medicines are put away in the correct location and amend stock
lists as appropriate
Delivery notes must be retained for a minimum of two years
Samples of medicines should not be used.
The nominated groups of staff authorised to
sign for receipt of medication are:Groups/members of staff to whom
medicines should be passed for
reconciliation and storage:3. Storage of medicines. Storage areas should comply with General Pharmaceutical
Council guidance (and local policy e.g. for vaccines) Keys giving access to
medicines storage should be in the custody of a professional member of staff
nominated by the service manager.
THE CHECKLIST ON PAGE 4 MUST BE COMPLETED ( EVERY......... )
Named person responsible for medicines
storage in this service is:Members of staff allowed custody of the
keys and to ensure the medicines cupboard
is locked when not in use are:Location of the lockable medicines
cupboard is:Were a service hold medicines that require refrigeration (2-8oC) these should be
stored in a fridge designed for medicines storage. The fridge temperature should be
monitored each day (Page 6)
Location of medicines fridge is:Person(s) responsible for checking fridge
temperature each day:-
Page 80 of 119
4. Administration of medicines.
Individual staff must ensure that:
They are trained and competent to administer medication and comply with all
professional standards, local policy and national guidance
A record of administration is made in the appropriate Medication Record
Chart. If medicines cannot be administered for any reason the MAR is
annotated accordingly.
A named person is responsible for ensuring that
A regular audit takes place of a sample of the Medication Record Chart to
ensure they are completed correctly.
An action plan is completed and forwarded to the line manager where
appropriate.
Person responsible for regular MAR sheet
audit is:5. Disposal of medicines. Out of date medication should be appropriately packaged
and returned to a licensed waste carrier for destruction. The Pharmacy Department
at RBH should be contacted for advice relating to excess stock. Details of stock
returned should be recorded and stock lists amended as necessary
6. Controlled Drugs. All areas that handle Controlled Drugs (CDs) should have
Standard Operating Procedure (SOP). The SOP should cover all aspects of
controlled drug risk management and audit trails for the ordering, storing,
prescribing, dispensing, recording, supply, administration, and destruction of CDs
appropriate to the setting and the team.
THE CHECKLIST ON PAGE 5 MUST BE COMPLETED (EVERY.......)
Staff member responsible for ensuring an
SOP is available and controlled drugs are
handled as detailed in the SOP
The nominated staff holding keys to the CD
cupboard are:-
Page 81 of 119
CHECKLIST FOR MEDICINES STORAGE

This checklist is to be used every.Any problems should be
documented along with actions taken. This checklist should be kept within
the service and available for inspection as necessary.
The storage area is clean and tidy

Medicines cupboard(s) and fridge(s)
contain only medicines
Yes/No
Yes/No
Yes/No
Medicines are organized logically in

cupboards and fridges and easily
accessible
Yes/No
Medicines for external use (e.g.

creams)are stored on separate shelves to
those for internal use
Yes/No
There is a system of date checking in

place to rotate stock in expiry date order
Yes/No
Stock lists are maintained to record

medicines received, used and disposed
Yes/No
Where 2 clinics share storage, distinct

area should be reserved for each clinic.
Yes/No
Flammable substances are stored

separately
Yes/No
Excessive amounts of stock are not kept
Yes/No
Expiry dates are checked monthly and

any out of date stock disposed of
appropriately
Yes/No
Clinical trials medicines are stored

separately
Yes/No
Controlled Drugs are kept in a separate

lockable cupboard to other medication
Yes/No
Medicines Fridge has temperature

monitored and recorded daily to ensure it
is between 2 C and 8 C
Anaphylaxis packs are appropriate for the
service, in an accessible location, in date
and no items have been removed,
Comments/actions
Yes/No
Yes/No
Actions required:Date checklist completed
Name of person completing
Job title
Signature
Page 82 of 119
CHECKLIST FOR CONTROLLED DRUGS

This checklist is to be used every.Any problems should be
documented along with actions taken. This checklist should be kept within
the service and available for inspection as necessary.
Yes/No
The current Standard Operating
Procedure (SOP) is available.
The CD cupboard is kept in a
lockable area not normally
accessible to patients
The room containing the CD
cupboard is kept tidy
The CDs are stored in a locked
secure container that is not
portable
If a safe is used to store CDs there
is a separate receptacle within the
safe to keep the CDs
actions
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
The CD register contains entries of

all stock received or removed
Yes/No
All the entries have been initialled

(by 2 members of staff if possible).
Yes/No
Does controlled drug stock balance

agree with that in register? If no
this must be investigated
Comments/
required
Yes/No
Actions required:-
Date checklist completed
Name of person completing
Job title
Signature
Page 83 of 119
Protocol checked by
(Signature)
..
Name in block capitals
Job Title
Date
This protocol must be reviewed no later than..
Page 84 of 119
Appendix 2 Patient Group Direction Template

DOCUMENT CONTROL PAGE
Title:
Version Number as from December

2004:
ADMINISTRATION / SUPPLY*
*delete as appropriate
OF
..
name of the drug(s)
IN THE
.
name of the ward/department
Document Type: Patient Group Direction
Scope:
Classification: Patient Group

Direction
Author:
Groups Consulted:
Validated By: Divisional Governance / Quality
Board
Equality Impact Assessed:

Date:
(If appropriate) Replaces:

Description of amendments:
Authorising Body: Drugs and Therapeutics
Committee
Date of Authorisation:
leave blank
Master Document Controller:

Brian Smith,
Chief Pharmacist
Review Date:
leave blank
Key Words:
Patient Group
Direction
INDEX
Purpose and Scope of document
Page 1
Guidelines/Procedure/Methods
Page 2 onwards
PURPOSE AND SCOPE:

A template to assist practitioners in developing a Patient Group Direction
Page 85 of 119
YOU MUST BE AUTHORISED BY NAME, UNDER THE CURRENT VERSION

OF THIS PGD BEFORE YOU ATTEMPT TO WORK ACCORDING TO IT
Clinical Condition
Indication
Inclusion Criteria
Exclusion Criteria
Cautions / Further Advice
Action if Patient Declines or is
Excluded
Drug Details
Name, Form
Medicine
&
Strength
of
Route/Method of Administration
Dosage
Frequency
Duration
of
Treatment
Maximum or Minimum Treatment

Period
Quantity to Supply/Administer
Side Effects: Common or High
Risk
Advice to Patient/Carer
Follow up
Page 86 of 119
Staff Characteristics
EXAMPLE:
Named Registered General Nurse
Qualifications
Specialist
Competencies
Qualifications
or
EXAMPLE:
Has undertaken appropriate training to carry out clinical
assessment of the patient leading to a decision that
requires treatment according to the indications listed in
this PGD
Has undertaken appropriate training for working under
PGDs for the supply and administration of medicines
Has undertaken training appropriate to this PGD
Continuing
Education
Training
&
EXAMPLE:
The practitioner should be aware of any change to the
recommendations for the medicine listed. It is the responsibility of
the individual to keep up to date with continued professional
development.
Referral Arrangements & Audit Trail

Records/Audit trail
EXAMPLE:
A record of administration supply must be maintained
according to local procedure. Records must contain:name of the medicine
dose/number of doses given
time of administration/supply
batch number and expiry date if applicable
a record of medicines administered/supplied under this
Patient Group Direction must be kept in the subjects
health record
References/Resources and Comments
Page 87 of 119
This patient group direction must be agreed to and signed by all health care professionals involved in its use.
The NHS Trust should hold the original signed copy. The PGD must be easily accessible in the clinical
setting.
Organisation
Bolton NHS Foundation Trust
*FOR PHARMACY OFFICE USE ONLY*
Authorisation Part 1
Lead Doctor
Name:
Signature:
Chief Nurse / Director of Patient

Safety and Experience
Name:
Signature:
Chief Pharmacist
Date:
Date:
Name:
Signature:
Date:
Confirmed by:
Date:
Authorisation Part 2
Ratified by the Divisional Governance
/ Quality Board
Division:
Divisional Governance / Quality Board Meeting Date:
Ratified by the Drugs & Therapeutics
Committee
Name:
Signature:
Date:
Page 88 of 119
Authorisation
PGDs DO NOT REMOVE INHERENT PROFESSIONAL OBLIGATIONS OR
ACCOUNTABILITY.
It is the responsibility of each professional to practice only within the bounds of
their own competence and in accordance with their own Code of Professional
Conduct.
Note to Authorising Managers: authorised staff should be provided with an individual
copy of the clinical content of the PGD and a photocopy of the document showing their
authorisation.
I have read and understood the Patient Group Direction and agree to supply/administer this
medicine only in accordance with this PGD.
Name of Professional
Signature
Authorising Manager
Date
Page 89 of 119
Appendix 3 - Guidance for Unregistered Staff in the

Administration of Medicines
1.
GUIDANCE FOR THE ASSISTANT PRACTITIONER (AP) IN THE

ADMINISTRATION OF MEDICINES
On completion of an initial assessment of need by a registered nurse, in bed based

services an AP can assist a registered nurse with medicine administration where the
patient may need time to take the medicine, or when the AP is caring for a particular
patient at the time of the prescribed medicine. The registered nurse retains the
responsibility for checking both the medicine and the patient.
APs in community/district nursing may administer some medications after the registrant
has ascertained competency.
Background:
An AP is a health and social care worker who delivers health and social care to patients
with a level of knowledge and skill beyond that of a traditional healthcare assistant or
support worker. They are able to undertake clinical work in domains that have previously
only been within the remit of registered professionals. In many case this role transcends
many of the boundaries that have previously been demarcated between different
professions. They have the underpinning knowledge and assessed level of competence
to undertake such a role. (GM SHA, 2005).
The Assistant Practitioner programme comprises of a two-year work-based foundation
degree in Health & Social Care. Within this training they complete Clinical Skills
Competencies, relevant to their clinical area for their role on qualification as an Assistant
Practitioner. Within the hospital practice competency framework are the following three
competencies once checked from the prescription chart by the registered Nurse:
Assist in the administration of clients medication
Administer a Normal Saline flush when performing Cannulation (using the BD
prefilled syringe as a non-prescribable device).
Establish and maintain an intravenous infusion of Sodium Chloride 0.9%, Dextrose
5%, Dextrose/Saline 0.45% & 0.9%, Hartmanns solution. (This may include the
correct use of an infusion pump after medical device training has been completed).
If it has been deemed appropriate for their role within their clinical area (including
community practice) and they have completed the clinical skills module within their
Foundation Degree and the Trusts Medicines Management training they can assist in
administering medication to a patient who has been assessed, checked and dispensed
and delegated by a registered nurse (NMC, 2004).
Page 90 of 119
Assisting Administration
Include
Oral medication
Nebulisers
No restrictions
0.9% Sodium Chloride, Combivent,
Salbutamol 2.5mg/5mg
Ipratroprium 250micrograms/500micrograms
Pulmicort/Budesonide 250micrograms/500micrograms
Respules only
No Restrictions
Glycerine and Bisacodyl Suppositories
Diclofenac and Paracetamol Suppositories
Phosphate/microlax only
Skin Preparations i.e. Iodine, Emla, Ametop, Instillagel,
Emollients and topical steroids
No restrictions
Hydroxycobalamin
Inhalers
Suppositories
Enemas
Topical skin preparations
Eye, ear, nose preparations
Vitamin B12 (IM) Injection
In hospital/bed based area the registered nurse retains responsibility for checking both
the medicine and the patient, before the AP administers the medicine; the AP is
accountable for the safe administration of the medicine and to report back to the
registered nurse that the medication has been administered. The registered nurse can
then sign the prescription sheet. In community nursing the AP will be delegated the task
of administering the medication on a "patient specific basis". The AP will then be
responsible for checking the medication and identity of the patient, in addition to the
safe administration of any prescribed medication. This will include completion
of the necessary Medication Administration Record (MAR) documentation.
Intravenous Fluids
On completion of the Trusts IV Therapy training and Cannulation training and the
associated clinical skills competencies the AP can establish and maintain an intravenous
infusion, that has been prescribed, of the following;
Normal Saline Flush when performing Cannulation
Sodium Chloride 0.9%
Dextrose Saline 5%
Dextrose/Saline 0.45% / 0.9%
Hartmans solution
The AP can use infusion pumps after the appropriate competency and medical device
training have been completed, as part of the clinical skills competencies, or Trust
training.
Second Checking
Assistant Practitioners can:

Act as the second checker in the administration of oral controlled drugs after
completing the Trust competencies (as long as these do not require a second check
of the calculation)
Act as the second checker in giving take-home medicines to patients at discharge
after appropriate training session
Commence and change sub-cutaneous fluids when checked by a registered nurse
via a line established by a registered nurse.
Page 91 of 119
There are a number of restrictions and the AP cannot carry out any of the
following tasks;
Hold the drug keys or complete drug rounds
Administer medicines by injection, including sub-cutaneous (apart from IM Cytamen
in community)
Sign for any medication alone, in the case of IV infusions these should be
countersigned by a registered nurse - APs in Community/District Nursing may sign
the MAR sheet alone, unless the visit requires a Registered Nurse to attend then the
registered nurse should sign the MAR sheet.
Act as second checker for intravenous antibiotics, or insulin
Act as a second checker where a dose calculation needs to be performed
Administer a saline flush or commence fluids via a central venous line
There are some exceptions to the above as additional assurances have been put into
place so that the specific requirements of discrete areas have been matched. Without
having these competencies, the role of the AP would be severely restricted. This range
of exceptions includes;
In Endoscopy and on completion of a specific competency workbook:
The AP can draw up medications to pass to clinicians for intra-operative
administration.
The AP can administer specific drugs via the scope under direct supervision of
the clinician, as they are unable to do so due to holding the instruments.
2
GUIDANCE FOR STUDENT NURSES IN THE ADMINISTRATION OF
MEDICINES
Student nurses can participate in the administration of medicines following theoretical
preparation from Higher Educational Institute (HEI). They must be under the direct
supervision of a registered practitioner who must ensure that the student has received
instruction in the administration of medicines; knowledge of the Medicines Policy,
Positive Patient Identification Policy and Medical Devices Policy, and is competent to
undertake the task.
Once a 2nd/ 3rd year student has completed the observed practice checklist for second
checking they can carry out second checks, in all areas except high risk areas which are:
Neonatal Unit, Intensive Care Unit, High Dependency Unit and Coronary Care Unit. The
registered practitioner should ask for verification of the observed practice checklist. At all
times the registered practitioner is accountable.
Student nurses can:

Act as the second checker in the administration of controlled drugs inclusive of patient
controlled analgesia after completing the Trust competencies (as long as these do not
require a second check of the calculation)
Act as the second checker in giving take-home medicines to patients at discharge after
appropriate training session
Act as the `second checker` in Normal Saline Flush when performing Cannulation,
Sodium Chloride 0.9%, Dextrose Saline 5%, Dextrose/Saline 0.45%/0.9%, Hartmans
solution.
Page 92 of 119
There are a number of restrictions and the Student Nurse cannot carry out any of
the following tasks;
Hold the drug keys or complete drug rounds
Sign for any medication alone, in the case of IV infusions these should be countersigned
by a registered nurse
Act as second checker for intravenous antibiotics, or insulin
Act as a second checker where a dose calculation needs to be performed
Administer a saline flush or commence fluids via a central venous line
HEALTH CARE SUPPORT WORKERS

In certain circumstances, registered nurses may delegate the administration of
certain medicines to Health Care Support Workers (HCSWs) who are based in
specific community settings i.e. children who attend special schools and children
with complex needs who are cared for in their own homes.
A registered nurse is responsible for the delegation of any aspects of the

administration of medicinal products and they are accountable to ensure that the
care assistant is competent to carry out the task.
In the care of children with complex needs, where an individual care plan has been
written and signed off by a registered nurse and the unregistered practitioner has
been assessed by a registered nurse as competent to undertake the specific
administration of medicinal products to a specific named patient, this may be
undertaken, for example, children with complex health needs in community
settings, palliative care (NMC Standards for Medicines Management, 2010)
Medications may only be administered by HCSWs via the following routes:
Oral
Inhalation
Rectal
Nasogastric
Percutaneous Endoscopic Gastrostomy (PEG)
Nebulised
Topical
Buccal
Health Care Support Workers must not administer medicines via the Intravenous ,
Intramuscular or Subcutaneous route.
A written instruction for the medication, which may be in the form of a prescription or
a Patient Specific Direction, must be given by a doctor, dentist or non medical prescriber
and a consent form must have been signed by the patients parent or legal
guardian.
Once the medication has been administered, the HCSW must record this on the
prescription sheet.
HCSWs must undertake specific training in the administration of the prescribed
medicines and their competence must be ascertained by a registered nurse.
A copy of the completed competency assessment form must be kept in the individuals
personal file and training must be recorded on their electronic staff record (ESR).
Page 93 of 119
Competency should be reviewed annually as part of the appraisal process.
References:
Greater Manchester Strategic Health Authority (2005) Medicine Matters
Assistant Practioner Guidance GMSHA.
Nursing and Midwifery Council (2004) Standards for Medicine Administration NMC
(Section 5 Delegation)
Page 94 of 119
Appendix 4 - Standard Operating Procedure for Controlled

Drugs for Royal Bolton Hospital and Bolton Community Unit
PRESCRIBING OF CONTROLLED DRUGS

See Trust Medicines Policy
RECORD-KEEPING
1. The following books are to be kept on every ward or any other area
receiving Controlled Drugs:
a) Controlled Drugs Record Book (CD register) main register, all stock
of Controlled Drugs received and administered to be recorded in there,
keeps running balances of all stocks of controlled drugs
b) Controlled Drugs Order Book to be used for all orders of controlled
drugs
c) Controlled Drugs Daily Drug Count Book a record of daily stock
check.
d) Patients Own Controlled Drugs Book a record of controlled drugs
received from patients, their administration and returns back to patients or
relatives acting on their behalf
e) Authorization List a list of staff authorized to order Controlled Drugs.
Controlled Drugs will not be supplied if person ordering is not an
authorized signatory.
2. New books and registers can be obtained from Pharmacy Department.
3. Completed Controlled Drugs Record Books and Controlled Drugs Order
Books to be stored on wards for at least the legal minimum of two years,
after the date of the last entry, and then destroyed securely.
4. It is recommended that all controlled drug records be kept securely for as
long as possible regardless of the legal minimum. Five years would be
considered appropriate.
ORDERING CONTROLLED DRUGS FOR INPATIENTS
1. Controlled Drugs Order Book to be used for all orders.
2. Fill in full information regarding name of drug, form, strength, ampoule size
(for injections where more than one exists) and quantity required.
3. Only registered nurses authorised to do this by their Ward or Department
Manager can order Controlled Drugs.
4. The name of the nurse requesting the Controlled Drugs should be printed
underneath the signature.
Page 95 of 119
5. A list of authorised signatories is held in the Pharmacy department for

each ward. Ward/Department managers are required to complete an
authorization form for any new signatory to be added to the existing list.
6. Pharmacy also have to be provided with a complete list of authorised
signatories every 6 months.
7. Requisition books should be sent to Pharmacy before 10am on weekdays.
8. Orders for Controlled Drugs for the weekend must be placed before
10am on Friday. Only in exceptional situations will Controlled Drugs
be supplied from Pharmacy on Saturday or Sunday. Such orders will
be monitored.
OBTAINING CONTROLLED DRUGS IN AN EMERGENCY OUT-OF-HOURS
1. Single doses of Controlled Drugs can be administered from another wards
stock.
2. For legal reasons only single doses can be administered this way.
3. Administration procedure is to be followed as per section 9.
4. A registered nurse from the supplying ward is to act as the second nurse
for the purpose of administration.
5. The CD register of the ward supplying the Controlled Drug should be
signed by the nurses of both the supplying and receiving ward.
6. The supplying nurse from the supplying ward must observe the Controlled
Drug being entered into the CD register of the receiving ward.
7. In cases of difficulty, the on-call pharmacist can provide advice.
DELIVERY OF CONTROLLED DRUGS FROM PHARMACY
1. Controlled Drugs may be collected from the Pharmacy by any member of
staff with a current Trust ID badge the messenger.
2. The messenger will sign for receipt of the sealed bag and must then gain
the signature of a registered nurse on the ward once delivered.
3. The messenger must ensure security of the Controlled Drugs in transit.
4. The registered nurse signing received by is responsible for the
immediate entry into the CD register and the immediate transfer to the
Controlled Drugs Cupboard.
5. The top copy of the requisition should not leave the Pharmacy.
6. For patient specific prescriptions (Outpatient / TTOs) the pharmacist must
ascertain whether the person collecting a Schedule 2 or 3 Controlled
Drugs is the patient, the patients representative or a member of staff.
Signatures must be recorded.
RECEIPT OF CONTROLLED DRUGS ON WARD
1. Controlled Drugs must be received on the ward by a registered nurse,
preferably person in charge, and signed for in the presence of the
messenger.
2. The drugs should be locked in the Controlled Drugs Cupboard
immediately.
Page 96 of 119
3. The appropriate entry should be made in the ward Controlled Drugs

Record Book (CD Register) by the person who received the controlled
drugs and witnessed by a second nurse.
STORAGE OF CONTROLLED DRUGS
1. For drugs to be stored in the Controlled Drugs Cupboard, see Medicines
Policy.
2. Access and keys should be restricted to persons authorised under the
Misuse of Drugs Act, i.e. the ward manager or the person in charge of the
ward or area.
3. All general wards should only keep standard strength opiates as routine
stock, if they need higher strength vials the ward pharmacist should be
informed and these should be kept on a shelf separate from the standard
strengths. (NPSA recommendation)
STOCK CHECKS OF CONTROLLED DRUGS
1. The ward or department manager / designated deputy is responsible for a
DAILY check of stocks of Controlled Drugs which must be recorded in the
Controlled Drugs Daily Drug Count Book.
2. Individual areas (e.g. Theatres, Endoscopy Unit) may decide to undertake
more frequent checks as deemed appropriate by the person in charge.
3. Discrepancies should be reported immediately to the matron or designated
deputy and the Ward Pharmacist, who will inform the Accountable Officer.
4. The pharmacist, along with the ward manager, will check the balance of
Controlled Drugs at three-monthly intervals.
5. Staff undertaking the daily stock check should be rotated periodically and
should not be involved in ordering or receiving of Controlled Drugs where
possible.
6. Stock check should involve checking of the balance in the Controlled
Drugs Register against the contents of the Controlled Drugs Cupboard to
ensure all balances are checked.
7. Stock balances of liquid medicines should be checked by visual
inspection, however the balance must be confirmed correct on completion
of a bottle
8. Segregation of duties should be maintained where possible.
ADMINISTRATION OF CONTROLLED DRUGS

1. Unless given by a doctor, administration of Controlled Drugs must be
carried out by two members of staff or members of the relevant
department, one of whom is a registered nurse.
2. Both the administering nurse and a witness should:
a)
b)
c)
d)
check the prescription

observe preparation of the dose
take the dose with the CD register to the patient
observe administration of the dose
Page 97 of 119
e) reconcile the stocks remaining

f) sign the register immediately
3. Administration should also be recorded on the prescription chart (All other
relevant policies, including those for parenteral and paediatric
administration still apply).
4. Exceptions to these rules are:
Administration of when required doses of up to 30mg of morphine
from 10mg in 5ml oral liquid for which a second check is not required
Administration of IV morphine injections, where 2 registered nurses
have to check the dose, however titration of the dose can be
undertaken by 1 nurse only
5. Please see separate guidelines for administration of :
-
IV morphine injections
Patient-controlled analgesia (PCA)
Epidural analgesia
PATIENTS OWN CONTROLLED DRUGS

1. These remain the patients own property, and should preferably be given
back to the patient or relatives acting on the patients behalf at discharge.
2. They should be locked in the Controlled Drugs cupboard, and an entry
made in the Patients Own Controlled Drugs Book.
3. This entry should include the patients name and the quantity and type of
drugs, (tablets, ampoules, etc.) and be witnessed by another nurse.
4. The administration of patients own Controlled Drugs to the patient they
belong to is recorded in the Patients Own Controlled Drugs Book.
5. Same procedure for administration and record keeping as in Section 9
applies.
6. Patients own Controlled Drugs should be returned to the patient or
relatives acting on patients behalf at discharge if still required.
7. If the dose has changed or the medicine has been stopped, and the
patient insists on the medicine to be returned to them, a single line must
be drawn through the label and the pack annotated with stopped do
not use. The ward pharmacist is available for advice. Document in
patients collaborative notes if they have insisted that their medicines be
returned against advice.
8. When the drugs are released to the patient or a relative acting on patients
behalf, the entry signing out the drugs should be countersigned by the
patient or the relative.
9. General rules about discharge medication also apply.
ILLICIT SUBSTANCES
1. See Guidelines for Handling of llicit Substances Section of Medicines
Policy
Page 98 of 119
2. ILLICIT (OR SUSPECT) SUBSTANCES MUST NEVER BE RETURNED

TO THE PATIENT OR RELATIVES. (This would contravene the Misuse of
Drugs Regulations and could constitute Supply of a Controlled Substance
for which a custodial sentence is possible).
3. Security must be informed and a decision on police involvement made by
the senior nurse and medic.
RETURN AND DESTRUCTION OF CONTROLLED DRUGS

Unwanted Controlled Drugs must be returned to Pharmacy via the ward
pharmacist. Theatres, OPD or any other area not covered by the ward pharmacy
service must ring Pharmacy for advice.
Page 99 of 119
Appendix 5 - Storage and Recording Requirements for

Controlled Drugs
CD
Morphine
Dexamphetamine
Diamorphine
Pethidine
Methadone
Methylphenidate
Oxycodone
Fentanyl
Pentazocine inj
Alfentanil inj
Remifentanil inj
Codeine inj.
Cocaine
CD
Buprenorphine
Temazepam
Pentazocine tablets
Midazolam
Phenobarbital
Schedule 2Controlled Drugs

Brand names
Legal Requirements
Various brands available
Store in a CD cupboard
Record in the CD register.
Oramorph Concentrated
oral solution 100mg/5ml ( Oramorph oral solution 10mg/5ml
is a Controlled Drug and
is not a controlled drug. However,
all storage & recording
CD storage and CD records are a
requirements necessary
good practice recommendation.)
Dexedrine
Physeptone
Ritalin, Concerta XL,
Medikinet
OxyNorm
OxyContin
Various brands and
formulations available
Fortral
Store in a CD cupboard
Record in the CD register.
Schedule 3 Controlled Drugs

Brand names
Legal Requirements
Temgesic, BuTrans,
Schedule 3 Controlled drugs need
Subutex, Transtec
to be stored in the CD cupboard.
None of the controlled drugs in this
schedule need to be recorded in the
CD register but this is a good
practice recommendation.
CD
Diazepam
Zopiclone
Zolpidem
Schedule 4 Controlled Drugs

Brand names
Legal Requirements
No legal requirements
Good practice to store in CD
cupboard and record usage
No legal requirements
Page 100 of 119
Appendix 6 - Protocol for the Use of Controlled Drug Denaturing

Kits in Community Services
Prescribed drugs, including CDs, are the property of the patient and remain so
even after death. However, it is illegal for a person to possess CDs that have not
been prescribed for them.
In the first instance, the patient/patients relatives should be advised that CDs no
longer required should be returned by them to a community pharmacy for safe
destruction.
Community nurses should not normally transport CDs to the community
pharmacy. This should only be undertaken in circumstances where there is no
other reasonable means available.
If return by relatives is not possible or appropriate, the following action should be

taken:
Nurse with another member of the nursing team, acting as a witness,
destroys the CD using a de-naturing kit.
This should be within the agreed local Standard Operating Procedure and
should include appropriate documentation in the patient nursing record.
If it is not possible for the nurse to destroy the CD in the patients home, the
following action should be taken:
Nurse takes CDs to local community pharmacy, who would be asked to
counter-sign patient nursing record.
Injectable controlled drugs that have been dispensed for a particular patient and
which have been monitored and recorded by Community Services nursing staff
will be destroyed in the patients home when they are no longer required.
The drugs will be denatured using supplied kits and by the following procedure.
1. If appropriate, drugs will need to be diluted, if not in liquid form.

2. The liquid drug will be deposited in the denaturing kit, which contains an
absorbent material. The instructions on the individual kit should be
followed.
3. Any glass ampoule/ other material will be disposed of in the usual manner.
I.e. sharps receptacle.
Page 101 of 119
4. For patients of the District Nursing Service the used denaturing kit will be
exchanged for an unused kit. These Kits are stored at Blackrod and
Waters Meeting Health Centres. Used denaturing kits MUST be hand
delivered and exchanged on the next working day. If this is not possible
then the used kit will be kept in a locked cupboard until exchange is
possible. Other services are required to make suitable systems for
collection and distribution of denaturing kits.
5. Monthly collections will be made from Waters Meeting and Blackrod health
centres for used denaturing kits. The used kits will be kept in a container
supplied by the waste collection company in a locked storage room.
6. When a CD is destroyed, details of the destruction must be recorded in the
CD register.
This should include:
the name of the drug
form
strength
quantity
date it was destroyed
the signature of the person who witnessed the destruction
the signature of the professional destroying the CD
Community Nurses are not responsible for the disposal or destruction of CDs in
Care Homes.
Please note:
The instructions with the kit indicate that the ampoules should be crushed
prior to disposing of them. However, it may be appropriate to dispose of
them into a sharps receptacle (as indicated above) as this is a safer and
more practicable action.
Page 102 of 119
Appendix 7 - Form for the removal or destruction of unauthorised

drugs or other suspicious substances
PART A: Description of substance removed from patient and placed in controlled
drug cupboard.
To be completed by the member of staff finding the drug and by the ward or
departmental manager.
Form: ................................... (e.g. powder, tablets, capsules) Colour:.....................
Quantity: ..................
Removed from: Patient Initials .Hospital
Number................................................
Ward/Dept: ......................................... Date: ..................................... Time:
Name of Finder: ............................... Title: ................................ Signed:......................
Ward Manager: ................................ Title: ................................. Signed:.....................
Date: .......... Time:
PART B Action by ward manager and consultant in charge of the patient.
We................................(ward manager) and............................. (consultant in
charge of patient)
(1) are in agreement* (2) are not in agreement* that the unauthorised
substances found on the
person or property of the above patient are of a quantity consistent with his or her
own personal use.
ACTION (1) We have authorised the transfer of the substance to the pharmacy.
ACTION (2) We have contacted the Incident Management Unit.
Signed: ...................................... (ward manager) Date: ................. Time: .............
Signed: .......................................(consultant)
Date:.............. Time: .............
*Delete both items (1) or both items (2) as appropriate.

PART C Collection and removal to pharmacy for destruction according to procedure
Sealed container received by:.....................(pharmacist) Date: ........ Time: ...........

Witnessed by: ............................ ......................... Date: .................. Time: ............
OR PART D Collection by police (when required)
Sealed container collected by:
Officers Name: ............................. Signed: ..........................................
Witnessed by Name: ..................... Signed: ..........................................
Date: ..................... Time: ......................
NB: One copy to be filed in patients medical record.
One copy to be retained by pharmacy department.
One copy to be given to the police (if appropriate)
Page 103 of 119
Appendix 8 - Self Administration of Medicines

Assessment Algorithm
Yes
2
Is the patient confused or disorientated

to time and place?
No
3
No
Is the patient medically fit to selfadminister following assessment?
Yes
Level 2
Re-assess regularly
Yes
Yes
Level 2
Re-assess regularly.
Is the patient willing to self-administer

es
and sign the consent form?
Yes
Does the patient have a history of, or
show signs of, drug abuse, alcoholism or
suicidal tendencies?
No
Level 2
Assess individually
Yes
No
6
Can the patient read and understand the

label and other instructions?
Level 2
Re-assess regularly
No
Yes
Level 2
Exclude from Self Medication
Supply support regarding
medicines.
No
Level 2
Assess individually, refer to
Patient Experience Team if
additional support is required
Yes
7
Can the patient open and administer

their medication either with or without
dexterity aids?
No
Yes
8
Does the patient understand the purpose

of the medicine, the dose (and special
instructions) and possible side effects?
No
Level 2
Assess individually, Pharmacy
staff can advise on dexterity
aids
Level 1
Initiate education and reassess as
required
Yes
9
Can the patient open the locker?
Yes
No
Level 1
Patient may be competent at home
but needs supervision on ward
Self administration (Level 0)

Continue to monitor and assess
Page 104 of 119
Contact ward pharmacy team for advice / support
Is the patient self administering at home

AND to continue once discharged?
Appendix 9 - Self Administration of Medicines Assessment

Record
21.1.1 Patient
Label
Ward
Review on a weekly basis or sooner if

condition changes
Admission Date
Initial Assessment
Level
Review of
Assessment Level
Review of
Assessment Level
Review of
Assessment Level
Review of
Assessment Level
Assessed by
Date
Assessed by
Date
Assessed by
Date
Assessed by
Date
Assessed by
Date
Levels of self administration

Level 0a
Full self administration following documented assessment
Level 0b
Full self administration of selected medicines
Level 1
Patient needs supervision with their medicines. The locker key is in possession of the nurse.
As a minimum the nurse and patient must together check the medicine dose to be taken. The
nurse will if appropriate educate the patient on how the medicines are to be administered and
why they are prescribed.
Level 2
Full Nurse administration of all types of medication
Level 3
Not applicable, Community Services/ Domiciliary settings only
Please note: Individual medicines may require a different level of support.
Page 105 of 119
Appendix 10 - Self Administration Consent Form

Name of patient .
Address ...
Date of birth.
I agree to be responsible for my medicines, as detailed below, whilst in hospital.
Medicines for self administration include:
..
A nurse or pharmacist has explained what my medicines are for and any other important
information.
I will:
Ensure my medicines are either on my person or locked up securely in the locker
provided. I will not leave them unattended on my locker or bedside table
Tell the nurse looking after me when I have taken my medicines
Ask the nurses or pharmacy staff if I am unsure about anything
Only takes medicines that are prescribed for me
Tell the nurse or pharmacy staff if I am running out of a medicine.
I understand that I can change my mind at any time and ask the nurses to resume
administering my medicines to me.
Signature of patient
To be completed by the assessor:
Signature of assessor.
Name of assessor
Date of assessment
Page 106 of 119
Appendix 11 - Information for Patients about Self Administration

of their Medicines
What is Self Administration of Medicines?

This is a scheme that allows you to take your own medicines whilst in hospital,
giving you greater independence and control in taking your medicines.
Why use this system?
When you look after your own medicines you become more familiar and
confident with your medicines, and understand more about your own health.
Who can I talk to about Self Administration?
Before taking part and looking after your own medicines, you can discuss this
with your nurse or the pharmacy staff who visit the ward every day. They can
answer any questions you may have about your medicines and self
administration.
Do I have to Self Administer?
No this is your choice, and you do not have to take part if you do not wish to.
What will happen if I want to look after my medicines?
If you wish to take part, a nurse or pharmacist will assess your suitability. They
will ask for your agreement by getting you to sign a consent form. A nurse or
pharmacist will explain self administration and go through your medicines with
you, explaining the dose, any side effects and any other important information.
You will use your own medicines from home once they have been assessed as
still suitable. We will supply any other medicines you need.
To make this work, you will need to:
Ensure my medicines are either on your person or locked up securely in
the locker provided. Do not leave them unattended on the locker or
bedside table
Inform the nurse looking after you when you have taken your medicines
Ask the nurses or pharmacy staff if you are unsure about anything.
Only take medicines prescribed for you
Tell the nurse or pharmacy staff if you are running out of a medicine.
Page 107 of 119
Keeping your medicines safe

If anyone tries to take your medicines or open your locker please tell a member
of staff immediately. The only people who should look in your locker are you,
the nurses or the pharmacy staff.
We understand that you may wish to keep such things as your inhalers or GTN
spray on your person, rather than in a locked cupboard, if you do so, please do
not leave them unattended on your locker or bedside table. Let the nurse know
what items you are keeping on you.
What will happen when I go home?
A prescription will be written with the medicines you need to take home. This
prescription will be checked against the medicines in your locker. These
medicines will be given back to you if they are still okay to use. If more medicines
are needed or your medicines need to be changed, the pharmacy staff will look
after this.
Please remember to return your locker key to the nurses before you leave the
ward.
If you need this leaflet in other languages or larger print then please ask a
member of staff.
Page 108 of 119
Appendix 12a Disclaimer for the Prescribing of Unlicensed

Medication Single Consultant
Drug name:__________________________________________________
Strength:____________________________________________________
I wish to use
Form:_______________________________________________________
in clinical practice because there is no suitable licensed alternative available.
I
understand that this medicine does not have a UK product license and that I take full
responsibility for its use.
It is to be used for either:

A:
Patients name: _________________________________________________________

Hospital number:_______________________________________________________
Date of birth:___________________________________________________________
Reason:_______________________________________________________________
OR
B:
Selected patients with a diagnosis of ______________________________________

_______________________________________________________________________
Consultant Name___________________________ Signature__________________________

Date___________
I wish to authorise medical officers in my team also to prescribe this medicine.
understand that I must inform them that they are fully responsible for its use.
Consultants signature__________________________ Date___________________________

THIS DISCLAIMER NEEDS TO BE RESUBMITTED EVERY TWO YEARS
Please complete and return form to:
Date received:
MEDICINES INFORMATION PHARMACIST

PHARMACY DEPARTMENT
Date for renewal:
Page 109 of 119
Appendix 12b Disclaimer for the Prescribing of Unlicensed

Medication Multiple Consultants
I wish to use
Drug name: ____________________________________

Strength:_______________________________________________
Form:_______________________________________________
in clinical practice because there is no suitable licensed alternative available.

I
understand that this medicine does not have a UK product license and that I take full
responsibility for its use.
It is to be used for either:
A:
B:
Patients name:
__________________________________________________
Hospital number:
___________________________________________________
Date of birth:
___________________________________________________
Reason:
___________________________________________________
OR
Selected patients with a diagnosis of ______________________________________
_______________________________________________________________________
Consultant Name___________________ Signature__________________ Date___________

I wish to authorise medical officers in my team also to prescribe this medicine.
I understand that I must inform them that they are fully responsible for its use.
Consultants signature_________________________________
Date____________________
Date____________________
Date____________________
Date____________________
THIS DISCLAIMER NEEDS TO BE RESUBMITTED EVERY TWO YEARS

Please complete and return form to:
Date received:
MEDICINES INFORMATION PHARMACIST

PHARMACY DEPARTMENT
Date for renewal:
Page 110 of 119
Appendix 13 List of Unlicensed Medicines that do not require a

disclaimer
Internal liquids
Chlorothiazide 250mg/5ml
Caffeine citrate 50mg/5ml
Joulies Phosphate solution 1mmol/ml
Sodium chloride 25mmol/5ml
Spironolactone 50mg/5ml
Sodium bicarbonate 8.4% solution
Tablets and capsules
Magnesium Glycerophosphate 4mmol tablets
Midodrine 5mg tablets
Injections and infusions
Bupivacaine 0.1% and fentanyl 5% epidural 250ml
Morphine 50mg in 50ml syringes
Potassium chloride 10mmol in glucose 10% 500ml
Potassium chloride 10mmol in glucose 5% /sodium chloride 0.45% 500ml
Potassium chloride 40mmol in sodium chloride 0.9% 100ml
Potassium chloride 40mmol in sodium chloride 0.9% 500ml
Sodium bicarbonate 4.2% 1ml and 5ml ampoule
Externals
Adrenaline 1 in 1000, 30ml solution
Cocaine plain solution 10%
Cocaine 5% with adrenaline 1 in 2000 solution
Cocaine 10% with adrenaline 1 in 2000 solution
Iodine 2.8% solution 100ml
Liquid paraffin sterile - check theatre/DCU
Page 111 of 119
Appendix 14 - Fridge Monitoring Sheet

Ward:..Month: Year:
Date
Time
Min
Temp
Current
Temp
Max
Temp
Reset
Signature
Action taken
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
29th
30th
31st
Fridge temperatures must be monitored daily, with the minimum and maximum function
of the thermometer reset daily. Fridges must be between 2 and 8 C, if they are not the
following must be done at the earliest opportunity:
Contact estates to come and look at the fridge (Ext 5995)
Contact pharmacy medicines information (ext 5478) or the on-call pharmacist via
switchboard to check if medications can still be used. Move drugs to an alternative
monitored fridge until the problem has been resolved. i.e a neighbouring ward.
Page 112 of 119
Appendix 15 - Algorithm for the use of patients own drugs (PODs)

1.
Is Medicine brought in by patient appropriate for patient?

Yes
No
Do not use
2.
If the medicine is labelled, is the label :

Legible,
Bears the correct name,
Details, drug name ,
Strength,
Suppliers name and address.
The product is in the original dispensed container and matches the label description.
Hospital Bed based services Note: products with no dosage instructions are acceptable, as are those with no pharmacy
label but which are in manufacturers original pack containing blister strips of tablets or capsules on which the drug name,
strength and expiry date are clearly visible. The pharmacist should consider relabeling such medicines with appropriate
instructions at the earliest opportunity
Yes
No
Do not use
3.
Dispensed within the last six months if not marked with a manufacturers expiry date?
If the product is a liquid, inhaler, injection, cream, suppository or pessary, is it in a manufacturers original pack with a
clearly visible expiry date?
Yes
4.
7.
No
Do not use
If there are loose tablets or capsules in a bottle, are they easily identifiable by colour or markings?
Yes
6.
Do not use
No mixed, dirty or broken tablets or capsules present?

Yes
5.
No
No
Do not use
If the product is an eye drop or ointment, has it been dispensed within the last month?
(These must be re-supplied within one week)
Yes
No
Do not use
Does the product require refrigeration( between 2 8c)?

No
Yes
Yes
Do not use
No
Are you satisfied that the cold storage
requirements have been met?
8. Are there any dosette type boxes (compliance aids) and dispensed within 28days?
No
Yes
Is the compliance aid Pharmacy filled?

Yes
No
Do not use
Are the contents clearly labeled?

Yes
No
Refer to Pharmacist /
Prescriber
If you are satisfied with the general condition, packaging and labelling, the
product is safe to use
Page 113 of 119
Appendix 16 - Protocol to remove discontinued and out of date

medication from patients home
Medication should never be disposed of in domestic or commercial refuse, and
disposal in the sewerage system is illegal. Staff must ensure the safe and secure
transfer of medication from the patients home to the community pharmacy.
Aim
To reduce the volume of stored medication in a patients home and the risk of
medication being taken inappropriately.
Medicines are often returned to a community pharmacy for destruction. Any
medication returned, is destroyed as the quality of the medicine can no longer be
guaranteed. Healthcare professionals should be aware that professional
guidance strongly recommends that medicines returned from patient stocks
should not be re-issued or used to treat other patients
When should medication be removed?
Medication in the first instance should be returned to the pharmacy by a
patients relative or friend where ever possible and should only be removed
if leaving them poses a risk to the patient or other members of the
family/carers/friends.
If the patient has their regular medication delivered by their local community
pharmacy, unwanted medication can be given to the driver to take back for
destruction.
In all cases the patients consent must be obtained.
Medication disposal
Medication should ideally be returned to the original dispensing pharmacy,
however all pharmacies must accept medicines for disposal as documented in
the essential services of the Pharmacy Contract.
If the patient has significant quantities of medication for disposal then a referral to
a pharmacist for a medication review should be considered. The pharmacist will
liaise with the GP with regard to any changes deemed necessary.
Medicines should never be transferred from the original pack into another
container, and must not be re-labelled or the label altered. If a label has been
defaced it should be referred to the originating pharmacy.
Controlled drugs
Page 114 of 119
Controlled drugs should be returned, ideally to the original dispensing pharmacy.

The patients permission must be obtained using the Removal of Discontinued
and Out of Date Medication Form shown below. On taking controlled drugs to
the community pharmacy the pharmacist may or may not document details of the
return (it is not a legal requirement but it is good practice to do so) to enable safe
destruction and maintaining records of drugs returned to the pharmacy.
If the patient is having controlled drugs administered by Community Services
nursing staff that are no longer required then the staff can destroy them using a
Controlled Drug Destruction Kit following the guidelines in Appendix 1.
Oxygen
Oxygen is no longer supplied by the community pharmacists, if it needs to be
removed then Air Products Healthcare should be contacted (telephone 0800
3890202).
Sharps disposal
Sharps (e.g. needles, lancets) will not be accepted by a community pharmacy for
disposal. All sharps and syringes must be safely disposed of in Sharps
receptacles in accordance with the FT Clinical Waste policy.
Carriage of medicines
Community Services staff may carry medicines for disposal that has been
prescribed for named patients. The drugs may be transported out of sight in a
locked car from the patient directly to the pharmacy.
Removal of Discontinued and Out of Date Medication
Complete the duplicate medication removal form (an example is shown below).
An explanation to the patient as to why the medication is being removed should
be given. Document the reasons for medication removal using the return codes
listed on the form.
If you have any concerns with regard to medication contact the community
pharmacist, or the pharmacy team at Darley Court (tel. 337071) for advice.
Page 115 of 119
Removal of Discontinued and Out of Date Medication

Patient name: ...
Patient address: ..............
Patients GP:
I (patient) give permission for the
following medicines (unwanted/expired/discontinued) to be removed from my home
(address as above) for safe disposal and destruction at the pharmacy.
Name of medicine
Return codes
A
B
Out
of Excess
date
amount
Strength
Form
Quantity (state if
bottled/boxed/loose)
Return
code
Comments
C
D
E
Dr stopped / no longer Unwanted Other, state reason
needed
comments
in
If any controlled drugs are being removed, clearly document name, form and quantity. Any
receipts obtained from the community pharmacy should be attached to the duplicate copy in
the book.
Signature of patient or
representative:
Print name:
Signature of health
professional:
Print name:
Date:
Date:
Designation:
Community Pharmacy details where medication has been returned to:

Name and address of ..
pharmacy: ..
Pharmacy stamp / signature
(patient copy and receipt
book to be stamped/signed)
Print name: .
...
Designation:
...
Date: .
Page 116 of 119
Appendix 17 Medicines Policy Monitoring Grid

Monitoring grid
Minimum
requirement
to be
monitored
Process for
monitoring
e.g. audit
Responsibl
e individual/
group/
committee
Frequency of
monitoring
Responsible
individual/
group/
committee for
review of results
Responsible
individual/grou
p/ committee
for
development of
action plan
Responsible
individual/gro
up/
committee for
monitoring of
action plan
a) Monitoring
of prescribing
and
administration
of medicines
Daily
(weekday)
monitoring by
pharmacy
team
Chief
Pharmacist
Daily
(weekdays)
Chief Pharmacist
Chief
Pharmacist
Clinical
Governance
and Quality
Committee.
b) techniques
to be used in
the
prescribing
and
administration
of medicines
Accident/
incident
reports
Professional
Leads /
Chief
Pharmacist
Monthly
Professional
Leads / Chief
Pharmacist
Professional
Leads / Chief
Pharmacist
Clinical
Governance
and Quality
Committee.
c) Security /
storage of
medicines
Audit of
storage areas
on wards
Chief
Pharmacist
Quarterly
Chief Pharmacist
Professional
Leads / Chief
Pharmacist
Clinical
Governance
and Quality
Committee.
d) Security /
storage of
Controlled
Drugs
Audit of
storage and
documentation
on wards
Chief
Pharmacist /
Accountable
Officer
Quarterly
Chief Pharmacist /
Accountable
Officer
Professional
Leads / Chief
Pharmacist
Clinical
Governance
and Quality
Committee.
e) Monitoring
of prescribing/
administration
standards
Audit of 30
drug charts
Medicines
Safety Nurse
6 monthly
Chief Pharmacist
Clinical
Governance and
Quality
Committee.
Clinical
Governance
and Quality
Committee.
Page 117 of 119
Equality Impact Assessment Initial Screening Tool

This Initial Screening Tool is the first step in completing an Equality Impact
Assessment (EIA) of your activity (strategies, functions, policies, procedures,
projects, services etc). Once this is completed, it will be apparent whether or not
a full EIA is required.
This proforma should be used in conjunction with the EIA Guidance available on
the Trusts intranet website under A-Z Services, using the Equality & Diversity
link, where you will also find links to the Trusts Single Equality Human Rights
Scheme (SEHRS).
1. Directorate
Diagnostics and Therapies
2. Department
Pharmacy
3. Name of activity being assessed
Medicines Policy
4. Person completing this form
Suzanne Schneider
5. Date
October 2012
6. Monitoring data/statistics compare activity data with population data (see Guidance)
Patients
Staff
N/A
N/A
Equality Target Groups (ETGs)

(See guidance for detail)
7. Which of the following Equality

Target Groups will this activity impact
on?
8. Could this activity

have a positive and/or
negative impact?
yes
no
Positive*
A. Age
B. Disability
C. Gender
D. Race
E. Religion/Belief
F. Language
G. Sexual Orientation
H. Gypsy/Roma/Traveller
I. Carers
J. Employees
9. Consultation/Involvement during the development of this activity? (see Guidance)
Groups Consulted:
Medicines Policy task and finish group. Paediatric department.
10. Details of positive and negative impacts
Positive Impacts:
Nil
Negative*
Negative Impacts
Persons under 18 years will not be permitted to self-administer medication. It was agreed that this
was necessary under medicines safety as all paediatric drugs administered within the trust require a
second check due to their complex nature and high risk of error.
11. Give details of actions required to remedy any negative impact(s) identified above.
Page 118 of 119
Action to address negative impact
Who
Target Date
Sexual
Orientation
Gypsy/roma
Traveller
N
N
10. Encourage the participation of

disabled people?
11. Consider more favourable

treatment of disabled people?
12. Promote and protect human

rights?
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Employees
Race
N
N
N
Carers
Employees
Language
Carers
Religion/Belief
Gender
5. Promote equality of opportunity?

6. Eliminate discrimination?
7. Eliminate harassment?
8.
Promote
good
community
relations?
9. Promote positive attitudes
towards disabled people?
Gypsy/roma
Traveller
Sexual
Orientation
4. Will the activity have a negative

effect on community relations?
Language
Religion/
Belief
Race
Gender
Disability
3. Does the activity have the potential

to worsen existing discrimination and
inequality?
Could the activity reduce inequalities?

Will it (answer Yes or No)
Positive impact
Disability
1. Will the activity present any

problems or barriers to any
community or group?
2. Will any group of people be
excluded as a result of your activity?
Age
Negative Impact
12. If the actions in 11 above are

completed (answer Yes or No) revisit
section 12 when action in 11 complete
Age
None taken as for health and safety reasons.
N
N
N
N
N
N
N
N
Decision
Work through the flowchart on page 24 of the Guidance, to determine whether you need to complete
a Full EIA or not.
Details of any objective justifications or amendments agreed with Divisional E&D Lead:
Full EIA required?
Yes
Completed by: SSchneider
No
Date approved by: Oct 12

Job Title: Medicines Information Pharmacist
Thank you for completing this EIA initial screening tool.

Please forward an electronic copy of the completed tool to your Divisional E&D Lead for
ratification by your Divisional Board and a copy to: Suzanne Hudson
Email: suzanne.hudson@rbh.nhs.uk Telephone extension: 4017
Page 119 of 119

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DOCUMENT CONTROL PAGE

Title: Medicines Policy

Version Number as from December

Document Type: Policy

Author: Medicines Policy Task & Finish Group

Equality Impact Assessed:

(If appropriate) Replaces:

Medicines Policy, version 3

Key Staff and Staff Groups Involved in Medicines Management ............................. 7

Monitoring Arrangements ......................................................................................... 9

Prescribing of Medicines ........................................................................................ 11

Patient Group Directions (PGDs) ........................................................................... 26

Administration of Medicines ................................................................................... 28

Controlled Drugs .................................................................................................... 38

Use of Methadone .................................................................................................. 42

Guidelines for the Handling of Illicit Substances .................................................... 47

Admission to bed based services and medicines reconciliation .......................... 50

Medicines on discharge ....................................................................................... 53

Mental capacity and Covert Administration of Medicines .................................... 56

Self Administration of Medicines ......................................................................... 57

Storage of Medicines ........................................................................................... 62

General rules for supply of medicines to Community Services ............................ 71

Disposal and Return of Medicines ....................................................................... 74

Management of Medication Errors and Near Misses ........................................... 76

Medicines Management Training ........................................................................ 78

Medicines Policy, version 3

The policy provides guidance on all aspects of medicines handling and

Objectives of the Policy

Medicines Policy, version 3

Medicines Policy, version 3

Issue to point of use /

Removal / disposal of waste

Removal of waste from the

Medicines Policy, version 3

2 Key Staff and Staff Groups Involved in Medicines Management

The Chief Pharmacist

Medicines Policy, version 3

The Foundation Trust Clinical Governance and Assurance Committee

Medicines Policy, version 3

Medicines Policy, version 3

See also Appendix 17 for Medicines Policy Monitoring Grid.

Medicines Policy, version 3

PRESCRIBING OF MEDICINES (IN-PATIENTS)

All other routes must be written in full.

Medicines Policy, version 3

For regular medicines prescribing times should be in accordance with regular

Medicines Policy, version 3

4.1.7 PRESCRIBING BY TELEPHONE VERBAL ORDERS

Bed Based Services

Medicines Policy, version 3

4.1.9 PRESCRIBING BY STAFF FOR THEMSELVES AND THEIR FAMILIES

If a change in dose, frequency or route of administration is required, the whole

Medicines Policy, version 3

4.1.11 OTHER ENTRIES

Medicines Policy, version 3

If a patient is admitted on a non-formulary preparation which is not stocked by

SUPPLY OF PRESCRIBED MEDICINES

Medicines Policy, version 3

Prescribing Using the Inpatient Chart

Medicines Policy, version 3

The front page of

Patient Demographics and Individual Information