Medicine Policy

Policy: P01

Policy Descriptor

This policy sets out the standards that all staff must adhere to regarding the safe and secure handling of medicines in order to comply with current legislation and best practice recommendations, as stipulated within professional codes of practice for registered practitioners.

If you require this document in a different format or language please speak to a member of Trust staff.

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Contact PALS – 01392 675686 or email dpn-tr.pals@nhs.net

Document Control

Policy Ref No & Title: P01 Medicine Policy

Version: v10

Replaces / dated: Previous policy dated March 21

Author(s) Job Title: Deputy Chief Pharmacist

MO Nurse Practitioner

Ratifying committee: Medicines Safety Committee

Director / Sponsor: Medical Director

Primary Readers:

All staff employed by Devon Partnership Trust including those employed through agencies or under Service Level Agreement who handle, order, prescribe, administer, store or dispose of medicines.

Additional Readers All Staff

Date ratified: July 2021

Date issued: July 2021

Date for Review / Ratify By: Feb 23 / July 2023

Date archived:

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Contents

1. Introduction .......................................................................................................................... 3

2. Purpose ................................................................................................................................. 3

3. Duties within the Organisation ............................................................................................ 4

4. Legal and Human Rights with regards to Medicines ......................................................... 4

5. Prescribing ........................................................................................................................... 6

6. Patient Group Directions (PGDs) ...................................................................................... 10

7. Ordering Medication .......................................................................................................... 10

8. Supply, Transportation and Receipt of Medicine ............................................................. 11

9. Safe and Secure Storage of Medicines ............................................................................. 12

10. Medical Gases .................................................................................................................... 12

11. Administration .................................................................................................................... 13

12. Delegation ........................................................................................................................... 17

13. Disposal of Medicines ........................................................................................................ 17

14. Poisoning or Overdose ...................................................................................................... 17

15. Controlled Stationery ......................................................................................................... 18

16. Medicines Optimisation Governance ................................................................................ 18

17. Prescribing Support ........................................................................................................... 19

18. Medicines Optimisation Training and Assessment ......................................................... 20

19. Audit and Monitoring ......................................................................................................... 20

20. References .......................................................................................................................... 20

Document Control ....................................................................................................................... 22

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1. Introduction

1.1. In addition to this policy, staff must be familiar with related Trust policies including:

Rapid Tranquillisation Policy (C36)

Controlled Drugs Policy (P02)

Resuscitation Policy (C12)

Consent to Treatment policy (C09)

Physical health Monitoring Policy (C34)

Non-Medical Prescribing Policy (P07)

1.2. This policy is supported by a number of Standard Operating Procedures (SOPs), practice standards, clinical protocols and prescribing guidelines. Available here on Daisy

1.3. The Department of Health requires that NHS Trusts establish, document and maintain effective systems to ensure that medicines are handled in a safe and secure manner.

1.4. The Trust must ensure that:

All staff dealing with medicines are aware of the Trust Medicines Policy and associated procedures.

The concepts of safe, personalised, timely, sustainable and recovery focused care are built in to policy and practice.

1.5. Persons authorised to handle medicines are accountable and comply with legal and

registration frameworks, professional guidance and/or organisational or relevant national policy requirements.

1.6. The following Professional Bodies also produce standards for their members which Trust staff are expected to comply with:

General Medical Council (GMC) Standards and Ethics Guidance for Doctors

Royal College of Nursing and the Royal Pharmaceutical Society

Professional Guidance on the Administration of Medicines in Healthcare Settings Royal College of Nursing and the Royal Pharmaceutical Society professional guidance on the safe and secure handling of medicines

Royal Pharmaceutical Society (RPS) Standards of Conduct, Ethics and Performance

1.7. If this document covered all relevant topics in detail it would be unfeasibly large. It has

therefore been written as a summary document, with references to other Trust documents. It also refers to National Professional Standards.

2. Purpose

2.1. This policy sets out the Trust standards that all staff must adhere to regarding the safe and secure handling of medicines whilst recognising and respecting the rights of people who use our services, staff and the wider community. All persons engaging in actions regulated by this policy should give due regard to the individual’s ethnicity, age, disability, gender (including transgender) or sexual orientation, religion and beliefs, which might all on some rare occasions be relevant to Medicines Optimisation. This policy expects practitioners to pay due regard to such issues and obtain specialist advice as and when required. The safe and secure management of medicines is extended to meet the 5 principles of the Human Rights Act 1998 (Fairness, Respect, Equality, Dignity and Autonomy).

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3. Duties within the Organisation

3.1. All staff employed by the Trust must adhere to this policy and associated Clinical Protocols (CPs), Standard Operating Procedures (SOPs), Practice Standards (PSs) and Prescribing Guidelines (PGs).

3.2. Locums, NHS Professionals and agency staff are required to operate to the same standards

as permanent staff. 3.3. Unit managers are responsible for ensuring that their staff act in accordance with this policy

and ensuring that staff have signed the ward staff list (Form P01b)

3.4. Where staff are in any doubt as to the correct procedure to follow they should contact the Devon Partnership NHS Trust Medicines Optimisation (MO) team for advice and guidance:

3.4.1. Email dpn-tr.pharmacyteam@nhs.net or phone 01392 675674

3.4.2. Local member of the MO team (contact details on Trust intranet).

3.5. All staff have a duty of care to ensure that medicines are used safely and effectively,

promoting concordance with medication and preventing stock piling of medication in patients’ homes.

4. Legal and Human Rights with regards to Medicines 4.1. Consent to Treatment (for full details see Consent to Treatment Policy C09)

4.1.1. Under English common law all mentally competent adults have an absolute right to give

or withhold consent to any medical treatment. This remains so even if withholding consent may seriously jeopardise the person’s health or even result in their death.

4.1.2. In general, therefore the treatment of informal (or voluntary) patients in Mental Health

Services follows the same principles as in general medicine and elsewhere and should only proceed on the basis of the informed consent of the patient.

4.1.3. Informed consent should be taken to mean at a minimum that:

The person is assessed by a competent professional as being capable of

understanding and decision-making in relation to the treatment in question.

The person has received and understood information about the nature of their

condition, the planned effects of treatment, and the possible side effects, the risks

of taking or not taking treatment.

The person has voluntarily and without undue pressure or duress, agreed to the

treatment in question.

4.1.4. ‘Continuing consent’ means that it should not be assumed that because a patient has once given consent they therefore continue to do so. For any course of treatment extending over time, steps must be taken by professionals to assure themselves that the patient continues to consent. If the patient withdraws consent for any reason, the treatment cannot continue on an informal basis.

4.1.5. To give treatment without informed and continuing consent may constitute assault and trespass against the person (unless the special provisions of the Mental Health Act 1983 or the Mental Health Capacity Act 2005 apply). It may result in legal action by the patient for compensation, redress in the criminal Courts and/or disciplinary action.

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4.2. Mental Capacity Act (Mental Capacity Act Policy M07) 4.2.1. The capacity/or lack of capacity of a person to consent to treatment must be recorded

in the relevant section of Care Notes.

4.2.2. If the person lacks capacity but it is considered to be in their best interest to receive treatment, then the reasons behind this decision and the people involved in the decision must be documented in the relevant section in Care Notes.

4.2.3. The MCA is applicable for people 16 and over.. 4.3. Mental Health Act

4.3.1. If the person has the capacity to consent to treatment their consent must be sought unless an exemption applies through the Mental Health Act.

4.3.2. When someone is detained under the Mental Health Act (MHA), the MHA Code of

Practice 1983 must be adhered to and the person must be informed:

of the nature, purpose and likely effects of the treatment which is planned

of their rights to withdraw their consent to treatment at any time and of the need for consent to be given to any further treatment

how and when treatment can be given without their consent, including by the second opinion process and, when treatment has begun, if stopping it would cause serious suffering to the patients.

4.3.3. There is a statutory duty to give this information to detained patients but it is good

practice for all people who use Trust services. 4.3.4. Medication for a mental disorder can be administered to a patient detained under a

section of the Mental Health Act under the authority of their Responsible Clinician without the need for consent or the authorisation of a Second Opinion Appointed Doctor, for a period of up to 3 months continuous detention commencing from the day such medication was first administered. The code of practice states that the patient’s consent should still be sought before any medication is administered wherever practicable. The patient’s consent, refusal to consent, or lack of capacity to give consent should be recorded by the Responsible Clinician.

4.3.5. After 3 months, Section 58 applies, and patients cannot continue to be given

medication unless one or more of the following documentation is in place:

T2 Form (certificate of consent) or

T3 Form (certificate of second opinion) or

Section 62 Form: For Urgent treatment to provide treatment that is necessary to save life or

prevent serious harm. For treatment after 3 months while waiting for a Second Opinion Appointed

Doctor (SOAD) to issue a T3 4.3.6. Patients in the community who are on a Supervised Community Treatment Order

(CTO) must have the corresponding documents to support administration in the community. They are:

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Form CTO12 (certificate to confirm community patient has capacity to consent and has done so)

Form CTO11 (certificate of appropriateness of treatment to be given to community patient).

4.3.7. These documents (T2, T3, S62, CTO11 and CTO12) must be included in the person’s

electronic notes. A copy of the T2/T3/S62 must also be kept with the Prescription and Administration chart. The list of medication must be checked by the Nurse prior to every administration to ensure that all mental health medications (and medication required because of side effects due to mental health medication) are covered.

4.3.8. Template forms are available on the Medicines Optimisation Charts and Forms page (under “Prescribing) or from the Mental Health Act Office

4.4. Section 117 Aftercare (see Medication Under Section 117 MM51)

4.4.1. Some people who have been in hospital under the Mental Health Act can get free aftercare when they leave hospital; this is called section 117 aftercare. Those under section 117 are entitled to free aftercare costs: this includes medication for mental health conditions. This will be funded by DPT.

5. Prescribing

GMC Standards and Ethics Guidance for Doctors

Practice Standard PS08 Prescribing Medication (Inpatient)

Practice Standard PS09 Prescribing Medication (Outpatient)

SOP MM43 Prescribing Clozapine

P07 Non Medical Prescribing Policy

C36 Policy for Rapid Tranquillisation with injectable medication on Devon Partnership Trust Inpatient Units

5.1. All Trust prescribers (including locums) will attend the MO introduction within the first 3

months in the Trust and a local induction with a member of the Medicines Optimisation Team. 5.2. Medicines will only be prescribed using Trust official prescription stationery (see the

Medicines Optimisation section of Daisy) or NHS FP10 prescriptions. 5.3. Supplementary Non-Medical Prescribers may only prescribe medicines in accordance with

an agreed clinical management plan. 5.4. Medical students are not permitted to prescribe medicines. 5.5. F1 medical staff are not allowed to prescribe using FP10s. 5.6. Doctors and Non-Medical Prescribers must not prescribe for their families, friends or

themselves. 5.7. Before writing a prescription, the prescriber will:

Record a working diagnosis for mental health conditions(s) in the person’s electronic notes.

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Carry out a thorough medicines reconciliation i.e. previous history of allergies and adverse reactions, and current medicines (including physical medicines and self- purchased medicines) ideally determined from at least 2 sources

Investigate previous medical history and check physical health monitoring results

SOP MM25 Medicines Reconciliation

Practice Standard PS11 Physical Health Monitoring

5.8. Whenever possible the choice of medicine should be made jointly by the prescriber and the

person. The choice should also be in line with the following formularies and guidance:

Local Joint Formulary Recommendations

Trust Clinical Protocols

Trust Prescribing Guidelines

National Prescribing Guidelines (e.g. NICE Guidance)

5.9. Where new medicine is prescribed, or an existing prescription is altered or cancelled, the

rationale behind the decision must be clearly documented in the person’s electronic notes, including details of information provided and discussion with the person.

5.10. Where prescription charts are used, as a minimum they must be scanned onto care notes on completion, but for community depot charts they will be scanned into care notes after each administration.

5.11. Prescribing for Inpatients

5.11.1. The latest version of the Trust Prescription and Administration chart must be used for all inpatient prescribing with additional specialist charts for Rapid Tranquilisation, Clozapine Initiation, Warfarin, Insulin and End of life care where applicable.

Practice Standard PS08 Prescribing Medication (Inpatient)

SOP CD1 Prescribing and Ordering CDs (Inpatients)

Policy C37 End of Life

Clinical Protocols CP2, CP4, CP11, CP19, CP29

5.12. It is recommended that a full list of regular medication (with doses) be recorded in the clinical

notes made at each ward round. 5.13. Prescribing for Discharge and Leave

5.13.1. A discharge or leave prescription will be completed by the prescriber and dispensed by the Trust Supply Pharmacy. Every attempt must be made to pre-empt the requirement for discharge prescriptions but when discharge hasn’t been predicted, and it is outside of pharmacy opening hours, or is at short notice, discharge prescriptions may be provided via alternative routes.

SOP MM33 FP10 Prescriptions in Inpatient Units

SOP MM37 Prescribing and Supply of Medication for Periods of Leave

SOP MM10 Exceptional Dispensing from Ward Stock

5.13.2. The quantity of medicine prescribed should take into consideration the risk of

suicide, likelihood of non-adherence and waste, ability of person to get further supplies from GP, future appointments and any locally negotiated agreements with

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GPs. Where the individual is assessed as at high risk of suicide or self-harm the quantity of medicine supplied on discharge will not generally exceed a 14 day supply particularly for opiates and psychotropic drugs.

5.13.3. Drug charts should be uploaded to CareNotes on the day of discharge from an in-

patient unit as community teams rely upon the prompt availability of this information to support their safe practice with medicines e.g. CRHTS facilitating urgent discharge.

5.13.4. Particular care must be taken with:

Depots to ensure clarity regarding date of next injection, source of prescription and person who will be administering the medication

Clozapine to ensure transfer of responsibility to community prescriber on CPMS and clear arrangements for supply and blood tests

SOP MM43 Prescribing and supply of Clozapine to community patients

5.14. Prescribing for Outpatients

5.14.1. Prescriptions provided to a person during an outpatient appointment will be written on hospital FP10 prescription forms (FP10 HNC) and dispensed at community pharmacies (apart from Clozapine).

Practice Standard PS09 Prescribing Medication (Outpatient)

5.14.2. Prescriptions for clozapine will be prescribed on the Trust‘s Community Clozapine

prescription and will be dispensed by the approved pharmacy.

SOP MM43 Prescribing Clozapine

5.14.3. Prescriptions should be limited to medicines for mental health conditions (or

conditions caused by mental health medicines). The quantity of medicine prescribed should take into consideration the risk of suicide, likelihood of non adherence and waste, ability of person to get further supplies from GP, future appointments and any locally negotiated agreements with GPs.

5.14.4. Prescriptions for antimicrobials should be prescribed in accordance with the Trust. It

is expected that prescribing of antimicrobials in the community will normally be achieved via the GP.

Antimicrobial Prescribing Policy (P05)

5.14.5. Details of prescribing must be recorded in the person’s electronic notes and the

person’s GP must be informed of the outcome of the appointment as soon as possible. 5.15. Prescribing in Special Circumstances

5.15.1. Prescribing Controlled drugs - The handling of controlled drugs is covered by the CD policy and associated SOPs

P02 Controlled Drugs Policy

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SOP CD1 Prescribing and Ordering CDs (Inpatients)

5.15.2. Prescribing of Non-Approved Medicines - The Trust has a Drugs and Therapeutics Committee whose remit is to review mental health medicines and issue prescribing guidelines. When a non- approved medicine is considered necessary the Non-Approved Drugs procedure should be followed:

SOP MM26 Prescribing Non-Approved Medication

Trust Prescribing Guidelines

5.15.3. Intravenous injections or infusions should not be routinely prescribed. If

considered necessary an incident form should be completed and whenever possible the prescription confirmed with the MO team prior to administration.

5.15.4. Prescribing Unlicensed Medicines - Whenever possible clinicians should prescribe

licensed medicines for licensed indications. However the Trust recognises that the use of an unlicensed medicine, or off-license (off-label) use of a licensed medicine, is occasionally necessary in order to provide optimum treatment.

In all circumstances, it is the responsibility of the prescriber to inform the person (and nursing staff administering the medicine where applicable) about the medicines licensing status. The prescriber must discuss the supporting evidence for its use, the expected benefits of treatment and possible risks. This must be fully documented in the person’s electronic notes.

GMC Standards and Ethics Guidance for Doctors

Royal College of Nursing and the Royal Pharmaceutical Society professional guidance on the safe and secure handling of medicines

SOP MM06 Prescribing Unlicensed and Off-Label Medication

Royal College of Paediatrics and Child Health statement on The use of unlicensed medicines or licensed medicines for unlicensed applications in

paediatric practice

5.15.5. Remote prescribing - Remote prescribing is not encouraged within the Trust but the

need is recognised for inpatient units during on call periods due to the geographical location of some units. Remote prescribing by ‘verbal order’ only (verbal instruction given by telephone) is un-acceptable, an e-mailed copy of the Remote Prescribing Order must be provided.

5.15.6. Prescribing medicines for use in the POS suite- there is a Trust SOP dedicated

to Safe Prescribing in a POS suite.

MM45 Procedure for Managing Medicines in a Place of Safety

5.15.7. Complementary Medicines - If a person using Trust services wishes to continue

non-prescribed complementary medicines during an admission to hospital they may do so providing:

a) the prescriber agrees that it is appropriate for them to continue taking it (i.e. it is

not contraindicated and does not interact with the person’s other medicines) b) The person provides the complimentary medicines as a “patient’s own drug” and

the integrity of the product can be verified

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SOP MM08 Patients Own Drugs

Where people using Trust services are assessed as not having capacity to consent to treatment, complementary therapies brought in to hospital by relatives or carers will only be continued if the prescriber considers them to be in the best interest of the person using Trust services. If they are not continued, the reason for this decision will be communicated to their relative or carer and recorded in the person’s electronic notes.

6. Patient Group Directions (PGDs) 6.1. Normally medicine is prescribed via a patient specific prescription. However, medicines may

be provided using a patient group direction if it would benefit the person without compromising safety.

6.2. Where specific services have identified that the introduction of PGD(s) would enhance the

delivery of care e.g. Crisis Teams or Night Nurse Practitioners, the Trust SOP should be adhered to

SOP MM07 Development and Implementation of PGDs

7. Ordering Medication

7.1. Inpatient Units Ordering of Medication for inpatient use is detailed in the following SOPs:

MM27 Ordering Ward Stock From Profile

MM47 Ordering Medication Using the A3 Multi-Functional Device

MM35 Ordering Non-Stock Items For Use On Inpatient Wards

MM46 Royal Devon and Exeter Hospital Pharmacy Supply of Clozapine to Devon Partnership Trust

7.2. Medication for Leave/Discharge. The following SOPs detail the procedure for ordering

medication on discharge or for periods of leave.

MM37 Medication for Leave

MM48 Prescribing, Ordering and Supplying Medication on Discharge from an Inpatient Unit

7.3. Exceptional Dispensing. Under most circumstance all dispensing will take place in the

supplying pharmacy dispensary. If under exceptional circumstances Trust staff are required to dispense medicine, a Nurse (Band 5 or above), MO Technician, Pharmacist or Doctor can dispense and a Pharmacist or accuracy checking technician can check the dispensing according to SOP MM10. The patient has the legal right to expect that the dispensing will be carried out with the same reasonable skill and care that would be expected from a pharmacy.

SOP MM10 Exceptional Dispensing from Ward Stock

Royal College of Nursing and the Royal Pharmaceutical Society professional guidance on the safe and secure handling of medicines

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7.5 Ordering for Community Patients Most medicines are supplied via prescriptions (FP10s or outpatient Clozapine prescriptions). One exception is the direct delivery of Risperidone/Paliperidone to some Trust community teams

SOP MM50 Direct Delivery of Risperidone

8. Supply, Transportation and Receipt of Medicine 8.1. Inpatient Units

8.1.1. For inpatient units, secure, sealed, tamper-evident containers must always be used

for the transport of medicines to and from the supply pharmacy department. 8.1.2. If orders are left in intermediate locations for collection by ward staff these locations

must be secure and maintained at an appropriate temperature. Staff must collect deliveries promptly.

8.1.3. If fridges are used, their temperatures must be monitored with a maximum/minimum

thermometer on a daily basis. 8.1.4. It is the responsibility of the Nurse in charge or deputy to check the contents of the

order and report any discrepancies or non-delivery items to the supply pharmacy department as appropriate.

SOP MM27 Ordering Ward Stock

SOP CD2 Collecting, Delivering, Receiving and Storing CDs

8.2. Medicines Supply Routes in Special Circumstances

8.2.1. Patients Own Medication - When a person is admitted to hospital, the staff admitting them must establish whether they have brought any medicine in to hospital with them, including non-prescribed medicines, complimentary therapies and creams. All medicines must be assessed before use and it must be stored in the treatment room unless self-administration has been agreed.

8.2.2. All patients’ own medication should be assessed and either used for that person while

on the ward, returned to the person on discharge or destroyed. If it is suspected that an illicit substance has been brought into the Trust it should be handled as directed in the SOP CD6.

SOP MM08 Patients Own Drugs

SOP CD6 Dealing with Illicit Substances

Royal College of Nursing and the Royal Pharmaceutical Society professional guidance on the safe and secure handling of medicines

8.2.3. Emergency Access to Medicines -If medicines are required when the supply

pharmacy department is closed they can be accessed from another ward, via an FP10, or by contacting the on-call pharmacist via the acute hospital switchboard. Calls will be made by the prescriber or Nurse in charge.

SOP MM09 Transfer of Medicines Between Wards

SOP MM10 Exceptional Dispensing from Ward Stock

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8.2.4. Transferring Medicines Between Wards - The transfer of stock medicines between wards is discouraged and will only be necessary in exceptional circumstances (NB this is not to be confused with transfer of named patient medicine when a person is transferred from one ward to another). Controlled Drugs can only be transferred in this way by pharmacists after the agreement of the CD Accountable Officer

SOP MM09 Transfer of Medicines Between Wards

SOP CD4 Transfer and Disposal of CDs

8.2.5. Sample Medicines and Clinical Trials – No samples (of medicines or dressings)

offered by representatives of the pharmaceutical industry may be accepted for use. If such a sample is found on a ward/unit this should be reported to a member of the Medicines Optimisation (MO) team.

8.2.6. All clinical trials materials should be obtained through a protocol that has been

approved by the Drugs and Therapeutics Committee 8.2.7. Community Teams - Nursing staff may transport medicines, including controlled

drugs, to people when necessary, although it is considered good practice that Nurses do not routinely transport CDs. Full details can be found in the following SOP:

PS13 Safe Handling of Medicines in Community Mental Health Teams

9. Safe and Secure Storage of Medicines

9.1. Policies should be in place to ensure all storage environments meet the standards required

for the product (www.emc.medicines.org.uk). This is particularly important for medicines requiring storage in a fridge. The Nurse in charge is responsible for ensuring that medicines are stored appropriately. The MO Technician will inspect the storage conditions for medicines quarterly in all inpatient units and 4 monthly in community units.

Practice Standard PS06 Storage of Medicines

PS13 Safe Handling of Medicines in Community Mental Health Teams

9.2. Breach of Security - Any incident where a breach of security is suspected or confirmed must

be reported immediately through the Trust Risk Management System and will initially be investigated by the Nurse in charge with advice sought from the MO team. If concerns are raised regarding medicines balances then the procedure for monitoring medicines liable to misuse may be introduced.

SOP MM13 Breach of Security (Medicines Optimisation)

SOP MM14 Action Required for Lost or Stolen FP10 Prescriptions

SOP MM40 Monitoring Medicines Liable to Misuse

10. Medical Gases

The nurse in charge is responsible for ensuring the safe handling and storage of oxygen as per SOP MM56. Auditing of oxygen will be completed as part of the quarterly medicines

storage audit.

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SOP MM56 Safe Handling And Storage Of Oxygen

11. Administration

11.1. Medicines are administered in accordance with a prescription, Patient Specific Direction,

Patient Group Direction or other relevant exemption specified in the Human Medicines Regulations 2012 (Schedules 17 and 19, as amended).

11.2. All staff administering medicines must ensure that they have the required knowledge to understand the reason for the medicine, the appropriate dose(s), the required monitoring and possible side effects. They will also be aware of potential interactions with food and/or other medicines and actions to take if an adverse drug reaction occurs.

11.3. The following describes the scope of practice of Nursing Associates in relation to Medicines Optimisation within the Trust

11.3.1. Nursing Associates can hold the medicines keys with the exception of the controlled drugs key. This should be detached and kept on the person of the Nurse in Charge.

11.3.2. Administration of drugs via oral; topical; subcutaneous; per rectum; and inhaled

routes will be part of the core role for Nursing Associates.

11.3.3. Controlled Drugs. Nursing Associates will form part of the second check for administration and checking of controlled drugs but NOT the administration.

11.3.4. IM injections including depots. Nursing associates will be able to administer

depot injections.

11.3.5. Rapid Tranquillisation. This will NOT be within the scope of the Nursing Associates role.

11.3.6. Safety critical Medicines. Within DPT these will include Clozapine, Lithium,

Insulin, anticoagulants, and off label medicines. Nursing Associates will be able to administer these medicines - Trust clinical protocols will be updated to include the role of nursing associates in administering these drugs.

11.3.7. As required “PRN” medication. Nursing Associates will NOT be able to

administer PRN medication.

11.3.8. Ordering, storage and Disposal of Medicines. Nursing associates will NOT be able to order or destroy medicines. Nursing Associates will be involved in the storage of medicines including putting medicines away and maintenance of clean and tidy treatment rooms.

11.3.9. “Homely Remedies”. Nursing Associate will NOT be able to administer Homely

Remedies.

11.3.10. PGDs. Nursing Associates will NOT be able to administer drugs via a PGD

11.4. Wherever possible, the actions of prescribing, dispensing/supply and administration are performed by separate healthcare professionals. Exceptionally, where clinical circumstances make it necessary and in the interests of the patient, the same healthcare professional can be responsible for the prescribing and

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supply/administration of medicines. Where this occurs, an audit trail, documents and processes are in place to limit errors.

Royal College of Nursing and the Royal Pharmaceutical Society Professional Guidance on the Administration of Medicines in Healthcare Settings

11.5. Administration of Oral Medicines on Inpatient Units - The Nurse in charge of a ward/unit

is responsible for ensuring that a local procedure is in place for the accurate identification of a person prior to administration of medicines. Individual Nurses administering medicine must ensure that they follow the procedure.

SOP MM24 Accurate Identification of Individuals

11.5.1. Administration of oral medicines must comply with the following SOPs:

SOP MM15 Administration of Medication

SOP CD3 Administration of CDs

Practice Standard PS08 Prescribing Medication (Inpatient)

Royal College of Nursing and the Royal Pharmaceutical Society Professional Guidance on the Administration of Medicines in Healthcare Settings

11.5.2. Preceptees must complete their observed competency assessment (SOP MM15) and prior to unsupervised administration of medicines on a Trust unit. Once competent and administering unsupervised, they must refrain from supervising nursing students and newly Qualified preceptees for a period of time (to be agreed with mentor for a probationary period) to allow for time for the preceptee to gain confidence and competence to support the development of their Medication knowledge and understanding.

11.6. Administration of medicines on Inpatient Units in Special Circumstances

11.6.1. Self-Medication – Self-medication may take place on inpatient units as:

a) part of an individual’s recovery programme.

b) a way of facilitating access to certain “as required” medicines e.g. emollient

creams and salbutamol inhalers. The prescription and administration chart must be endorsed “for self medication” in the additional instructions section.

Documentation of the administration should be according to SOPand practice standards for inpatient charts.

SOP MM38 Self-Administration of Medication

Practice Standard PS08 Prescribing Medication (Inpatient)

11.7. Administration from blister packs and other compliance aids - Compliance aids provide

a convenient way for many people to administer their own medicines. Inpatient staff may be

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involved in supervising administration of medicines supplied in this form as part of a self-medication scheme providing it has been supplied according to a Trust prescriber’s prescription.

11.8. However, when inpatient staff are responsible for the administration of the medicine and a person has brought in a filled compliance aid from home, nursing staff must not administer the medicine unless they have confirmed this use with the ward pharmacist.

SOP MM23 Use of Compliance Aids

11.9. Covert administration - Covert administration of medicines must only be considered if

necessary to save life, prevent deterioration, or ensure improvement in the physical and/or mental state of the individual. Medicines are administered covertly only to people who actively refuse their medication and who are considered to lack mental. Capacity, in accordance with an agreed management plan. Where deemed necessary, covert administration of medicines takes place within the context of existing legal and best practice frameworks

SOP MM21 Covert Administration of Medication

Royal College of Nursing and the Royal Pharmaceutical Society Professional Guidance on the Administration of Medicines in Healthcare

Settings

11.10. Administration of medicines in end of life care - All administration of medication for end

of life care will be under direction of Palliative Care Nurses.

Policy C37 End of Life

Clinical Protocol CP29 Protocol for Prescribing & Administering Medicines in the Last Days of Life on DPT Inpatient Units that do not have End of Life

Support on Site

11.11. Administration of Homely Remedies (Medicines under Protocol) - Certain commonly

used medicines for the treatment of self limiting ailments can be administered on inpatient units without a prescription by nurses Band 5 or above, according to the Homely Remedies SOP providing the nurse has signed the Homely remedies register on the ward to indicate they have completed the training.

SOP MM15 Administration Of Medication On Inpatient Wards

11.12. Administration of oral medicines in the community - Home treatment teams may

administer medicines providing that they meet the standards specified by the Royal College of Nursing. The person administering the medicine must ensure that:

a) The medicine is currently prescribed for that person (or can legally be provided and

b) administered using a Trust PGD). See SOP MM07

c) The medicine if fit for purpose. See SOP MM08

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d) The person has been positively identified. See SOP MM24

e) The administration is documented according to PS13 Safe Handling of Medicines in

Community Mental Health Teams 11.13. Preparation and Administration of Injectable Medicines (Inpatient and in Community)

11.13.1. Preparing and injecting medicines involves risks due to potential calculation errors,

microbial and particulate contamination. Unsupervised administration of injections can only be carried out by registered Nurses (RMNs, RGNs, and Nursing Associates) who have completed the Trust Injection training and suitably trained medical staff. Whenever possible a second person should check the calculation, this may involve phoning another trained member of staff on another ward or unit where there is only one registered nurse on the ward or unit.

11.13.2. Nurses in Training who have completed the Trust Nurse in Training medicines

optimisation training may undertake administration of injectable medicines under the direct supervision of a registered nurse.

11.13.3. The administration of an injection must be recorded on the appropriate Trust

administration chart in accordance with the following standards 11.13.4. A register of all injections which are held as stock on any DPT ward, commonly used

in DPT or included in PGDs or written instructions will be held by the medicines optimisation team and published on Daisy. Each of the injections on this list will be risk assessed using the Medusa injectable medicines guide or if a monograph does not exist then the risk assessment tool completed as per MM28. This list will be reviewed annually through MOGG.

11.13.5. Any injection which is not included in the register will be individually risk assessed

by the ward pharmacist and ward manager as per MM28 11.13.6. Any injection which is rated as amber or red will require risk reduction measures to

be put in place and must be added to the ward/MO Team risk register as described in MM28. The effectiveness of these risk reduction measures will be monitored through MOGG or locality medicines safety groups by reviewing incident reports and recorded in the medicines safety report.

SOP MM28 Safer Use of Injectable Medicines

PS13 Safe Handling of Medicines in Community Mental Health Teams

Policy R07 Infection Prevention and Control

11.14. The Administration of Injectable Medicines in Special Circumstances

11.14.1. The administration of injections for rapid tranquillisation - Injectable

formulations of benzodiazepine and antipsychotics are used in situations that require rapid tranquillisation.

Policy C36 Rapid Tranquillisation

Clinical Protocol CP11 Rapid Tranquillisation

11.14.2. The administration of intravenous injections or infusions - Intravenous

injections should not be routinely prescribed or administered throughout the Trust. Only doctors or appropriately trained registered practitioners may administer intravenous injections or infusions. Wherever possible, two practitioners should

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check the medicines and doses to be administered intravenously. Technical information on intravenous administration is available from the Trust’s MO team or from the supplying pharmacy department.

SOP MM28 Safer Use of Injectable Medicines

12. Delegation

12.1. If a Nurse delegates any aspects of the administration process they are accountable to

ensure that the patient, carer or care assistant is competent to carry out the task The registered nurse remains accountable for their actions, non-actions and omissions, and exercise professionalism and professional judgement at all times.

12.2. Nurses in Training may participate in the administration of medicines under the direct and

immediate supervision of an approved practitioner. The registered Nurse must clearly countersign the signature of the trainee. The registered Nurse retains full accountability for the correct administration and recording of the prescribed medicine at all times.

SOP MM36 Delegation of Medication Administration

13. Disposal of Medicines

13.1. The removal/disposal of surplus or waste medicines from wards or community units must

comply fully with local and national regulations, i.e. The Hazardous Waste Regulations (England and Wales) 2005, and Trust procedures. Nursing Associates cannot be involved in the routine destruction of medicines without a Band 5 nurse present

Policy G18 Waste Management Policy and Waste Management Procedures

SOP MM29 Medicines Destruction and MHRA/CAS Alert Returns

PS13 Safe Handling of Medicines in Community Mental Health Teams

SOP CD4 Transfer and Disposal of CDs

SOP CD7 CDs in the Community

Royal College of Nursing and the Royal Pharmaceutical Society professional guidance on the safe and secure handling of medicines

14. Poisoning or Overdose

14.1. Poisoning denotes exposure to a substance that is dangerous to health or life. A poison may

be a drug, household product, industrial chemical, or plant or animal derivative. Poisoning may be accidental or deliberate.

14.2. Overdose is the use of a quantity of drug in excess of its intended or prescribed dose. It may

be accidental or deliberate and involve the use of prescribed or illicit drugs. 14.3. If an individual is suspected of poisoning or overdose this will be treated as a medical

emergency, basic life support applied and 999 called to ensure that the person is transferred and treated by people with the appropriate clinical knowledge, skills and experience within the appropriate care setting.

14.4. An incident report must be completed for any suspected poisoning or overdose.

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14.5. Incidents of poisoning or overdose will be monitored through the medicines optimisation

governance group to ensure that any learning is shared. 14.6. NICE guidance on poisoning and overdose can be found via the following link:

Poisoning or overdose - NICE CKS

15. Controlled Stationery 15.1. All controlled stationery will be stored securely in a locked location and any loss or theft must

be reported immediately to the Nurse in charge of the ward or department lead. An incident form must be completed.

SOP MM14 Action Required for Lost or Stolen FP10 Prescriptions

SOP MM32 Ordering and Storage of FP10 Prescriptions

16. Medicines Optimisation Governance 16.1. The Trust’s MO team is responsible for overseeing the safe and effective use of medicines

across the Trust. This includes clinical screening of prescriptions, provision of medicines related information, supervision of medicines storage, allocation and provision of FP10s, provision of training and audit.

PS04 Medicines Management Team Standards – Inpatients

16.2. Medicines Safety Committee Group (MSC)

The purpose of the Medicines Safety Committee is to strengthen governance arrangements around all aspects of safe and secure handling of medicines within and across the Trust:

Ensure that medicines are used safely, securely and cost-effectively.

Ensure that medicines are used in accordance with currently accepted best practice.

Within the Trust and in collaboration with other stakeholders, to support the delivery of safe, timely, personalised, recovery focused and sustainable care.

Where medicine related incidents occur regularly review reports and share learning. Every two months a medicines safety report including issues and actions from MSC will be presented to the Quality Governance Assurance Committee (QGAC) and summarised in the Medicines Optimisation Annual Report.

16.3. Key Performance Indicators 16.3.1. Medicines Safety KPIs will be included as part of monthly reports to MSC. These

measures will include:

Medicines reconciliation at all transitions of care - i.e. admission, transfer

and discharge.

Missed/omitted doses

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Patient Identification with drug charts

Completed controlled drug checks

16.4. Medicines Incidents

16.4.1. All medicines incidents or near misses must be reported using the Trust Risk

Management System. This includes notifiable events including rapid tranquillisation and Covert administration.

16.4.2. Medicines incidents are regularly reviewed and monitored through Directorate Medicines Safety Groups and MS. Learning is identified and shared via Safety Briefings and incorporated into the MO training programme. This whole process is overseen by the Medicines Safety Officer.

16.5. Risk Register

Medicines Optimisation risks are captured on the Trust Risk Management System (RMS). This is reported into and reviewed at MSC.

16.6. Drugs and Therapeutics Committee The purpose of the Drugs and Therapeutics Committee is to ensure that:

Up-to-date, evidence based prescribing guidelines are produced, maintained and available to all prescribers and clinical teams in order to support evidence based best practice.

Condition based prescribing guidelines inform and reflect pharmacological treatment choices included in locally developed formularies

Trust prescribing guidelines are used by prescribers as a tool to assist in promoting safe, appropriate and cost-effective prescribing.

Medicines are prescribed and monitored in accordance with currently accepted best practice.

People using our services receive safe, timely, personalised, recovery focused, equitable and sustainable treatment throughout the Trust where medication is an appropriate treatment intervention.

Clinical Protocols

Medicines Optimisation Briefings

SOP CD8 Monitoring Controlled Drug Usage

17. Prescribing Support

17.1.1. The Trust MO team provides medicines advice to staff and members of the public. This is currently achieved via a Medicines Information helpline and local MO team.

Medicines Information

Helpline

0300 555 5000

Available 10am - 4pm Monday to Friday

(excluding Bank Holidays)

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17.1.2. The MO team provides prescribing reports to ensure that Trust prescribing is in line with prescribing recommendations and usage of medicines is within expected norms.

18. Medicines Optimisation Training and Assessment

18.1.1. MO Training requirements are assigned according to staff role. Training is monitored using the Trust Learning Management System, Develop.

18.1.2. Further education and training requirements should be identified through continuing

professional development (CPD) and annual PDRs. 18.1.3. All staff required to undertake any aspect of medicines optimisation are required to

read the Medicines Policy and associated documents and complete the core training assigned to them.

18.1.4. Where additional training resources are required, but not available, the risks

associated with not providing training must be assessed and included on the Trust Risk Register.

SOP MM39 Medicines Optimisation Training

19. Audit and Monitoring

19.1.1. It is the responsibility of Trust Management and the Board to monitor and review all aspects of the system for the safe and secure handling of medicines. A specific MO report is produced and submitted to the Trust Board annually.

19.1.2. The MO team recognises its responsibility to check practice in adherence to all

medicines related Trust Policies. 19.1.3. Regular audits include:

Weekly prescription chart checks reported via Orbit for population of the MO Dashboard

Controlled drug checks. An audit is completed every three months

SOP CD5 CD Stock Checks and Audits

Storage of medicine audit to be completed quarterly on inpatient units and 4 monthly in community teams

Annual Audit Program monitored via MOGG/DTC 19.1.4. The MO Governance Group will review Trust Incident reports (incidents, near misses

and complaints) concerning medication regularly and, where appropriate, recommend audits to review current practice if areas of concern are highlighted.

19.1.5. The results of audits concerning any aspect of MO will be reported to the MO

Governance Group, and other relevant Trust Committees. Where areas of concern are confirmed, action plans will be developed including training schemes and policy review. The audit cycle will then be repeated after implementation of modifications.

20. References

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National Patient Safety Agency NPSA Alert 20. Safer Management of Injectable Medicines www.npsa.nhs.uk/health/alerts Human Rights Act, 1998 The Medicines Act, 1968 Medicines, Ethics & Practice, Royal Pharmaceutical Society of Great Britain, 2014 Pharmacy Law and Ethics (7th Edition), Appelbe,G and Wingfield J. Pharmaceutical Press Mental Health Act Code of Practice, Department of Health, 1983 (amended 2007) The Safe and Secure Handling of Medicines: A Team Approach. A revision of the Duthie Report (1988) led by the Hospital Pharmacists’ Group of the Royal Pharmaceutical Society, Royal Pharmaceutical Society, 2005 Building a Safer NHS for Patients: Improving Medication Safety, Department of Health, 2004 The Hazardous Waste (England and Wales) Regulations 2005 Interim Guidance for the NHS Hospital Sector for England and Wales and Information for Scotland, Royal Pharmaceutical Society, 2005 Royal College of Nursing and the Royal Pharmaceutical Society professional guidance on the safe and secure handling of medicines 2019 Royal College of Nursing and the Royal Pharmaceutical Society Professional Guidance on the Administration of Medicines in Healthcare Settings 2019 The third WHO Global Patient Safety Challenge: Medication Without Harm 2017

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Document Control

Version Date Issued Author

Name / Job Title / e mail 1.0 October 2008 Tina Campbell, Associate Director Medicines Management / Controlled

Drugs Accountable Officer, tina.campbell@nhs.net

2.0 November 2009

Tina Campbell, Associate Director Medicines Management / Controlled Drugs Accountable Officer, tina.campbell@nhs.net Kelly Smith, Prescribing Information Analyst, Kelly.smith8@nhs.net 3.0 April 2012

4.0 January 2013 Tina Campbell, Associate Director Medicines Management / Controlled

drugs Accountable Officer, tina.campbell@nhs.net 5.0 April 2015 Debbie Marriott, Network Lead Clinical Pharmacist,

Deborah.marriott@nhs.net

6.0 January 2017 Debbie Marriott, Network Lead Clinical Pharmacist, Deborah.marriott@nhs.net

7.0 June 2019 Samantha Churchward, Deputy Chief Pharmacist Samantha.churchward@nhs.net Elizabeth Milverton, Medicines Optimisation Technician elizabethmilverton@nhs.net

8.0 July 2020 Samantha Churchward, Deputy Chief Pharmacist Samantha.churchward@nhs.net

9.0 March 2021 Samantha Churchward, Deputy Chief Pharmacist Samantha.churchward@nhs.net

10 August 2021 Samantha Churchward, Deputy Chief Pharmacist Samantha.churward@nhs.net Thea Bull, MO Nurse Practitioner thea.bull@nhs.net

Target audience/ staff groups:

All clinical and skilled non-registered staff directly employed by Devon Partnership Trust and those employed through agencies or under Service Level Agreement (SLA) arrangements who handle, order, prescribe, administer, store and dispose of controlled drugs in Trust inpatient, outpatient and community settings.

Director / Sponsor Medical Director

EIA Date Completed November 2009

Ratifying Group: Medicines Safety Committee (MSC)

Date ratified: July 2021

Implementation date: July 2021

Review date: July 2023

CQC essential standards Outcome 9 Management of Medicines

Document History Version

Start date

End date Author History

2.1 Mar11 Mar12 TC AG DM

AG has kept a rolling record of minor suggested changes that need to be incorporated into any future update review of this policy. These changes were reviewed by the trusts Pharmacy Forum (Chair DM) and it was decided that as the policy and SOPs are likely to need a full and comprehensive redesign following the results of the MM Training Needs Analysis and training plan which is underway (planned implementation date of July 2012) and given the fact there were no major / immediate items that need changing. It was agreed that pending confirmation from Vanessa Ford about advice on competency assessments of NHS Professionals and agency; the forum has recommended that a working group be set up by MMGG to look at a total policy redesign. As such an interim review date of 6 months has been given to the existing document. Sections 17.19 and 17.20 have been added to clarify the Trusts position in respect of NHS Professionals and agency staff involvement in the administration of medicines. Document control section updated. Document history section added. Approval/ review date footer added.

3.0 Mar12 Apr12 KS Policy hyperlinks updated and document signed off

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3.0 Oct12 Oct12 TC Policy hyperlinks updated to include PS08, PS09, S01 and MM39 and document signed off

4.0 Nov12 Dec12 TC Working party of MMGG advised November 12 meeting that work on medicines policy redesign is underway but will take longer to implement. Immediate risk assessment of current version undertaken and no major changes needed apart from – 1. Following feedback from TRIRG clarity on stance of use of IV infusions requested. Sections 7.12 and 18 updated to include advice in relation to IV injections applies to both bolus injections and infusions. 2. Feedback from NHSLA level 1 assessment section 22 updated to include information on how the organisation identifies and implements learning from medication related incidents. Pending these changes P01 can be given a further 12months; it will be replaced by a new redesigned version on or before this date.

4.0 Nov13 TC / KS

Document extended for a further 12 months. This was approved at MMGG on 21st November 2013

4.0 Feb14 KS Document extended until July 2015. This was approved at MMGG on 19th February 2015

4.1 Feb15 DM Revised format and improved links to supporting documentation to ensure improved accessibility to staff

5.0 Apr15 KS Document ratified at MMGG

5.1 Nov 16 DM Consent to treatment in increased depth, 5.10 – community depot charts to be scanned after each use, 7.3 only pharms can check emergency dispensing, 9.1 frequency of PS06 checks, 10 preceptees have to complete MM15 & Injection training prior to admin, 10.10 all nurses must complete injection training before administering injections, added references to SOPs that had been written since last edition of the policy. Addition of Ward Signature list

6.0 Jan 17 JBS Document ratified at MOGG

Nov 18 TC Following discussion at November MOGG, no urgent/immediate changes are required. Community Practice Standards are under development (CQC and related internal audit action plan) therefore agreed to interim extension until June 2019 with a view of building the new guidance in development into newer versions

6.1 May 19 June 19 SC/EM Complete review and update – changes documented in policy checklist on shared MO drive.

7.0 June 19 JBS Document ratified at MOGG

7.1 July 20 July 20 SC Added section 11.12.4 to 11.12.6 to describe the new risk assessment process for injectables updated in line with MM28

8.0 July 20 JBS Ratified at MOGG and signed off

8.1 Mar 21 TB Minor change to Section 11.4.2 to clarify preceptee supervision of students

9.0 JBS Ratified at MSC and signed off

9.1 Jul 21 SC/TB Updated to include Nursing Associates

10.0 July 21 JBS Ratified at MSC and signed off